General Information
Source Article ID
N/A
Article ID
A57759
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Routine Foot Care and Debridement of Nails
Article Type
Billing and Coding
Original Effective Date
12/26/2019
Revision Effective Date
08/22/2024
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act:
Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Section 1862 (a) (1) (A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Section 1862 (a) (13)(C) defines the exclusion for payment of routine foot care services.
Code of Federal Regulations:
(CFR) Part 411.15., subpart A addresses general exclusions and exclusion of particular services.
CMS Publications:
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:
290 Foot care services which are exceptions to the Medicare coverage exclusion.
CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Part 1:
70.2.1 Services provided for diagnosis and treatment of diabetic peripheral neuropathy.
CMS Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5:
National Correct Coding Initiative.
Article Guidance
Article Text This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Routine Foot Care and Debridement of Nails. National Coverage Provisions: The following services are considered to be components of routine foot care, regardless of the provider rendering the service: The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body. Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections. Exceptions to Routine Foot Care Exclusions Presence of Systemic Condition The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease requiring scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from coverage). Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet. Documentation of the class findings below supports these conditions: Class Findings Class A findings Non-traumatic amputation of foot or integral skeletal portion thereof. Class B findings Absent posterior tibial pulse; Advanced trophic changes such as (three required): Absent dorsalis pedis pulse. Class C findings Claudication; Temperature changes (e.g., cold feet); Edema; Paresthesias (abnormal spontaneous sensations in the feet); and Burning. The presumption of coverage may be applied when the physician rendering the routine foot care has identified: Mycotic Nails Treatment of mycotic nails or onychogryphosis, or onychauxis (codes 11719, 11720, 11721 and G0127 may be covered under the exceptions to the routine foot care exclusion when one of the situations below is present: Clinical evidence of mycosis of the toenail, and Marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate. Clinical evidence of mycosis of the toenail, and the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate. Loss of Protective Sensation (LOPS): For coverage information on Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (LOPS), and its relation to coverage of Routine Foot Care Services, refer to Medicare National Coverage Determinations (NCD) Manual, Section 70.2.1. According to this National Coverage Determination, Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim. LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically. Heavily callused areas should be avoided. As suggested by the American Podiatric Medicine Association, an absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation. The examination includes: A patient history, and A physical examination that must consist of at least the following elements: Visual inspection of forefoot and hindfoot (including toe web spaces); Evaluation of protective sensation; Evaluation of foot structure and biomechanics; Evaluation of vascular status and skin integrity; Evaluation of the need for special footwear; and Patient education. Coding Information: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported. In addition, the beneficiary may have complicated diagnosis(es) that require them to be under the care of a primary physician for the disease that is causing the beneficiary to seek provider based routine foot care. For the asterisked conditions below, the name of the primary physician (must be a D.O. or M.D.) who made the diagnosis, and the approximate date of the last visit should be included in the record and entered on the appropriate claim forms or electronic equivalent when billing Medicare per the Benefit Policy Manual noted above. Please refer to the CMS website for instructions for billing Part A and Part B claims. Specific Coding Guidelines: Global surgery rules will apply to routine foot care procedure codes 11055, 11056, 11057, 11719, 11720, 11721, and G0127. As a result, an E&M service billed on the same day as a routine foot care service is not eligible for reimbursement unless the E&M service is a significant separately identifiable service, indicated by the use of modifier 25, and documented by medical records. Documentation Requirements: The patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation supporting the medical necessity, such as physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement must be maintained in the patient record. The clinical documentation must clearly show that the patient’s condition warrants a provider rendering these services in accordance with the above instruction, and failure to provide such professional services would be hazardous to the beneficiary due to their underlying medical condition(s). The billed diagnoses should be supported with clinical findings. Failure to properly document the reasoning for the care rendered may result in denial of the claim. There should be documentation of co-existing systemic illness. The physical examination and findings must be precise and specific, with documentation of the location, appearance, characteristics and symptoms of the nails and/or lesion(s). The procedure note must describe what, how and where the procedures were performed and correlate these treatments to the lesions documented on the physical examination. The procedure note may reference the physical examination when describing the treatment(s) given during the procedure(e.g., left great toe, or right foot, 4th digit.) There must be adequate medical documentation to demonstrate the need for routine foot care services as outlined in this determination. This documentation may be office records, physician notes or diagnoses characterizing the patient’s physical status as being of such severity to meet the criteria for exceptions to the Medicare routine foot care exclusion. Routine identification of fungi in the toenail either by culture or similarly by either nucleic acid probes or amplified probe technique only is medically indicated only when necessary to differentiate fungal disease from psoriatic nail, or when definitive treatment for prolonged oral antifungal therapy has been planned and there must be adequate documentation in the file. If cultures or nucleic acid probes or amplified probe techniques are performed and billed, documentation of cultures or nucleic acid probes or amplified probe techniques and the need for prolonged oral antifungal therapy must be in the patient record and available to Medicare upon request. Utilization Guidelines: Routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be considered not medically necessary. Services for debridement of more than five nails in a single day may be subject to special review. Coding Information/Limitations