Miriam Trimble of the District said she visits a podiatrist about every eight weeks. At age 83, "you can't see very well," she said, so "you really need somebody to do" the clipping of toenails and other routines that can help prevent foot problems.

Until recently, Medicare has been helping pay for podiatric visits, which often cost $40 to $50.

Those days are ending. In 2002, Medicare directed its claims processors to remind doctors of its limitations on foot care, noting that about a quarter of claims filed for toenail cutting did not have adequate documentation. Last year, the firm that handles Medicare claims for the Washington area rewrote its guidelines, said Ross Taubman, a spokesman for the American Podiatric Medical Association.

"Were they paying for people who shouldn't have been covered before? I don't know the answer to that," said Taubman. "What I know is that they've tightened up the descriptors and the documentation required to get somebody to be covered."

"Patients often come in saying, 'I have diabetes, I should be covered' " under Medicare, said Taubman, who has a podiatric practice in Columbia. "It's confusing to patients all the time" that routine foot care is not covered unless a diabetic has other problems such as swollen feet, dry skin or severe vascular disease.

Complicating the picture further, Taubman said, are "the nuances" of each claims handler.

"I often see patients, especially my patients who travel south for the winter, [who] are under two different sets of coverage rules -- which really [puts] the doctor in a very nice place because I'm telling somebody it's not covered where it might be covered [elsewhere]."

"If you are blind and have no arms, there is no coverage" for routine foot care under Medicare, said Taubman. "That's a pretty harsh thing to say, but it's true."

"I think it's unfair," said Susan Marlowe of the District. "I go every four to five weeks," said Marlowe, who is 82 and has two artificial hips that make it hard for her to reach her toes with nail clippers.

"It's very difficult to tell patients that it's no longer covered and that they have to pay out-of-pocket," said Marlowe's podiatrist, Harold Glickman. "How can a blind person or a severely arthritic person take care of their feet?"

"It's just one more example of the elderly, the fixed income, getting a pinch," said Michael Droulette, a District podiatrist who said some people are beating the system by "doctor-hopping."

"If you go to somebody different every time, it's a covered service because you're getting" an assessment as part of a new-patient visit. A patient who rotates among a dozen or more podiatrists could have his visits covered by Medicare indefinitely, he said.

-- Tom Graham

The System welcomes comments from patients, providers, insurers and others about the delivery of health care. While we cannot advocate on behalf of individuals, we are looking for examples of problems and solutions that may direct our reporting. Contact us by U.S. Mail at the address that appears on Page F2 or by e-mail at thesystem@washpost.com. Do not send original documents.