Routine Foot Care (L30322)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30322 LCD Title Routine Foot Care Contractor's Determination Number FT-001 AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 08/16/2009 Original Determination Ending Date Revision Effective Date For services performed on or after 05/01/2012 Revision Ending Date |
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 100-2, Medicare Benefit Policy Manual, (MBPM) Chapter 15:
290 Foot care services which are exceptions to the Medicare coverage exclusion.
CMS Publication 100-3, Medicare National Coverage Determination Manual, Part 1:
70.2.1 Services provided for diagnosis and treatment of diabetic peripheral neuropathy.
CMS Publication 100-9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5: National Correct Coding Initiative.
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 100-2, Medicare Benefit Policy Manual, (MBPM) Chapter 15:
290 Foot care services which are exceptions to the Medicare coverage exclusion.
CMS Publication 100-3, Medicare National Coverage Determination Manual, Part 1:
70.2.1 Services provided for diagnosis and treatment of diabetic peripheral neuropathy.
CMS Publication 100-9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5: National Correct Coding Initiative.
Indications and Limitations of Coverage and/or Medical Necessity
Routine
foot care is the paring, cutting, or trimming of corns and calluses, or
debridement and trimming of toenails in the absence of localized
illness, injury or symptoms involving the foot. Routine foot care is
usually performed by the beneficiary himself or herself, or by a
caregiver.
Medicare allows payment for routine foot care only if the conditions under "Indications and Limitations of Coverage" are met. These conditions describe the systemic diseases and their peripheral complications that increase the danger for infection and injury if a non-professional provides these services.
NOTE
Normally claims submitted with CPT codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127 must have modifier Q7, Q8, or Q9 and an ICD-9 code listed in this policy. However, if a beneficiary has peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class findings of such severity that care by a non-professional person would put the patient at risk the service would also be covered.
The following services are considered to be components of routine foot care and are generally excluded from coverage under both Part A and Part B, regardless of the provider rendering the service:
Indications:
While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits.
1. Covered Routine Foot Care CPT codes 11055, 11056, 11057, 11719, and G0127, and 11720 - 11721.
Medicare payment may be made for routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient's legs or feet).
Services normally considered routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.
In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement.
Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. Payment may be made for the debridement of a mycotic nail (whether by manual method or electrical grinder) when definitive antifungal treatment options have been reviewed and discussed with the patient at the initial visit and the physician attending the mycotic condition documents that the following criteria are met:
NAIL DEBRIDEMENT DEFINITION: Nail debridement involves the removal of excessive nail material (i.e., the reduction of nail thickness or bulk) from clinically thickened, diseased (e.g., mycotic or dystrophic) nail plate, that may or may not also be misshapen in appearance or brittle in characteristic. (This definition has been approved by the American Podiatric Medical Association.)
In the absence of a systemic condition, Medicare covers debridement of the nail when the following criteria are met:
In the case of ambulatory patients there exists:
Clinical evidence of mycosis of the toenail, (110.1) and
Marked limitation of ambulation (719.7 or 781.2), or pain (729.5 or 703.0 Note: Painful ingrown toenail),and/or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate.
In the case of non-ambulatory patients there exists:
Clinical evidence of mycosis of the toenail (ICD-9 code 110.1), and
The patient suffers from pain (729.5 or 703.0 Note: Painful ingrown toenail) or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate.
In the case of non-ambulatory patients there exists clinical evidence of mycosis of the toenail (ICD-9 code 110.1), and the patient suffers from pain (729.5 or 703.0) or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate.
