Biopsy to Prove Onychomycosis in Routine Foot Care

National Government Services has been made aware of a situation where podiatrists have been approached by laboratories stating that they need to biopsy their patients to make sure they have onychomycosis and telling them that this is part of a Medicare LCD. We want to make sure that providers understand that this is not a Medicare requirement, nor is there any current indication for it to become a requirement.

The following documentation requirement is included in the Routine Foot Care and Debridement of Nails LCD:

“Routine identification of cultures of fungi in the toenail is medically indicated when necessary to differentiate fungal disease from psoriatic nail, or when definitive treatment for prolonged oral antifungal therapy has been planned. If cultures are performed and billed, documentation of cultures and the need for prolonged oral antifungal therapy must be in the patient record and available to Medicare upon request.”

Therefore, please note that Medicare covers the cost of a biopsy/culture when medically necessary and used to distinguish fungal disease from noninfectious causes of nail disease such as psoriasis. Cultures should not be ordered routinely or without a suspicion of a noninfectious condition. This is not a policy change. 

Reviewed 9/13/2024