Georgia Medicare Podiatry Coverage

::: hero

Georgia Medicare Podiatry Services

By Brevy Care Team · Last verified May 13, 2026

Foot problems are among the most common chronic complaints in adults aged 65 and older. Diabetes, peripheral neuropathy, and peripheral vascular disease are widespread in the Medicare population, and without proper professional foot care, high-risk patients face serious complications including ulceration and lower-extremity amputation. Despite this clinical reality, Medicare's coverage of podiatry is one of the most narrowly bounded benefits in Part B.

The framework rests on four pillars of federal law. Section 1861(r)(3) of the Social Security Act, which has appeared in the Medicare statute since 1965, recognizes doctors of podiatric medicine as Medicare physicians for functions they are legally authorized to perform under state law. Section 1862(a)(13)(C) of the same Act excludes from coverage the "treatment of flat foot conditions and the prescription of supportive devices therefor, the treatment of subluxations of the foot, or routine foot care." The implementing regulation at 42 CFR 411.15(l) defines routine foot care to include nail cutting, callus and corn removal, and hygienic maintenance. And National Coverage Determination 70.2.1 establishes the diabetic foot care exception, the Class A/B/C findings system for systemic disease exceptions, and the Loss of Protective Sensation (LOPS) documentation standard that uses a 10-gram Semmes-Weinstein monofilament.

A fifth pillar sits alongside these: Section 1861(s)(12) of the Social Security Act, added by Section 4072 of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66) and implemented at 42 CFR 410.36. This is the Therapeutic Shoe Benefit for Persons with Diabetes. Beneficiaries with diabetes who meet specific risk criteria receive one pair of depth-inlay or custom-molded therapeutic shoes plus three pairs of multi-density inserts each calendar year. The benefit is one of the most cost-effective items in the Medicare DMEPOS catalog: a properly fitted pair of therapeutic shoes substantially reduces the risk of the ulceration cascade that ends in amputation.

In Georgia, the rules play out on the ground through licensed podiatrists overseen by the Georgia State Board of Podiatry Examiners under O.C.G.A. §43-35. Georgia is among the more progressive states for podiatric scope of practice. O.C.G.A. §43-35-13 authorizes Georgia D.P.M.s to perform foot and ankle surgery below the knee, partial foot amputations, and (with appropriate credentialing) ankle joint reconstructions. Palmetto GBA serves as the Medicare Administrative Contractor for Jurisdiction J, which includes Georgia, and publishes Local Coverage Determinations that flesh out the federal rules.

This guide walks through each layer of the framework: the statutory recognition of podiatrists, the routine foot care exclusion, the NCD 70.2.1 diabetic foot care exception with LOPS documentation, the Class A/B/C findings system, the Section 1861(s)(12) therapeutic shoe benefit, and the HCPCS coding architecture that translates the rules into billed claims. We work through six Georgia case studies covering the most common patient situations: a diabetic patient with LOPS receiving routine foot care every 60 days, a hammertoe correction covered as standard surgery, the annual therapeutic shoe benefit, plantar fasciitis treatment, an ABN-acknowledged self-pay nail trim, and a mycotic nail debridement under HCPCS G0127. Fourteen common mistakes are identified along the way. A 25-question accordion FAQ and a 20-contact CTA close the guide. :::

::: callout

Key takeaways for Georgia Medicare beneficiaries

1. Section 1861(r)(3) recognizes D.P.M.s as Medicare physicians since 1965. A podiatrist's medically necessary services are billed and paid like any other physician's, subject to the routine foot care exclusion.

2. Section 1862(a)(13)(C) excludes routine foot care. Nail trimming, callus paring, and hygienic foot maintenance are non-covered unless a specific exception applies. The exclusion is statutory and absolute outside the recognized exceptions.

3. NCD 70.2.1 creates two exception pathways. Diabetic peripheral neuropathy with Loss of Protective Sensation (LOPS) qualifies. Systemic disease meeting Class A, Class B, or Class C findings also qualifies. Covered frequency is once every 60 days.

4. LOPS is documented with a 10-gram Semmes-Weinstein monofilament. The monofilament is applied to multiple plantar sites. Failure to perceive the monofilament at the test sites confirms LOPS. Documentation must be refreshed at least every 6 months.

5. The Class A/B/C findings system is precise. Class A: nontraumatic amputation alone qualifies. Class B: all three findings (absent posterior tibial pulse, absent dorsalis pedis pulse, advanced trophic changes). Class C: at least two of five findings plus symptoms.

6. Section 1861(s)(12) therapeutic shoes from OBRA 1993 Section 4072. Diabetic beneficiaries meeting risk criteria receive one pair of shoes plus three pairs of inserts per calendar year, with 20 percent Part B coinsurance. The benefit was effective May 1, 1994.

7. Medically necessary podiatry is fully covered. Treatment of bunions, hammertoes, plantar fasciitis, fractures, infections, and ulcer debridement is paid under standard Part B physician services without routine foot care analysis.

8. Georgia's ~350 podiatrists practice broad scope. O.C.G.A. §43-35-13 authorizes foot and ankle surgery below the knee, partial foot amputation, and (with credentialing) ankle reconstruction. Most Georgia podiatrists accept Medicare assignment, and Palmetto GBA Jurisdiction J administers claims. :::

The clinical case for understanding Medicare podiatry rules

Before the legal framework, the clinical stakes deserve a moment of attention. Diabetes, peripheral neuropathy, and peripheral arterial disease are widespread among Medicare beneficiaries aged 65 and older. The combination of sensory neuropathy (the patient cannot feel a developing wound), vascular insufficiency (the wound does not heal well), and even small mechanical trauma (an ill-fitting shoe, a sharp toenail) creates the diabetic foot ulcer.

Diabetic foot ulcers frequently precede lower-extremity amputations, which are devastating events carrying substantial mortality, significant rehabilitation costs, loss of independence, and major direct hospital costs. Properly delivered podiatric care, including regular professional nail and callus maintenance for high-risk patients and appropriate use of therapeutic shoes, substantially reduces ulceration risk.

This clinical reality is why NCD 70.2.1 carves out exceptions to the routine foot care exclusion for diabetics with LOPS and for patients with severe vascular disease. It is also why Section 1861(s)(12) and OBRA 1993 Section 4072 established the therapeutic shoe benefit. The Medicare rules are not arbitrary: they are calibrated to deliver covered routine foot care to the patients most at risk of amputation if such care is not delivered. Knowing the rules helps Georgia beneficiaries and their families ensure that the care they need is properly documented and properly billed.

Statutory authority: Section 1861(r)(3) podiatrist recognition

Section 1861(r) of the Social Security Act defines the term "physician" for Medicare purposes. The statute lists five physician categories. The third, at Section 1861(r)(3), reads in relevant part:

"The term 'physician,' when used in connection with the performance of any function or action, means a doctor of podiatric medicine for the purposes of subsections (k), (m), (p)(1), and (s) and sections 1814(a), 1832(a)(2)(F)(ii), 1835, 1862(a)(4), 1872, 1881, 1886, and 1888 of this title but only with respect to functions which he is legally authorized to perform as such by the State in which he performs them."

A few features deserve attention. First, podiatrist recognition has been in the Medicare statute since the original 1965 enactment. Medicare did not initially exclude podiatrists and add them later; podiatrists were recognized as physicians from day one of the program.

