11/02/2015    Neil Goldberg, DPM

Medicare Requirement for Positive Fungal Nail Cultures? (Mark Ray, DPM)

An LCD (local coverage determinant) # L 35013
issued 10/1/15 for 12 states covered by the
Medicare administrator, Novitas, has dictated a
series of provisions regarding mycotic nail care
which are challenging to understand and implement.
I guarantee that this LCD will be adopted by all
other carriers shortly, so none of us are immune.
It is clearly an opportunity by them to restrict
such care.

There are numerous components with which I have
difficulty:

1-Who mandated that Kerydin and Jublia are
sufficiently effective in re-mediating
onychomycosis? Do they understand the exorbitant
cost ($400/ bottle) to the medical system with
products that "may" show some temporary benefit to
20% of those treated?

2-In a nursing home setting, the presiding
physician must sign off in advance of treatment on
a consultation in order to debride mycotic nails.
How are these physicians to be made aware of this
condition unless we have already provided such
care to the resident?

3-We are now to measure size and thickness of the
nail plate, and color. Who of you can or will
measure the thickness of a toenail?

4-Nail culture is now "required" if :the patient
fails nail treatment; is not a candidate for such
treatment,whatever that means; or if the patient
is to be treated quarterly. What is this cost to
the medical system for such cultures ( naturally,
not those tests performed in an office setting)
and how will it benefit healthcare once the
patient has failed treatment?

Are there other new mycotic nail therapies now
available to us that are FDA approved and covered
by Novitas?

5-Podiatric care in nursing home settings is a
mandated service. If Novitas restricts such
services, who will be financially responsible?
6-Nursing home patients or their family can
independently request podiatric care. Are we then
able to treat and submit to Novitas for these
individuals without a physician consultation
request?

7-What if the physician refuses to sign off on
such consultations? Who then is responsible for
their care?

8- "Complete" documentation is needed for billing
for 6 or more nails. What does complete mean? Must
I measure and describe each nail color as well as
culture each nail for completeness sake?

I could go on, but I need to go buy a new ruler to
measure toenails.

Neil Goldberg, DPM, Newark, NJ

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