Modifier Q9- One Class B and Two Class C Findings

Modifier Q9 indicates that one qualifying Class B finding and two qualifying Class C findings are present when reporting certain Medicare routine foot care services.

Home > All Categories > Medicare Modifiers > Modifier Q9

What Is Modifier Q9?

Modifier Q9 is a HCPCS modifier used with certain routine foot care services when the patient's examination documents one qualifying Class B finding and two qualifying Class C findings.

Routine foot care is generally excluded from Medicare coverage. An exception may apply when a systemic condition causes severe peripheral involvement that makes professional foot care medically necessary.

Q9 is part of the class-finding modifier group used to identify the clinical findings supporting this presumption of coverage:

Q7: One Class A finding.

Q8: Two Class B findings.

Q9: One Class B finding and two Class C findings.

Reporting Q9 does not automatically make a service covered. The medical record must support the findings represented by the modifier, along with the underlying condition, service performed, and other applicable coverage requirements.

Class B and Class C Findings

Modifier Q9 requires a specific combination of findings rather than simply evidence of a systemic condition.

Class B Findings: Qualifying findings include an absent posterior tibial pulse, an absent dorsalis pedis pulse, or advanced trophic changes.

When advanced trophic changes are used as a Class B finding, three qualifying changes are required. These may include decreased or absent hair growth, thickened nails, pigmentary changes, thin or shiny skin, and rubor or redness.

Class C Findings: Qualifying findings include claudication, temperature changes such as cold feet, edema, paresthesias, and burning.

For Q9, the record must support one Class B finding plus two separate Class C findings.

When to Use Modifier Q9

One Class B Finding Is Present: The clinical examination supports one qualifying Class B finding.

Two Class C Findings Are Present: Two separate qualifying Class C findings are documented in addition to the Class B finding.

Routine Foot Care Meets a Coverage Exception: The service involves otherwise routine foot care that may qualify for coverage because of a complicating systemic condition and severe peripheral involvement.

The Findings Are Documented: The record identifies the actual Class B and Class C findings supporting Q9.

Applicable Diagnosis Requirements Are Met: The patient's underlying systemic condition and diagnosis support the applicable coverage requirements.

When NOT to Use Modifier Q9

One Class A Finding Is Present: Modifier Q7 represents one Class A finding.

Two Class B Findings Are Present: Modifier Q8 represents two Class B findings.

Only Class C Findings Are Present: Q9 requires one Class B finding in addition to the two Class C findings.

Only One Class C Finding Is Present: One Class B and one Class C finding do not satisfy Q9 requirements.

The Findings Are Not Documented: Do not report Q9 simply because the patient has diabetes, peripheral vascular disease, or another systemic condition.

A Different Coverage Provision Applies: Certain foot care services may qualify under separate coverage provisions that do not require Q7, Q8, or Q9.

Billing Example

A patient with a qualifying systemic condition receives medically necessary routine foot care.

During the examination, the provider documents:

Absent dorsalis pedis pulse: One Class B finding.

Edema: One Class C finding.

Paresthesias: One Class C finding.

Together, these findings satisfy the Q9 requirement of one Class B finding and two Class C findings.

Modifier Q9 may be appended to the qualifying routine foot care service when the remaining diagnosis, documentation, medical necessity, and coverage requirements are also satisfied.

Documentation Requirements

Specific Class B Finding: Document the Class B finding used to support Q9 rather than simply stating that a Class B finding exists.

Two Specific Class C Findings: Identify both Class C findings separately in the medical record.

Clinical Examination: The examination should support the physical and clinical findings represented by the modifier.

Underlying Condition: Document the systemic condition responsible for the severe peripheral involvement when applicable.

Service Performed: Record the foot care service provided, the anatomical location, relevant clinical findings, and the reason professional care was necessary.

Active Care Information: When active-care requirements apply, documentation may also need to identify the practitioner managing the underlying condition and when the patient was last evaluated for that condition.

Billing and Claim Considerations

Modifier Q9 is a class-finding modifier. It should not be used as a general modifier for every Medicare foot care claim.

The presence of Q9 indicates that the required combination of one Class B and two Class C findings has been identified. It does not replace the need for an appropriate diagnosis or other medical necessity requirements.

Anatomical modifiers may also be required depending on the service performed. These can include LT and RT for the left and right foot or TA and T1 through T9 for individual toes.

Coverage requirements can also vary according to the patient's underlying condition and applicable Medicare contractor policy. Providers should verify diagnosis, frequency, active-care, and claim-reporting requirements before submitting the service.

Q7 vs. Q8 vs. Q9

The three class-finding modifiers represent different combinations of clinical findings.

Modifier Q7: One Class A finding.

Modifier Q8: Two Class B findings.

Modifier Q9: One Class B finding and two Class C findings.

These modifiers are not interchangeable. Selection should be based on the findings actually documented during the patient's examination.

For example, a patient with an absent posterior tibial pulse and an absent dorsalis pedis pulse has two Class B findings, making Q8 the applicable class-finding modifier rather than Q9.

A patient with an absent posterior tibial pulse, edema, and burning has one Class B and two Class C findings, which corresponds to Q9.

Common Billing Mistakes

Using Q9 for Two Class B Findings: Two Class B findings correspond to Q8, not Q9.

Reporting Q9 Without a Class B Finding: Two Class C findings alone do not satisfy the Q9 definition.

Documenting Only One Class C Finding: Q9 requires two Class C findings in addition to the Class B finding.

Reporting Q9 Based Only on Diagnosis: A systemic condition does not automatically establish the physical findings required for Q9.

Using Vague Documentation: Documenting only “Q9 criteria met” does not clearly identify the clinical findings supporting the modifier.

Assuming Q9 Guarantees Coverage: Q9 identifies the class findings but does not override diagnosis, medical necessity, frequency, or other coverage requirements.

Common Denial Reasons

Incomplete Class Findings: The documentation does not establish one Class B and two Class C findings.

Missing Qualifying Diagnosis: The reported diagnosis does not support the applicable routine foot care coverage requirements.

Insufficient Medical Record: The record lacks specific clinical findings supporting the modifier.

Missing Active-Care Information: Required treating-practitioner or date-last-seen information is absent when applicable.

Noncovered Routine Foot Care: The service does not meet an applicable exception to the routine foot care exclusion.

Claim and Documentation Mismatch: Q9 is submitted on the claim, but the record supports a different class-finding combination.

Frequently Asked Questions

Can two Class C findings qualify for Modifier Q9 without a Class B finding?
No. Q9 requires the complete combination of one Class B finding and two Class C findings. Multiple Class C findings alone do not satisfy the Q9 requirement.

Can edema and burning count as the two Class C findings for Modifier Q9?
Yes. Edema and burning are separate Class C findings. If both are clinically documented along with one qualifying Class B finding, they can satisfy the class-finding combination represented by Q9.