What CPT codes are used for podiatric foot care?

Nail debridement: 11720 (1-5 nails), 11721 (6+ nails). Callus/corn removal: 11055 (1 lesion), 11056 (2-4), 11057 (5+). These are separately billable from E/M. For diabetic foot exams with peripheral neuropathy risk assessment, document findings supporting G0245/G0246. Ingrown nail procedures: 11730-11750 based on complexity.

What documentation is required for Medicare-covered routine foot care?

Routine foot care (nail trimming, callus removal) requires documented qualifying condition: diabetes with neuropathy (Class A), PVD with claudication or decreased pulses, or systemic conditions affecting lower extremities. Document: specific qualifying diagnosis, physical findings supporting risk (monofilament testing, pulse assessment), and that patient cannot safely perform self-care.

How should diabetic foot examination be documented?

Document: vascular exam (DP and PT pulses, capillary refill, skin temperature, edema), neurological exam (10g monofilament testing at specific sites with results, vibratory sense), dermatological exam (skin integrity, calluses, nail pathology, ulcer risk areas), and musculoskeletal exam (deformities, Charcot changes). Include risk stratification and preventive recommendations.

What is required for Medicare Class A/B/C finding documentation?

Class A: Nonambulatory requiring regular foot care. Class B: Systemic conditions (neuropathy with LOPS, PVD, peripheral edema). Class C: Ambulatory with nail changes preventing self-care. Document specific findings supporting classification: monofilament results (LOPS = ≤6/10 sites), pulse exam, nail description (thickened, mycotic, dystrophic). Classification determines coverage for routine care.

What documentation supports medical necessity for diabetic footwear (DME)?

Document: diabetes diagnosis, peripheral neuropathy with LOPS (monofilament testing results), foot deformity, history of ulceration or amputation, poor circulation, or pre-ulcerative callus. Include certification that patient has diabetes and qualifying condition, is being treated under comprehensive diabetes care plan, and needs therapeutic shoes/inserts. Specific form (PDAC) may be required.

Podiatry Foot Exam Template - Diabetic & Nail Care

Podiatry — Detailed Foot Examination Template

Specialty Podiatry Updated: 1/4/2026

The Podiatry Foot Examination Template is designed for podiatrists evaluating patients for diabetic foot care, nail pathology, or musculoskeletal foot pain. This template captures vascular status (pulses), neurological status (monofilament), dermatological findings (nails, calluses, ulcers), and musculoskeletal exam. Supports billing for diabetic foot care and routine foot care (when qualified). Ideal for podiatry practices.

Patient Information

Date: [Date]
Visit Type: New Patient / Established / Diabetic Foot Care / At Risk Protocol
Chief Complaint: [Pain / Nail issue / Check-up]

History

HPI: [Onset, duration, severity of foot pain or change] Diabetic History (if applicable):

Last A1c: [Value]
Glucose control: Good / Fair / Poor
History of ulcers/amputation: Yes / No

Physical Examination

Vascular Exam:

Dorsalis Pedis (DP): Palpable / Doppler / Absent (L/R)
Posterior Tibial (PT): Palpable / Doppler / Absent (L/R)
Capillary refill: <3 sec / >3 sec
Edema: None / Pitting / Non-pitting
Skin temp: Warm / Cool / Cold

Neurological Exam:

Semmes-Weinstein Monofilament (10g): Intact (10/10) / Loss of Protective Sensation (LOPS)
Vibratory sense: Intact / Diminished

Dermatological Exam:

Skin: Intact / Dry / Scaling / Erythema
Calluses/Corns: [Location - e.g., plantar 2nd met head]
Nails:
Normal / Thickened (Onychomycosis) / Incurvated / Discolored
Class findings (Medicare): Class A / B / C

Musculoskeletal Exam:

Deformities: Bunions (HAV) / Hammer Toes / Flat Foot (Pes Planus)
ROM: Ankle / STJ / MPJs [WNL or Limited]
Gait: [Observations]

Assessment

1) [Primary Diagnosis - e.g., Onychomycosis, Diabetic Neuropathy, Plantar Fasciitis]
2) [Secondary Diagnosis - e.g., Type 2 Diabetes]

Plan

Procedures Performed:

Nail Debridement (11720/11721): Length/Thickness reduced on [Toes #1-10].
Callus Paring (11055-11057): Paring of hyperkeratotic lesions [Location].
Ingrown Nail Avulsion (11730): [Details if performed]

Prescriptions/Orders:

Topicals/Orals: [Medication]
Orthotics: Casted / Dispensed / Recommended
DFO (Diabetic Footwear): Prescription provided

Patient Education:

Daily foot checks recommmended.
Proper footwear discussed.
Return to clinic if signs of infection.

Follow-up:

[Timeframe] weeks/months

Podiatry — Detailed Foot Examination Template

Template

Patient Information

History

Physical Examination

Assessment

Plan

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