In addition, procedures for treating toe nails are covered for the following:
Onychogryphosis(703.8) (defined as long standing thickening, in which typically a curved hooked nail (ram's horn nail) occurs), and there is marked limitation of ambulation (719.7 or 781.2), pain (729.5 or 703.0 Note: Painful ingrown toenail), and/or secondary infection (681.10 or 681.11) where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe, and/or
In addition, procedures for treating toe nails are covered for the following:
Onychogryphosis(703.8) (defied as long standing thickening, in which typically a curved hooked nail (ram's horn nail) occurs), and there is marked limitation of ambulation (719.7 or 781.2), pain (729.5 or 703.0), and/or secondary infection (681.10 or 681.11) where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe, and/or
Onychauxis (703.8) (defined as thickening (hypertrophy) of the base of the nail/nail bed) and there is marked limitation of ambulation (719.7, 781.2, pain (729.5 or 703.0 Note: Painful ingrown toenail), and /or secondary infection (681.10, 681.11) that causes symptoms.
Onychauxis (703.8) (defined as thickening (hypertrophy) of the base of the nail/nail bed) and there is marked limitation of ambulation (719.7, 781.2, pain (729.5 or 703.0), and /or secondary infection (681.10, 681.11) that causes symptoms.
The following physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the patient record, in order for routine foot care services to be reimbursable
Class A findings
Non-traumatic amputation of foot or integral skeletal portion thereof
Class B Findings
Absent posterior tibial pulse;
Advanced trophic changes as: hair growth (decrease or absence) nail changes (thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin color (rubor or redness) (Three required); and
Absent dorsalis pedis pulse
Class C findings
Claudication
Temperature changes (e.g., cold feet)
Edema
Paresthesias (abnormal spontaneous sensations in the feet)
Burning
The presumption of coverage may be applied when the physician rendering the routine foot care has identified:
1. A Class A finding (Modifier Q7)
2. Two of the Class B findings (Modifier Q8); or
3. One Class B and two Class C findings (Modifier Q9).
Note: Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class findings. The neuropathy should be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the ICD-9 CM codes in list three of "ICD-9 Codes that Support Medical Necessity" listed below
Medicare allows payment for routine foot care only if the conditions under "Indications and Limitations of Coverage" are met. These conditions describe the systemic diseases and their peripheral complications that increase the danger for infection and injury if a non-professional provides these services.
NOTE
Normally claims submitted with CPT codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127 must have modifier Q7, Q8, or Q9 and an ICD-9 code listed in this policy. However, if a beneficiary has peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class findings of such severity that care by a non-professional person would put the patient at risk the service would also be covered.
The following services are considered to be components of routine foot care and are generally excluded from coverage under both Part A and Part B, regardless of the provider rendering the service:
- Cutting or removal of corns and calluses;
- Clipping, trimming, or debridement of nails,
- Shaving, paring, cutting or removal of keratoma, tyloma, and heloma;
- Non-definitive simple, palliative treatments like shaving or paring of plantar warts which do not require thermal or chemical cautery and curettage;
- Other hygienic and preventive maintenance care in the realm of self care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients;
- Any services performed in the absence of localized illness, injury, or symptoms involving the foot.
Indications:
While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits.
1. Covered Routine Foot Care CPT codes 11055, 11056, 11057, 11719, and G0127, and 11720 - 11721.
Medicare payment may be made for routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient's legs or feet).
Services normally considered routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.
In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement.
Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. Payment may be made for the debridement of a mycotic nail (whether by manual method or electrical grinder) when definitive antifungal treatment options have been reviewed and discussed with the patient at the initial visit and the physician attending the mycotic condition documents that the following criteria are met:
NAIL DEBRIDEMENT DEFINITION: Nail debridement involves the removal of excessive nail material (i.e., the reduction of nail thickness or bulk) from clinically thickened, diseased (e.g., mycotic or dystrophic) nail plate, that may or may not also be misshapen in appearance or brittle in characteristic. (This definition has been approved by the American Podiatric Medical Association.)
In the absence of a systemic condition, Medicare covers debridement of the nail when the following criteria are met:
In the case of ambulatory patients there exists:
Clinical evidence of mycosis of the toenail, (110.1) and
Marked limitation of ambulation (719.7 or 781.2), or pain (729.5 or 703.0 Note: Painful ingrown toenail),and/or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate.
