11/04/2021

Billing for RFC-Medicare as Primary and Empire as Secondary

I have a patient who is medicare and 2ndary NYS empire. He has no systemic disease at all and ONLY thin mildly long toenails. I have advised him that nail care/routine is not covered and he must self pay and sign a waiver - He stated he called and said NYS empire will pay. We have submitted 3 times to insurance ( with me having an abn- advising it wont be covered) and on each occasion with only the diagnosis code L60.3 for 11719- nys pays. I have had my billing department follow up with NYS empire who does NOT have a foot care policy to review and look at - and they came back yesterday saying that L60.3 is considered a systemic disease and that is why it is covered and paid for. Can you please help me , figure out/understand, as I do not feel this is correct and not sure what I am supposed to do as I know he has NO systemic disease and does not 1) need a medical profession to cut his mildly long nails , 2) or should be a self pay. is there a better ICD code than this to have it not be considered systemic.

Different insurance companies have different guidelines on what they consider medically necessary for routine foot care. While most commercial, managed care, and Medicaid plans follow Medicare guidelines, some plans may have broader or more restrictive guidelines on what they cover. In the instance of the Empire Plan, their guidelines will cover a nail trimming if a patient has an ingrown nail diagnosis. While it may be considered cosmetic or not medically necessary, it is a covered benefit for this specific patient as long as the claim is submitted to Medicare prior to the Empire Plan.

For future encounters, the patient should continue to sign an ABN since it is not medically necessary from Medicare’s perspective, and the non-covered balance should be billed to the Empire Plan as secondary for reimbursement. If the Empire Plan no longer covers nail trimmings for ICD-10 L60.3, then you have full right to bill the patient the non-covered charge or bill them as a self-pay patient for this specific service. However, as it stands right now, there is no reason why Medicare and the Empire Plan should not be billed for this service since you are guaranteed reimbursement from the secondary insurance based on the clinical findings billed.