Second, the recognition is conditional on state licensure scope. A Georgia D.P.M. can perform Medicare services that the State of Georgia authorizes a D.P.M. to perform. If state law limited podiatric practice to certain anatomic regions, the Medicare recognition would be similarly limited. In Georgia, O.C.G.A. §43-35-13 authorizes a broad podiatric scope, so Georgia D.P.M.s can perform an unusually wide range of foot and ankle services and bill them as Medicare physician services.

Third, the recognition applies to specific cross-referenced Medicare subsections. These cross-references mean that podiatrists are physicians for purposes of inpatient hospital services, outpatient services, certain teaching arrangements, and the relevant payment provisions. A podiatrist can serve as the admitting physician for a foot or ankle surgery, can supervise residents, can serve as the operating surgeon in a Medicare-covered procedure, and can prescribe DMEPOS items within their scope.

Fourth, the statute is silent on the routine foot care exclusion. That exclusion arrives in Section 1862, which we turn to next.

The exclusion: Section 1862(a)(13)(C) and 42 CFR 411.15(l)

Section 1862 of the Social Security Act enumerates items and services that Medicare may not pay for. Subsection (a)(13)(C) reads:

"Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services... where such expenses are for the treatment of flat foot conditions and the prescription of supportive devices therefor, the treatment of subluxations of the foot, or routine foot care (including the cutting or removal of corns or calluses, the trimming of nails, and other routine hygienic care)."

Three categories are excluded:

1. Flat foot conditions and supportive devices. Pes planus (flat foot) and the orthotic or supportive devices prescribed for it are excluded.

2. Subluxations of the foot. Specific partial dislocations of the foot joints are excluded from Medicare coverage.

3. Routine foot care. This is the broad category that encompasses nail trimming, callus and corn removal, and other hygienic maintenance.

42 CFR 411.15(l) implements the statutory exclusion. The regulation:

• Defines routine foot care to include cutting or trimming of nails, trimming or paring of corns or calluses, and other hygienic and preventive maintenance care
• Establishes the general rule that routine foot care is non-covered
• Lists the qualifying exceptions in detail
• Establishes the Class Findings framework for systemic disease exceptions

The regulation makes one structural point worth emphasizing: routine foot care can be covered when the patient has a systemic condition that would make self-administered or non-professional foot care dangerous. The rationale is harm prevention. A patient with severe peripheral arterial disease who tries to trim a thickened nail at home and creates a small wound may end up with a non-healing ulcer that progresses to infection, gangrene, and amputation. Professional care delivered every 60 days reduces this risk.

Understanding this rationale helps interpret the exceptions: they are not about chronic conditions in general, but about conditions where the absence of professional care creates real risk of serious harm.

NCD 70.2.1: the diabetic foot care exception

National Coverage Determination 70.2.1 is the central CMS coverage policy implementing the exceptions to the routine foot care exclusion. The current NCD recognizes two pathways to covered routine foot care: diabetic peripheral neuropathy with Loss of Protective Sensation (LOPS), and Class Findings for other systemic diseases.

The LOPS pathway

Loss of Protective Sensation (LOPS) is the gold-standard test for clinically significant diabetic peripheral neuropathy. The test uses a 10-gram Semmes-Weinstein monofilament: a calibrated nylon filament that buckles when 10 grams of force is applied. The examiner touches specified plantar sites with the monofilament and asks the patient (eyes closed) whether they can perceive the contact. If the patient cannot perceive the monofilament at the standard test sites, LOPS is present.

The typical LOPS examination tests 10 plantar sites:

• First metatarsal head (medial)
• Third metatarsal head
• Fifth metatarsal head (lateral)
• Plantar surface of the great toe
• Plantar surface of the third toe
• Plantar surface of the fifth toe
• Plantar arch (medial)
• Plantar arch (lateral)
• Heel
• Dorsal surface (added in some protocols)

Documentation requirements under NCD 70.2.1:

• LOPS testing must be performed and documented at least every 6 months
• The medical record must specify the test sites and the patient's responses
• The diabetes diagnosis must be confirmed (ICD-10 codes E10 through E14 with neuropathy specifiers)
• The qualifying threshold is typically failure to perceive the monofilament at multiple test sites

A patient with documented LOPS qualifies for:

• Routine foot care visits once every 60 days
• A comprehensive diabetic foot examination (annually under HCPCS G0246, initially under G0245)
• The routine foot care portion billed under HCPCS G0247

The Class Findings pathway

For patients without diabetes-LOPS, NCD 70.2.1 establishes the Class Findings system for systemic disease exceptions. The system has three classes:

Class A. Any one of the following alone qualifies:

• Non-traumatic amputation of the foot or any integral skeletal portion thereof

Class B. All three of the following are required:

• Absent posterior tibial pulse
• Absent dorsalis pedis pulse
• Advanced trophic changes (three or more of: hair growth changes, nail changes, pigmentary changes, skin texture changes, skin color changes)

Class C. At least two of the following plus pain or symptoms:

• Claudication (pain with walking that resolves with rest)
• Temperature changes (cold feet, asymmetric temperature)
• Edema
• Paresthesia (abnormal sensation: tingling, numbness)
• Burning

A patient meeting Class A on its own qualifies. A patient with all three Class B findings qualifies. A patient with two Class C findings plus symptoms qualifies. Mixing classes is not the standard approach; the typical documentation pathway focuses on the strongest qualifying class.

Systemic diseases commonly producing qualifying findings:

• Diabetes mellitus
• Arteriosclerosis obliterans (peripheral arterial disease)
• Buerger's disease (thromboangiitis obliterans)
• Chronic thrombophlebitis with vascular insufficiency
• Peripheral neuropathies from non-diabetic causes (alcoholism, chronic renal disease, nutritional, hereditary)
• Drug-induced neuropathies (e.g., post-chemotherapy)

The Class Findings pathway also supports covered routine foot care once every 60 days, billed under standard CPT codes (11719 nail trimming, 11720 single-nail debridement, 11721 six-or-more nail debridement, 11055 through 11057 corn and callus paring) with documentation supporting the qualifying class.

Why 60 days?

The 60-day frequency limit reflects clinical evidence on the rate of recurrence of foot complications in high-risk patients. Nails grow slowly enough that less-than-60-day visits are typically not medically necessary. Callus formation similarly reaches problematic thickness on roughly a two-month cycle. Patients with very rapid callus formation or rapid nail growth (rare) may receive more frequent care with additional documentation, but the standard limit is 60 days.

Section 1861(s)(12): the therapeutic shoe benefit for persons with diabetes

The Medicare statute also includes a specific benefit for therapeutic shoes for diabetics, separate from the routine foot care framework. Section 1861(s)(12) was added by Section 4072 of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66). The implementing regulation appears at 42 CFR 410.36.

Eligibility criteria

The therapeutic shoe benefit is narrow and specific. The beneficiary must:

1. Have diabetes mellitus (confirmed by the physician managing the diabetes), AND

2. Have at least one of the following conditions:

   • Previous amputation of the other foot or part of either foot
   • History of previous foot ulceration of either foot (any time previously)
   • History of pre-ulcerative callus formation of either foot
   • Peripheral neuropathy with evidence of callus formation of either foot
   • Foot deformity of either foot (e.g., hammertoes, bunions, Charcot deformity, claw toes)
   • Poor circulation in either foot (documented vascular insufficiency)

The prescription must come from the physician managing the diabetes (typically the primary care physician, internist, endocrinologist, or family physician). The prescription is a clinical certification that the patient meets the diabetes diagnosis and one of the qualifying conditions.