In the case of non-ambulatory patients there exists:
Clinical evidence of mycosis of the toenail (ICD-9 code 110.1), and
The patient suffers from pain (729.5 or 703.0 Note: Painful ingrown toenail) or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate.
In the case of non-ambulatory patients there exists clinical evidence of mycosis of the toenail (ICD-9 code 110.1), and the patient suffers from pain (729.5 or 703.0) or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate.
In addition, procedures for treating toe nails are covered for the following:
Onychogryphosis(703.8) (defined as long standing thickening, in which typically a curved hooked nail (ram's horn nail) occurs), and there is marked limitation of ambulation (719.7 or 781.2), pain (729.5 or 703.0 Note: Painful ingrown toenail), and/or secondary infection (681.10 or 681.11) where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe, and/or
In addition, procedures for treating toe nails are covered for the following:
Onychogryphosis(703.8) (defied as long standing thickening, in which typically a curved hooked nail (ram's horn nail) occurs), and there is marked limitation of ambulation (719.7 or 781.2), pain (729.5 or 703.0), and/or secondary infection (681.10 or 681.11) where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe, and/or
Onychauxis (703.8) (defined as thickening (hypertrophy) of the base of the nail/nail bed) and there is marked limitation of ambulation (719.7, 781.2, pain (729.5 or 703.0 Note: Painful ingrown toenail), and /or secondary infection (681.10, 681.11) that causes symptoms.
Onychauxis (703.8) (defined as thickening (hypertrophy) of the base of the nail/nail bed) and there is marked limitation of ambulation (719.7, 781.2, pain (729.5 or 703.0), and /or secondary infection (681.10, 681.11) that causes symptoms.
The following physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the patient record, in order for routine foot care services to be reimbursable
Class A findings
Non-traumatic amputation of foot or integral skeletal portion thereof
Class B Findings
Absent posterior tibial pulse;
Advanced trophic changes as: hair growth (decrease or absence) nail changes (thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin color (rubor or redness) (Three required); and
Absent dorsalis pedis pulse
Class C findings
Claudication
Temperature changes (e.g., cold feet)
Edema
Paresthesias (abnormal spontaneous sensations in the feet)
Burning
The presumption of coverage may be applied when the physician rendering the routine foot care has identified:
1. A Class A finding (Modifier Q7)
2. Two of the Class B findings (Modifier Q8); or
3. One Class B and two Class C findings (Modifier Q9).
Note: Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class findings. The neuropathy should be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the ICD-9 CM codes in list three of "ICD-9 Codes that Support Medical Necessity" listed below
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 022x | Skilled Nursing - Inpatient (Medicare Part B only) |
| 074x | Clinic - Outpatient Rehabilitation Facility (ORF) |
| 075x | Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) |
| 085x | Critical Access Hospital |
Revenue Codes:
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
| 051X | Clinic - General Classification |
| 0940 | Other Therapeutic Services - General Classification |
| 11055 | PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION |
| 11056 | PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS |
| 11057 | PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS |
| 11719 | TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER |
| 11720 | DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 |
| 11721 | DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE |
| G0127 | TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER |
ICD-9 Codes that Support Medical Necessity
LIST ONE:
For covered routine foot care that requires date last seen by physician:
CPT codes: G0127, 11055, 11056, 11057, 11719 and 11720-11721 billed with the appropriate Q modifier and date last seen by a doctor of medicine or osteopathy (MD or DO) for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service or if the patient sees their primary care physician no later than 30 days after the services were furnished.
| 249.00 - 249.91 | SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED - SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION, UNCONTROLLED |
| 250.00 - 250.13 | DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 250.20 - 250.23 | DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 250.40 - 250.43 | DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 250.70 - 250.73 | DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 250.80 - 250.83 | DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 250.90 - 250.93 | DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 446.7 | TAKAYASU'S DISEASE |
| 453.9 | EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE |
| 585.5 - 585.6 | CHRONIC KIDNEY DISEASE, STAGE V - END STAGE RENAL DISEASE |
| 795.39 | OTHER NONSPECIFIC POSITIVE CULTURE FINDINGS |
| V58.61 | LONG-TERM (CURRENT) USE OF ANTICOAGULANTS |
The following HCPCS codes do not require the date last seen by the physician on the claim when one of list of ICD-9 codes on list two is used.
CPT codes: G0127, 11055, 11056, 11057, 11719 and 11720-11721 billed with the appropriate Q modifier and the following ICD-9 codes
For CPT codes: 11720, 11721
ICD-9 CM code 110.1 or 703.8 must be reported as primary condition and the appropriate Q modifier showing that a coverage criterion has been met.
| 039.4 | MADURA FOOT |
| 040.0 | GAS GANGRENE |
| 066.41 - 066.49 | WEST NILE FEVER WITH ENCEPHALITIS - WEST NILE FEVER WITH OTHER COMPLICATIONS |
| 110.1 | DERMATOPHYTOSIS OF NAIL |
| 272.7 | LIPIDOSES |
| 277.30 | AMYLOIDOSIS, UNSPECIFIED |
| 277.31 | FAMILIAL MEDITERRANEAN FEVER |
| 277.39 | OTHER AMYLOIDOSIS |
| 289.89 | OTHER SPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING ORGANS |
| 331.0 | ALZHEIMER'S DISEASE |
| 332.0 | PARALYSIS AGITANS |
| 333.2 | MYOCLONUS |
| 333.4 | HUNTINGTON'S CHOREA |
| 335.10 | SPINAL MUSCULAR ATROPHY UNSPECIFIED |
| 335.20 | AMYOTROPHIC LATERAL SCLEROSIS |
| 335.21 | PROGRESSIVE MUSCULAR ATROPHY |
| 440.0 - 440.9 | ATHEROSCLEROSIS OF AORTA - GENERALIZED AND UNSPECIFIED ATHEROSCLEROSIS |
| 442.3 | ANEURYSM OF ARTERY OF LOWER EXTREMITY |
| 443.0 | RAYNAUD'S SYNDROME |
| 443.1 | THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) |
| 443.81 - 443.9 | PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE - PERIPHERAL VASCULAR DISEASE UNSPECIFIED |
| 444.22 | ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY |
| 444.81 | EMBOLISM AND THROMBOSIS OF ILIAC ARTERY |
| 444.89 | EMBOLISM AND THROMBOSIS OF OTHER ARTERY |
| 446.0 | POLYARTERITIS NODOSA |
| 447.8 | OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES |
| 447.9 | UNSPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES |
| 451.0 - 451.9 | PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES - PHLEBITIS AND THROMBOPHLEBITIS OF UNSPECIFIED SITE |
| 454.0 - 454.9 | VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER - ASYMPTOMATIC VARICOSE VEINS |
| 459.10 - 459.19 | POSTPHLEBETIC SYNDROME WITHOUT COMPLICATIONS - POSTPHLEBETIC SYNDROME WITH OTHER COMPLICATION |
| 459.81 - 459.9 | VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED - UNSPECIFIED CIRCULATORY SYSTEM DISORDER |
| 579.0 | CELIAC DISEASE |
| 579.1 | TROPICAL SPRUE |
| 700 | CORNS AND CALLOSITIES |
| 703.8 | OTHER SPECIFIED DISEASES OF NAIL |
| 706.2 | SEBACEOUS CYST |
| 707.06 | PRESSURE ULCER, ANKLE |
| 707.07 | PRESSURE ULCER, HEEL |
| 707.14 | ULCER OF HEEL AND MIDFOOT |
| 707.15 | ULCER OF OTHER PART OF FOOT |
| 707.9 | CHRONIC ULCER OF UNSPECIFIED SITE |
| 729.5 | PAIN IN LIMB |
| 785.4 | GANGRENE |
| 893.0 - 893.2 | OPEN WOUND OF TOE(S) WITHOUT COMPLICATION - OPEN WOUND OF TOE(S) WITH TENDON INVOLVEMENT |
| 917.0 - 917.9 | ABRASION OR FRICTION BURN OF FOOT AND TOE(S) WITHOUT INFECTION - OTHER AND UNSPECIFIED SUPERFICIAL INJURY OF FOOT AND TOES INFECTED |
| 924.3 | CONTUSION OF TOE |
| 928.3 | CRUSHING INJURY OF TOE(S) |
| 945.12 | ERYTHEMA DUE TO BURN (FIRST DEGREE) OF FOOT |