Annual benefit

For each calendar year, the beneficiary is entitled to:

• One pair of depth-inlay shoes (A5500) OR custom-molded shoes (A5501), AND
• Three pairs of multi-density inserts for depth-inlay shoes, OR
• Two additional pairs of inserts for custom-molded shoes (which include one pair built in)

In rare cases of unusual foot pathology, a single insert (rather than a pair) may be furnished. The standard provision is full pairs.

Provider requirements

Several provider rules apply:

• The prescribing physician must be the physician managing the diabetes
• The prescribing physician must have managed the diabetes within the prior 6 months
• The actual fitting and dispensing must be done by a podiatrist, orthotist, prosthetist, pedorthist, or other qualified individual
• The dispensing provider must be enrolled with Medicare as a DMEPOS supplier

In practice, the workflow often is: the primary care physician confirms diabetes diagnosis and qualifying condition, then refers to a podiatry practice that is enrolled as a DMEPOS supplier. The podiatrist performs the fitting and dispenses the shoes and inserts. Some podiatrists serve dual roles as the managing physician (when they are the diabetic foot care provider) and the dispenser.

HCPCS codes for therapeutic shoes

::: table caption="HCPCS Codes for Therapeutic Shoes"

Cost-sharing for therapeutic shoes

The therapeutic shoe benefit is paid under Medicare Part B DMEPOS rules. Cost-sharing applies:

• The annual Part B deductible ($283 in 2026) must be met
• After the deductible, Medicare pays 80 percent of the approved amount
• The beneficiary is responsible for 20 percent coinsurance
• Most Medigap plans cover the 20 percent coinsurance

CMS publishes the DMEPOS fee schedule for therapeutic shoe codes annually. Beneficiaries can look up current approved amounts at medicare.gov or by contacting Palmetto GBA (1-877-567-9230). Cost-effectiveness analyses have repeatedly shown the therapeutic shoe benefit prevents enough amputations to be a net saver for Medicare.

HCPCS coding for podiatry

The HCPCS coding architecture for podiatry covers four main categories: routine foot care codes (generally non-covered), the diabetic foot care codes (covered with LOPS documentation), the surgical and treatment codes (covered as standard physician services), and the DMEPOS codes for therapeutic shoes.

Routine foot care codes (Section 1862(a)(13)(C) exclusion applies)

::: table caption="Routine Foot Care HCPCS Codes (Section 1862(a)(13)(C) exclusion applies)"

When the patient meets a qualifying exception (LOPS or Class Findings), these codes can be billed with appropriate documentation and modifiers. The provider typically documents the qualifying condition (LOPS test results, Class Findings, systemic disease diagnosis) and submits the claim with supporting information.

Diabetic foot care codes (Section 1861(r) physician services applied via NCD 70.2.1)

::: table caption="Diabetic Foot Care HCPCS Codes (NCD 70.2.1)"

G0245 is billed for the initial diabetic foot examination, which includes the LOPS test, comprehensive examination, and patient education. G0246 is billed for follow-up examinations (typically annually). G0247 is billed for the routine foot care portion delivered at the standard 60-day interval.

G0127 is a specific code for trimming of dystrophic nails when the patient has documented mycotic complications causing pain or affecting ambulation, even if the patient does not meet full Class Findings. This recognizes that severe nail fungal infections can require professional intervention to relieve pain.

Surgical and treatment codes (standard Part B physician services)

::: table caption="Surgical and Treatment HCPCS Codes (Standard Part B Physician Services)"

These codes are billed and paid like any other Part B physician service: Medicare pays 80 percent of the approved amount after the deductible; the beneficiary owes 20 percent coinsurance (usually covered by Medigap). The routine foot care exclusion analysis does not apply because these are medically necessary surgical or treatment services, not maintenance care.

Mycotic nail debridement and HCPCS G0127

Severe nail fungal infections (onychomycosis with secondary complications) deserve special attention. NCD 70.2.1 and CMS guidance recognize that severely thickened, dystrophic fungal nails can cause pain with walking, limit ambulation, and require professional debridement even in patients who do not meet full Class Findings. HCPCS G0127 (trimming of dystrophic nails, any number) is the appropriate billing code.

For G0127 to be covered, documentation should include:

1. Diagnosis of onychomycosis (clinical or with confirmatory testing)
2. Severe nail thickening, deformity, or pain affecting ambulation
3. The therapeutic benefit of debridement (pain relief, improved mobility)
4. The patient's overall foot health context

G0127 is distinct from CPT 11719 (trimming of nondystrophic nails). The mycotic nail debridement code recognizes the medical necessity that arises from the fungal complications. Patients should ensure their podiatrist uses G0127 (not 11719) when severe mycotic nails are being treated.

Medically necessary podiatric services: covered without exclusion analysis

Many podiatric services are fully covered under standard Part B without any need to analyze the routine foot care exclusion. These include:

Surgical correction of deformities. Hammertoe correction (CPT 28285), bunion correction (CPT 28290 to 28299), tailor's bunion, Tarsal coalition resection, and other reconstructive procedures are standard Part B surgical services. Coverage is full subject to standard deductible and coinsurance.

Treatment of acute injuries. Fractures (closed or open), sprains, lacerations, contusions, and other traumatic foot injuries are covered as medically necessary care. Initial evaluation, imaging, casting, splinting, and follow-up are all covered.

Treatment of infections. Cellulitis, abscess (incision and drainage), osteomyelitis (when present), paronychia, and other foot infections are covered. The full course of evaluation, debridement, antibiotic prescription, and follow-up is covered.

Diabetic ulcer care. Active diabetic foot ulcers receive comprehensive covered care including wound debridement (CPT 11042 to 11047 for selective debridement; CPT 97597 to 97598 for active wound care), application of advanced wound dressings, evaluation, and follow-up. This is one of the most important Medicare benefits for high-risk diabetic patients.

Treatment of plantar fasciitis. Evaluation, conservative measures (taping, padding, education), corticosteroid injection (CPT 20550), and (in severe refractory cases) surgical fasciotomy (CPT 28008) are covered. The treatment of plantar fasciitis is medically necessary care, not routine foot care.

Treatment of warts and skin lesions. Destructive procedures for plantar warts (CPT 17110 to 17111 for benign lesions; CPT 11900 to 11901 for intralesional injection) are covered when medically appropriate.

Nail surgery. Permanent or partial excision of chronically ingrown nail (CPT 11750, 11752) is covered when the ingrown nail causes recurrent infection or pain.

For all these covered services, the beneficiary owes the standard Part B deductible plus 20 percent coinsurance after the deductible. Most Medigap policies cover the coinsurance. Medicare Advantage cost-sharing varies by plan.

Telehealth and podiatric care

Telehealth has expanded substantially under the COVID-19 public health emergency and subsequent Consolidated Appropriations Act extensions. Most current telehealth flexibilities are extended through at least the end of 2025, with various permanent provisions for specific services (e.g., behavioral health, rural health clinics, end-stage renal disease).

For podiatry, telehealth use has remained limited because the core podiatric work is hands-on:

• Hands-on examination of skin, nails, pulses, deformities
• Performance of procedures (nail care, injection, debridement)
• Gait and footwear assessment
• Manual sensation testing including the LOPS monofilament

Some E&M-only visits can be furnished via telehealth (e.g., follow-up consultation, post-operative check without examination, patient counseling on foot care). These can be billed under standard E&M codes with the appropriate telehealth modifiers (95, GT, or place of service 02 / 10).

In practice, most podiatric care continues to be delivered in person.

The Georgia podiatric landscape

Licensure and oversight

Georgia podiatrists are licensed by the Georgia State Board of Podiatry Examiners under O.C.G.A. §43-35. The Board:

• Issues and renews podiatrist licenses (every two years)
• Reviews disciplinary matters and consumer complaints
• Approves continuing education programs
• Maintains a public registry of licensed podiatrists

Contact information:

• Address: 237 Coliseum Drive, Macon, GA 31217
• Phone: 404-657-9019 (Professional Licensing Boards Division of the Georgia Secretary of State)
• Email: pod_board@sos.ga.gov

Georgia's licensed podiatrists are distributed unevenly across the state. Metro Atlanta has the largest concentration, followed by regional centers:

• Metro Atlanta (Fulton, DeKalb, Cobb, Gwinnett, Clayton, Cherokee, Forsyth, Henry counties)
• Macon and Warner Robins
• Savannah and the coastal corridor
• Augusta and the Central Savannah River Area
• Columbus and the Chattahoochee Valley
• Athens and the northeast
• Albany and southwest Georgia
• Other regional centers and rural Georgia

Beneficiaries in rural counties may need to travel for podiatric care. Some rural areas have visiting podiatrists who travel to satellite clinics weekly or monthly.

Georgia scope of practice

O.C.G.A. §43-35-13 defines the scope of Georgia podiatric practice. Georgia is among the more progressive states. Georgia D.P.M.s can:

• Diagnose and treat conditions of the foot, ankle, and lower leg (within the medically and surgically definable boundaries)
• Perform surgical procedures on the foot and ankle below the knee
• Perform partial foot amputations (within scope)
• Perform ankle joint reconstructions with appropriate hospital credentialing
• Prescribe medications including controlled substances
• Order diagnostic tests and imaging

Some states limit podiatric practice to below-the-malleolus only. Georgia's broader scope reflects strong podiatry training and advocacy in the state. The Georgia statutory framework allows Georgia D.P.M.s to provide a wider range of services to Medicare beneficiaries within the bounds of their Section 1861(r)(3) recognition.

Georgia Podiatric Medical Association

The Georgia Podiatric Medical Association (GPMA), headquartered in Atlanta (770-908-4994), is the state professional society. GPMA:

• Advocates for podiatric interests at the Georgia General Assembly
• Provides continuing education programs
• Maintains a member directory accessible to the public
• Publishes practice guidance and clinical updates for members

Palmetto GBA Jurisdiction J

Palmetto GBA serves as the Medicare Administrative Contractor (MAC) for Jurisdiction J, which covers Georgia. Palmetto GBA:

• Processes Medicare Part A and Part B claims for Georgia providers
• Publishes Local Coverage Determinations (LCDs) that flesh out federal NCDs with regional specifics
• Conducts targeted probe-and-educate reviews on high-error coding areas
• Provides provider education on billing requirements

For podiatry, Palmetto GBA's LCDs touch on routine foot care documentation, mycotic nail debridement, therapeutic shoes, and other commonly billed services. Providers and patients can contact Palmetto GBA at 1-877-567-9230.

Worked example one: Margaret 78 Atlanta T2DM with LOPS

Margaret is a 78-year-old retired bookkeeper in Atlanta with Type 2 diabetes diagnosed 18 years ago. Her HbA1c is currently 7.2 percent on metformin and basal insulin. Her primary care physician at Emory referred her to a participating podiatrist for diabetic foot care.

The podiatrist conducted an initial comprehensive examination:

• Bilateral lower extremity inspection
• Vascular assessment (pulses, capillary refill, skin temperature)
• Neurological assessment using a 10-gram Semmes-Weinstein monofilament
• Biomechanical and structural assessment

The LOPS test result: Margaret failed to perceive the monofilament at 7 of 10 plantar sites bilaterally, confirming loss of protective sensation.

Coding for the initial visit:

• G0245 (Initial diabetic foot evaluation with LOPS): approximately $98 approved
• Medicare pays 80 percent after the deductible

Margaret returns every 60 days for routine foot care. Each routine visit includes:

• Verification of current LOPS documentation (within 6 months)
• Nail and callus care
• Inspection for any new lesions, ulcers, or concerning findings

Coding for the routine 60-day visit:

• G0247 (Routine foot care, diabetic patient with LOPS): approximately $42 to $45 approved

Annual coding (every 12 months):

• G0246 (Follow-up diabetic foot evaluation with LOPS): approximately $52 approved (replacing one of the G0247 visits)

Total Medicare-approved charges over a calendar year:

• One G0245 (initial year only) or G0246 (subsequent years): $52 to $98
• Five G0247 routine visits at $42 each: $210
• Total approximately $260 to $300 per year

Cost to Margaret with Medigap Plan G (after deductible):

• Plan G covers the 20 percent coinsurance
• Margaret's out-of-pocket: $0 per year for podiatry

This is the structure NCD 70.2.1 was designed to support: regular professional foot care for a high-risk diabetic patient with documented LOPS, preventing the ulceration cascade.

Worked example two: Robert 81 Savannah hammertoe correction

Robert is an 81-year-old retired ship pilot in Savannah. He has a painful third-toe hammertoe that catches on shoes and causes pain with walking. He visits a podiatrist who recommends surgical correction.

The procedure is performed at an Ambulatory Surgical Center (ASC) in Savannah. Local anesthesia. The podiatrist performs an osseous hammertoe correction (CPT 28285) with K-wire fixation.

Billing components:

• Podiatrist surgeon fee (CPT 28285 in ASC place of service): approximately $480
• ASC facility fee: approximately $670
• Local anesthesia (often bundled or minor): approximately $0 to $180

Total approved charges: approximately $1,150.

Robert has already met his 2026 Part B deductible. Medicare pays 80 percent of each component. Robert's 20 percent coinsurance is approximately $230.

Robert carries Medigap Plan G, which covers the 20 percent coinsurance after the deductible. Robert's out-of-pocket: $0.

The hammertoe correction is fully covered as standard Part B physician and ASC services. The routine foot care exclusion does NOT apply. Surgical correction of a painful, functionally limiting hammertoe is medically necessary care.

Worked example three: Linda 75 Macon therapeutic shoes

Linda is a 75-year-old in Macon with Type 2 diabetes for 15 years and a history of one prior foot ulceration (right great toe, healed two years ago after extended wound care). Her primary care physician is an internist at Atrium Health Navicent.

Linda's internist documents:

• Diabetes mellitus, Type 2, with diabetic peripheral neuropathy
• History of previous foot ulceration on the right foot (now healed)
• Continued care relationship for diabetes management (Linda is seen quarterly)
• Recommendation for therapeutic shoes

The internist writes a prescription for therapeutic shoes meeting the 42 CFR 410.36 requirements:

• The diabetes diagnosis is confirmed
• The qualifying condition is documented (history of foot ulceration)
• The internist certifies the medical need

Linda is referred to a podiatry practice in Macon that is enrolled as a Medicare DMEPOS supplier. The podiatry practice:

• Measures Linda's feet (length, width, special features)
• Selects appropriate depth-inlay shoes
• Casts or scans for custom inserts (or selects pre-fabricated inserts based on foot type)
• Fits the shoes and verifies proper fit
• Provides patient education on foot care and shoe wear

Annual benefit furnished:

• 1 pair A5500 (depth-inlay shoes): approximately $140 approved
• 3 pairs A5512 (pre-fabricated multi-density inserts): approximately $25 per pair = $75 approved
• Total approximately $215 approved

Linda has already met her 2026 Part B deductible. Medicare pays 80 percent of $215 = $172. Linda's 20 percent coinsurance = $43.

Linda has Medigap Plan G, which covers the $43. Linda's out-of-pocket: $0.

The benefit recurs each calendar year. In January 2027, Linda can receive a new pair of shoes and three new pairs of inserts. The cumulative effect of properly fitted therapeutic shoes (reduced pressure points, accommodation of foot deformities, prevention of skin breakdown) substantially reduces Linda's risk of a second ulcer.

Worked example four: Charles 79 Augusta plantar fasciitis

Charles is a 79-year-old in Augusta with worsening heel pain attributed to plantar fasciitis. The pain is most severe on first steps in the morning and after prolonged sitting. He visits a podiatrist at AU Health.

The podiatrist conducts the evaluation:

• History and review of symptoms
• Examination demonstrating tender medial calcaneal tuberosity
• Positive provocation tests (windlass test, calcaneal squeeze)
• Inspection of footwear (worn-out cushion supports)
• Discussion of conservative treatment options

The podiatrist:

• Provides patient education on stretching and self-care
• Recommends night splint use
• Performs a corticosteroid injection into the plantar fascia (CPT 20550)
• Recommends shoe modifications and follow-up

Billing:

• 99213 (established patient E&M, level 3, 20 to 29 minutes): approximately $85 approved
• 20550 (injection of tendon sheath): approximately $48 approved
• Total approximately $133 approved

Charles has met his deductible. Medicare pays 80 percent = $106.40. Charles's 20 percent coinsurance = $26.60. Medigap Plan G covers it. Charles's out-of-pocket: $0.

Treatment of plantar fasciitis is medically necessary care, NOT routine foot care. Full coverage applies.

Note one important caveat: an arch support (orthotic) prescribed for Charles's plantar fasciitis would generally NOT be covered by Medicare. The therapeutic shoe benefit applies to diabetics meeting specific criteria; it does not extend to general orthotic coverage for non-diabetic conditions. If Charles wishes to purchase custom orthotics, he typically pays out of pocket (or through Medicare Advantage supplemental benefits, if his plan covers them).

Worked example five: Patricia 73 Columbus routine nail trim

Patricia is a 73-year-old in Columbus with no diabetes, no peripheral arterial disease, and no qualifying systemic conditions. She has osteoarthritis affecting her hands and decreased flexibility, which makes self-trimming of her toenails difficult and risky. She visits a podiatrist for routine nail care.

The podiatrist explains the Medicare rules:

• Patricia does not meet any Class Findings (her pulses are intact, no advanced trophic changes, no claudication)
• Patricia does not have diabetic LOPS (she has no diabetes)
• The nail trimming is statutorily excluded routine foot care under Section 1862(a)(13)(C)

Because the service is unlikely to be covered, the podiatrist provides Patricia with an Advance Beneficiary Notice of Noncoverage (ABN, CMS form R-131). The ABN explains:

• Why the service is unlikely to be covered (does not meet routine foot care exceptions)
• The estimated cost ($35)
• Patricia's options (proceed with full responsibility for payment, or decline the service)

Patricia signs the ABN, checks Option 1 (proceed and accept responsibility), and proceeds with the service.

The podiatrist bills CPT 11719 (trimming of nondystrophic nails, any number) with the GA modifier indicating an ABN is on file.

Medicare denies the claim as routine foot care without qualifying exception. Patricia is responsible for the full charge of $35.

This example illustrates the fundamental coverage limitation. Patricia's situation is sympathetic (an older adult who cannot easily trim her own nails) but does not fall within the statutory exceptions. Options for patients in Patricia's situation include:

• Paying out of pocket (typical $25 to $50 per visit)
• Medicare Advantage plans that offer routine foot care as a supplemental benefit (often with flat copay $15 to $30 per visit)
• Lower-cost services through community health programs, senior centers, or charitable foot care clinics
• Family or volunteer foot care (with appropriate care to avoid injury)

GeorgiaCares SHIP (1-866-552-4464) can help beneficiaries compare Medicare Advantage plans for supplemental foot care benefits.

Worked example six: Henry 84 rural Tifton mycotic nail debridement

Henry is an 84-year-old in rural Tifton with severe onychomycosis (fungal infection) affecting eight of his ten toenails. The nails are markedly thickened, dystrophic, and cause pain when walking. Henry also has hypertension and mild peripheral arterial disease (palpable but diminished posterior tibial pulse, intact dorsalis pedis pulse). He does not have diabetes.

Henry visits the podiatrist in Tifton (one of the regional providers serving rural southwest Georgia). The podiatrist documents:

• Onychomycosis confirmed clinically (severe dystrophy, characteristic discoloration)
• Pain with walking attributed to thickened nails impacting shoes
• Diminished but present peripheral pulses (does not fully meet Class B findings)
• No diabetes, no LOPS
• Functional limitation: Henry has difficulty walking long distances due to nail pain

The podiatrist bills HCPCS G0127 (trimming of dystrophic nails, any number). G0127 has different requirements than the standard Class Findings: it requires documented mycotic nail complications causing pain or functional limitation in walking, even when the patient does not fully meet Class A or B.

Billing approved at approximately $24. Medicare pays 80 percent ($19.20). Henry's 20 percent coinsurance is approximately $4.80.

In this scenario Henry does not have Medigap. Henry pays $4.80 out of pocket.

If Henry had been billed under CPT 11719 (routine nail trimming) without the G0127 mycotic exception, the claim would have been denied as routine foot care. The G0127 code recognizes that severe mycotic complications can require professional intervention even in patients who do not meet full Class Findings. Patients in Henry's situation should ensure their podiatrist uses G0127 with appropriate documentation when mycotic complications are present.

Fourteen common mistakes in Medicare podiatry coverage

Mistake one: assuming all podiatry is non-covered

Many beneficiaries assume Medicare covers no podiatry. In fact, Medicare covers a wide range of medically necessary podiatric services. The routine foot care exclusion applies only to specific maintenance services (nail trimming, callus paring, hygienic maintenance). Surgical care, treatment of infections, treatment of plantar fasciitis, diabetic ulcer care, fracture care, and treatment of biomechanical conditions are all covered.

Mistake two: assuming all foot care for diabetics is automatically covered

Diabetes alone does not automatically qualify a beneficiary for routine foot care coverage. The beneficiary must have documented Loss of Protective Sensation (LOPS) confirmed by 10-gram monofilament testing, OR meet other Class Findings criteria. A diabetic patient with intact protective sensation and no Class Findings does not qualify for covered routine nail trimming. (However, surgical care, ulcer care, and other medically necessary services remain covered for all patients including diabetics.)

Mistake three: confusing routine foot care with routine foot examination

Routine foot care (nail trimming, callus paring) is generally non-covered. Routine foot examination (visual assessment, neuropathy screening, ulcer detection) is covered as part of a standard E&M visit or, for diabetics with LOPS, under HCPCS G0245 (initial) and G0246 (follow-up). The semantic similarity creates confusion: the words are similar but the coverage rules are different.

Mistake four: not understanding the 60-day frequency limit

When routine foot care is covered (LOPS, Class Findings), the frequency is limited to once every 60 days. More frequent visits without supporting medical necessity may be denied. Beneficiaries should schedule visits at appropriate intervals (typically 60 to 70 days).

Mistake five: assuming any podiatrist can prescribe therapeutic shoes independently

The therapeutic shoe benefit at 42 CFR 410.36 requires that the prescribing physician be the physician managing the diabetes (typically the primary care physician, internist, or endocrinologist). The prescribing physician must have managed the diabetes within the prior 6 months. The shoes must be furnished by a qualified DMEPOS supplier. While a podiatrist can both manage diabetic foot care and dispense therapeutic shoes, the prescriber-supplier requirements must be met.

Mistake six: not maximizing the therapeutic shoe benefit

The annual therapeutic shoe benefit (one pair of shoes plus three pairs of inserts) is available each calendar year. Beneficiaries who use the benefit fully (replacing shoes annually) get substantial value. Some beneficiaries are unaware of the inserts entitlement and do not request all three pairs. Beneficiaries should ensure their podiatrist orders the full benefit each year.

Mistake seven: confusing routine podiatry with surgical podiatry

Routine podiatry (nail care, callus care) and surgical podiatry (bunion correction, hammertoe repair, fracture treatment) are governed by different coverage rules. Surgical podiatry follows standard Part B physician services rules with full coverage and standard cost-sharing (deductible, 20 percent coinsurance). The routine foot care exclusion analysis does not apply.

Mistake eight: assuming Medicare Advantage covers more without checking specific benefits

Medicare Advantage plans must cover what Original Medicare covers (medically necessary services subject to the same exclusions). Many MA plans add supplemental benefits for routine foot care (covering nail trimming for non-Class-Finding patients, additional therapeutic shoes, expanded orthotic coverage). However, the specific supplemental benefits vary by plan, year, and county. Beneficiaries should review their plan's Summary of Benefits or contact the plan directly.

Mistake nine: not obtaining an ABN before non-covered services

For likely-non-covered services (e.g., routine nail trimming for a patient without qualifying findings), the podiatrist should obtain an Advance Beneficiary Notice (ABN, CMS form R-131) before providing the service. The ABN explains why the service is unlikely to be covered, the estimated cost, and the patient's options. Without an ABN, the podiatrist cannot bill the beneficiary if Medicare denies. With a signed ABN, the beneficiary is responsible for payment.

Mistake ten: choosing custom-molded shoes when depth-inlay would suffice

Custom-molded shoes (A5501) are paid at a higher rate than depth-inlay shoes (A5500). CMS requires custom-molded shoes only when depth-inlay would not work (severe deformity, partial foot amputation, unusual foot shape). Custom-molded shoes for patients who could be properly fitted with depth-inlay shoes may be denied or downcoded. The clinical justification for custom-molded should be documented.

Mistake eleven: not coordinating diabetic foot care with primary care

The therapeutic shoe benefit requires prescription by the physician managing diabetes. Beneficiaries should ensure their primary care or endocrinology physician is willing to prescribe and document the medical need. Some primary care physicians refer to podiatrists for the actual prescription, which can introduce delays. Beneficiaries can ask the primary care physician to write the prescription directly to streamline the process.

Mistake twelve: missing the LOPS documentation refresh requirement

LOPS documentation must be updated at least every 6 months for ongoing covered routine foot care under NCD 70.2.1. Beneficiaries (and their podiatrists) should ensure documentation remains current. A patient whose LOPS testing falls out of date (e.g., the most recent test was 9 months ago) may have claims denied until LOPS is reverified.

Mistake thirteen: not understanding orthotic coverage

Standard orthotic devices (arch supports, cushion inserts) prescribed for general foot conditions (flat foot, plantar fasciitis as a non-diabetic condition) are GENERALLY NOT covered by Medicare. The therapeutic shoe benefit for diabetics is a specific exception. Therapeutic devices fitted to a brace or splint may be covered under different DMEPOS rules. Beneficiaries should not assume orthotic coverage based on a general prescription.

Mistake fourteen: confusing podiatry with general medical foot care

A podiatrist (D.P.M.) is a foot and ankle specialist. An M.D. or D.O. (family physician, internist, geriatrician) can also treat foot conditions and bill standard physician services. The routine foot care exclusion at Section 1862(a)(13)(C) applies regardless of who performs the service. Whether the provider is a podiatrist or an M.D., routine nail trimming is non-covered absent qualifying findings.

Coordination with Medicare Advantage

Many Medicare Advantage plans add supplemental benefits for foot care that Original Medicare does not cover. Plan-specific options can include:

• Routine foot care for non-Class-Finding patients. Some MA plans cover nail trimming and callus care at flat copay rates ($15 to $30 per visit) regardless of LOPS or Class Findings status. The frequency limit (number of visits per year) varies by plan.

• Additional therapeutic shoes. Some MA plans cover more than one pair of therapeutic shoes per year for diabetic patients, or expand the inserts allowance.

• Custom orthotics for non-diabetic conditions. Some MA plans cover custom orthotics for plantar fasciitis, flat foot pain, or other non-diabetic conditions (which Original Medicare does not cover).

• Lower cost-sharing on standard podiatry. MA plans often use flat copays ($20 to $40 per office visit) rather than the 20 percent coinsurance after deductible structure.

Beneficiaries with significant foot care needs may benefit substantially from MA plan supplemental benefits. The trade-offs are network restrictions (the MA plan may require in-network podiatrists), referral requirements (some plans require primary care referral for specialist care), and prior authorization requirements for some services.

GeorgiaCares SHIP (1-866-552-4464) provides free Medicare plan comparison counseling. Beneficiaries can call GeorgiaCares to discuss their specific foot care needs and identify plans with strong supplemental benefits.

Coordination with Medicaid for dual-eligible beneficiaries

Medicare beneficiaries who are also enrolled in Georgia Medicaid (dual-eligible beneficiaries) receive additional support for podiatric care:

• Medicare cost-sharing assistance. The Medicaid Qualified Medicare Beneficiary (QMB) program pays Medicare Part B premiums and the 20 percent coinsurance for Medicare-covered services. For QMB beneficiaries, podiatry services covered by Medicare result in $0 out-of-pocket cost.

• Medicaid routine foot care coverage. Georgia Medicaid covers limited routine foot care for adults under specific medical necessity rules. The coverage is more limited than for children but can supplement Medicare's restricted coverage.

• Therapeutic footwear extension. Medicaid may cover orthotic devices not covered by Medicare in specific medical necessity circumstances.

Dual-eligible beneficiaries should ensure their podiatrist is enrolled with both Medicare and Georgia Medicaid. Some podiatrists accept Medicare only; for dual-eligibles, this can create gaps in coverage for Medicaid-covered services beyond Medicare.

The Georgia Department of Community Health Medicaid Member Services line (1-866-211-0950) can confirm Medicaid coverage and provider participation.

How to find a participating podiatrist in Georgia

Several pathways help Georgia beneficiaries identify participating podiatrists:

• Medicare's Care Compare tool (medicare.gov/care-compare) lists Medicare-enrolled providers by specialty, location, and accepting status. Search by "podiatrist" and Georgia zip code.

• The Georgia Podiatric Medical Association directory (770-908-4994) lists GPMA member podiatrists by region.

• The Georgia State Board of Podiatry Examiners (404-657-9019) maintains the public license registry.

• Medicare Advantage plan provider directories for MA enrollees, available through the plan's website or member services line.

• Primary care physician referral. For diabetic patients in particular, the primary care or endocrinology physician often has working relationships with podiatrists experienced in diabetic foot care.

When selecting a podiatrist, beneficiaries should ask:

• Does the practice accept Medicare assignment?
• Is the practice in-network for my Medicare Advantage plan (if applicable)?
• Does the practice serve dual-eligible Medicare-Medicaid beneficiaries?
• For diabetic patients: does the practice routinely perform LOPS testing and bill covered diabetic foot care?
• For therapeutic shoe needs: is the practice enrolled as a DMEPOS supplier?

Appeals and disputes

When Medicare denies a podiatric claim, several appeal pathways exist:

1. Redetermination. The first level of appeal is a redetermination by the Medicare Administrative Contractor (Palmetto GBA Jurisdiction J in Georgia). Beneficiaries (or providers on their behalf) submit a written request within 120 days of the initial denial. The MAC reviews the claim and additional documentation.

2. Reconsideration. The second level of appeal is a reconsideration by a Qualified Independent Contractor (QIC). Submitted within 180 days of the redetermination decision.

3. Administrative Law Judge (ALJ) hearing. The third level. Submitted within 60 days of the reconsideration decision. ALJ hearings can be conducted by phone, video, or in person.

4. Medicare Appeals Council. The fourth level. Submitted within 60 days of the ALJ decision.

5. Federal District Court. The fifth and final level. Submitted within 60 days of the Council decision (subject to amount-in-controversy threshold).

For podiatric claim denials, the most common issues involve:

• Disputed routine foot care coverage (was LOPS adequately documented? Were Class Findings properly recorded?)
• Disputed therapeutic shoe coverage (did the prescribing physician meet the diabetes management requirement? Was the qualifying condition adequately documented?)
• Coding disputes (was the appropriate code used? Were modifiers correctly applied?)

The Medicare Rights Center (1-800-333-4114) and the Center for Medicare Advocacy (1-860-456-7790) provide free guidance on appeals. Atlanta Legal Aid Society (404-377-0701) and Georgia Legal Services Program (1-800-498-9469) provide free legal assistance to qualifying low-income beneficiaries on Medicare appeals.

At Brevy, we help Georgia families understand Medicare podiatry coverage

At Brevy, we publish trustworthy, comprehensive eldercare guides for American families. Our goal is to help Georgia Medicare beneficiaries, their adult children, and the clinicians who care for them understand how Medicare's complex coverage rules work in practice. This guide on Medicare podiatry services is part of a broader Georgia Medicare Part B series at brevy.com that covers physician services, preventive services, ambulatory surgical centers, outpatient hospital services, rural health clinics, and many other benefit categories. We update our guides regularly as CMS issues new policy and as fee schedules, deductibles, and other thresholds change.

This guide is informational and does not constitute medical, legal, or financial advice. For specific coverage questions about your situation, contact 1-800-MEDICARE, your Medicare Administrative Contractor (Palmetto GBA at 1-877-567-9230 for Georgia), GeorgiaCares SHIP (1-866-552-4464), the Medicare Rights Center (1-800-333-4114), or a qualified Medicare counselor or attorney. For specific medical questions, consult your podiatrist or primary care physician.

::: accordion

Frequently asked questions about Georgia Medicare podiatry services

Q1: Does Medicare cover podiatrist visits in Georgia?

Yes, for medically necessary care. Section 1861(r)(3) of the Social Security Act has recognized doctors of podiatric medicine as Medicare physicians since the original 1965 statute. Medicare pays for podiatrist services within the scope of practice authorized by Georgia law (O.C.G.A. §43-35-13), subject to the routine foot care exclusion at Section 1862(a)(13)(C). Surgical care, treatment of infections, treatment of plantar fasciitis, diabetic foot care for patients with LOPS, fracture treatment, and many other services are fully covered.

Q2: What is "routine foot care" and why is it excluded?

Routine foot care under Section 1862(a)(13)(C) and 42 CFR 411.15(l) means nail cutting, callus and corn removal, and other hygienic maintenance care. It is excluded by statute, meaning Medicare may not pay for it absent a specific exception. The historical rationale was that routine maintenance care is something patients (or family members) can typically perform without professional intervention. The exceptions at NCD 70.2.1 address the specific patient populations where self-administered care creates real risk of harm.

Q3: How does the diabetic foot care exception work?

NCD 70.2.1 establishes that Medicare beneficiaries with diabetic peripheral neuropathy resulting in Loss of Protective Sensation (LOPS) qualify for covered routine foot care every 60 days. LOPS is documented using a 10-gram Semmes-Weinstein monofilament test, refreshed at least every 6 months. Covered services include nail care (HCPCS G0247), an initial diabetic foot examination (G0245), and follow-up diabetic foot examinations (G0246).

Q4: What is LOPS and how is it tested?

LOPS is Loss of Protective Sensation, the threshold of sensory loss at which patients are at significantly elevated risk of foot injury and ulceration. It is tested using a 10-gram Semmes-Weinstein monofilament. The examiner touches specified plantar sites (typically 10 sites including metatarsal heads, plantar toes, arch, and heel) with the monofilament while the patient's eyes are closed. If the patient cannot perceive the monofilament at multiple test sites, LOPS is present.

Q5: What are Class A, B, and C findings?

The Class Findings system at NCD 70.2.1 provides an exception pathway for non-LOPS patients with systemic disease. Class A: nontraumatic amputation alone qualifies. Class B: three findings (absent posterior tibial pulse, absent dorsalis pedis pulse, advanced trophic changes). Class C: at least two of five findings (claudication, temperature changes, edema, paresthesia, burning) plus pain or symptoms.

Q6: How often can I receive covered routine foot care?

When the patient meets a qualifying exception (LOPS or Class Findings), the covered frequency is once every 60 days. More frequent visits without additional medical justification may be denied.

Q7: Does Medicare cover therapeutic shoes for diabetes?

Yes. Section 1861(s)(12) of the Social Security Act, added by Section 4072 of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66) and effective May 1, 1994, establishes the Therapeutic Shoe Benefit for Persons with Diabetes. Eligible diabetic beneficiaries receive one pair of depth-inlay or custom-molded shoes plus three pairs of multi-density inserts each calendar year. The implementing regulation is at 42 CFR 410.36.

Q8: What conditions qualify a diabetic for therapeutic shoes?

Under 42 CFR 410.36, the beneficiary must have diabetes plus at least one of six conditions: previous amputation, history of foot ulceration, history of pre-ulcerative callus formation, peripheral neuropathy with callus formation, foot deformity, or poor circulation.

Q9: Who can prescribe therapeutic shoes?

The prescription must come from the physician managing the diabetes (typically the primary care physician, internist, endocrinologist, or family physician), who must have managed the diabetes within the prior 6 months. The shoes themselves must be furnished by a podiatrist, orthotist, prosthetist, pedorthist, or other qualified DMEPOS-enrolled supplier.

Q10: How much do therapeutic shoes cost?

For depth-inlay shoes (A5500), approximately $130 to $150 Medicare-approved per pair. For custom-molded shoes (A5501), approximately $410 to $450 per pair. Pre-fabricated inserts (A5512) approximately $25 to $30 per pair. Beneficiaries pay 20 percent coinsurance after the Part B deductible. Medigap typically covers the coinsurance.

Q11: Is bunion or hammertoe surgery covered by Medicare?

Yes. Surgical correction of bunions (CPT 28290 through 28299), hammertoes (CPT 28285), and other foot deformities is covered as standard Part B physician services when medically necessary. The routine foot care exclusion does NOT apply to these surgical procedures.

Q12: Is plantar fasciitis treatment covered?

Yes. Evaluation, corticosteroid injection (CPT 20550), conservative measures, and (in refractory cases) surgical fasciotomy are covered. Standard arch support orthotics for non-diabetic plantar fasciitis, however, are generally not covered.

Q13: Are custom orthotics covered by Medicare?

Generally no, except in specific circumstances. The therapeutic shoe benefit covers diabetic-specific inserts for qualifying patients. Standard orthotic arch supports prescribed for non-diabetic conditions (flat foot, plantar fasciitis) are typically non-covered. Some orthotic devices that are integral parts of a brace or splint may be covered under different DMEPOS rules.

Q14: What is HCPCS G0127 and when is it used?

G0127 (trimming of dystrophic nails, any number) is the code for debridement of severely thickened, mycotic (fungal) nails when the nail condition causes pain or impairs walking. It applies even when the patient does not fully meet Class Findings, as long as the mycotic complications and functional impact are documented. This is distinct from CPT 11719 (routine nail trimming) which is non-covered.

Q15: Does Medicare cover diabetic ulcer treatment?

Yes, comprehensively. Active diabetic foot ulcers receive covered wound debridement (CPT 11042 through 11047 for selective debridement; CPT 97597 to 97598 for active wound care), evaluation, advanced wound dressings, and follow-up. This is one of the most important Medicare benefits for high-risk diabetic patients.

Q16: How does Medicare Advantage differ from Original Medicare for podiatry?

MA plans must cover what Original Medicare covers, but many add supplemental benefits: routine foot care for non-Class-Finding patients (typically with flat copay $15 to $30), additional therapeutic shoes, custom orthotic coverage for non-diabetic conditions, and lower cost-sharing structures. Specifics vary by plan, year, and county.

Q17: What is an ABN and when should I receive one?

An Advance Beneficiary Notice of Noncoverage (CMS form R-131) is a written notice that informs you when a service is unlikely to be covered by Medicare and that you may be financially responsible. You should receive an ABN before any service that the provider expects to be denied (e.g., routine nail trimming when you do not have qualifying findings).

Q18: What if I do not have qualifying findings but need help with nail care?

Options include paying out of pocket (typically $25 to $50 per visit), enrolling in a Medicare Advantage plan with routine foot care supplemental benefits, using community resources (some senior centers and charitable clinics provide foot care), or arranging family/caregiver assistance.

Q19: How many podiatrists practice in Georgia?

Approximately 350 licensed podiatrists. The largest concentration is in metro Atlanta (200+), with regional centers in Macon, Savannah, Augusta, Columbus, Athens, and Albany. Rural areas may have fewer podiatrists; some travel to satellite clinics on a regional basis.

Q20: What is Georgia's podiatric scope of practice?

Under O.C.G.A. §43-35-13, Georgia D.P.M.s can diagnose and treat foot, ankle, and lower-leg conditions; perform surgery on the foot and ankle below the knee; perform partial foot amputations; perform ankle joint reconstructions with appropriate credentialing; prescribe medications including controlled substances; and order diagnostic tests. Georgia is among the more progressive states for podiatric scope.

Q21: How do I find a Medicare-participating podiatrist in Georgia?

Use Medicare's Care Compare tool at medicare.gov/care-compare, the Georgia Podiatric Medical Association directory (770-908-4994), or your Medicare Advantage plan's provider directory. Ask whether the practice accepts assignment, is in-network for your plan, and is enrolled as a DMEPOS supplier if you need therapeutic shoes.

Q22: Can I appeal if Medicare denies my podiatric claim?

Yes. Five appeal levels exist: redetermination by the Medicare Administrative Contractor (Palmetto GBA in Georgia), reconsideration by a Qualified Independent Contractor, Administrative Law Judge hearing, Medicare Appeals Council review, and Federal District Court. The Medicare Rights Center (1-800-333-4114) and the Center for Medicare Advocacy (1-860-456-7790) provide free guidance.

Q23: How does coverage work for dual-eligible Medicare-Medicaid beneficiaries?

Dual-eligible beneficiaries enrolled in the Medicaid Qualified Medicare Beneficiary (QMB) program have their Medicare cost-sharing covered by Georgia Medicaid, resulting in $0 out-of-pocket cost for Medicare-covered services. Georgia Medicaid also covers limited additional foot care under medical necessity rules. Contact Georgia Department of Community Health Member Services at 1-866-211-0950.

Q24: How often must LOPS be re-documented?

LOPS testing must be documented at least every 6 months. If a patient's most recent LOPS test is older than 6 months, the podiatrist may need to retest and re-document before billing further covered diabetic foot care.

Q25: What is the cost of routine foot care in Georgia if I pay out of pocket?

Approximately $25 to $50 per visit for routine nail trimming and callus care. Some podiatry practices offer concierge or membership pricing. Some senior centers and charitable foot care clinics provide free or low-cost foot care. Pricing varies by region and practice. :::

::: cta

Georgia podiatry and Medicare contacts

**Medicare and Federal

• 1-800-MEDICARE (1-800-633-4227): Medicare beneficiary services, claims, coverage questions
• Palmetto GBA Jurisdiction J: 1-877-567-9230 (Medicare Administrative Contractor for Georgia)
• Social Security Administration: 1-800-772-1213
• HHS Office for Civil Rights: 1-800-368-1019 (discrimination complaints)
• Medicare Rights Center: 1-800-333-4114 (free appeals guidance)
• Center for Medicare Advocacy: 1-860-456-7790 (free policy and appeals support)
• Kepro Quality Improvement Organization: 1-844-455-8708 (quality and appeals concerns)
• Eldercare Locator: 1-800-677-1116

**Georgia State and Regional

• Georgia Department of Community Health Medicaid Member Services: 1-866-211-0950
• GeorgiaCares State Health Insurance Assistance Program (SHIP): 1-866-552-4464
• Georgia State Board of Podiatry Examiners: 404-657-9019
• Georgia Department of Public Health: 404-657-2700
• Georgia Office of the Attorney General Consumer Protection: 404-651-8600
• 211 Georgia (dial 211): community resource referrals
• Atlanta Legal Aid Society: 404-377-0701
• Georgia Legal Services Program: 1-800-498-9469

**Podiatry-Specific Resources

• Georgia Podiatric Medical Association: 770-908-4994
• American Podiatric Medical Association: 301-581-9200
• American Diabetes Association: 1-800-342-2383
• VA Benefits Information: 1-800-827-1000 (for veterans with foot care needs) :::