| 945.21 | BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF TOE(S) (NAIL) |
| 945.22 | BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FOOT |
| 945.31 | FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF TOE(S) (NAIL) |
| 945.32 | FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOOT |
| 945.41 | DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TOE(S) (NAIL) WITHOUT LOSS OF TOE(S) |
| 945.42 | DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOOT WITHOUT LOSS OF FOOT |
| 945.51 | DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TOE(S) (NAIL) WITH LOSS OF TOE(S) |
| 945.52 | DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOOT WITH LOSS OF FOOT |
| 956.0 - 956.9 | INJURY TO SCIATIC NERVE - INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB |
| 959.7 | OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT |
| 976.0 | POISONING BY LOCAL ANTI-INFECTIVES AND ANTI-INFLAMMATORY DRUGS |
| 976.2 | POISONING BY LOCAL ASTRINGENTS AND LOCAL DETERGENTS |
| 976.3 | POISONING BY EMOLLIENTS DEMULCENTS AND PROTECTANTS |
| 991.1 | FROSTBITE OF HAND |
| 991.2 | FROSTBITE OF FOOT |
| V07.39 | NEED FOR OTHER PROPHYLACTIC CHEMOTHERAPY |
| V12.3 | PERSONAL HISTORY OF DISEASES OF BLOOD AND BLOOD-FORMING ORGANS |
| V49.3 | SENSORY PROBLEMS WITH LIMBS |
| V49.70 - V49.77 | UNSPECIFIED LEVEL LOWER LIMB AMPUTATION STATUS - HIP AMPUTATION STATUS |
| 681.10 | UNSPECIFIED CELLULITIS AND ABSCESS OF TOE |
| 681.11 | ONYCHIA AND PARONYCHIA OF TOE |
| 703.0 | INGROWING NAIL |
| 719.7 | DIFFICULTY IN WALKING |
| 729.5 | PAIN IN LIMB |
| 781.2 | ABNORMALITY OF GAIT |
The ICD-9 codes below represent those diagnoses where the patient has evidence of neuropathy, but no vascular impairment, for which class findings modifiers are not required.
For these diagnoses, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service.
Note: only MI/MN providers may bill the ICD-9 codes listed for services to the hand.
| 030.0 | LEPROMATOUS LEPROSY (TYPE L) |
| 030.1 | TUBERCULOID LEPROSY (TYPE T) |
| 030.3 | BORDERLINE LEPROSY (GROUP B) |
| 030.8 | OTHER SPECIFIED LEPROSY |
| 030.9 | LEPROSY UNSPECIFIED |
| 042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
| 045.10 - 045.13 | ACUTE POLIOMYELITIS WITH OTHER PARALYSIS UNSPECIFIED TYPE OF POLIOVIRUS - ACUTE POLIOMYELITIS WITH OTHER PARALYSIS POLIOVIRUS TYPE III |
| 053.13 | POSTHERPETIC POLYNEUROPATHY |
| 088.81 | LYME DISEASE |
| 094.0 | TABES DORSALIS |
| 094.1 | GENERAL PARESIS |
| 094.2 | SYPHILITIC MENINGITIS |
| 094.81 | SYPHILITIC ENCEPHALITIS |
| 094.82 | SYPHILITIC PARKINSONISM |
| 094.9 | NEUROSYPHILIS UNSPECIFIED |
| 250.60* | DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED |
| 250.61* | DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED |
| 250.62* | DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED |
| 250.63* | DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 265.2* | PELLAGRA |
| 281.0 | PERNICIOUS ANEMIA |
| 323.9 | UNSPECIFIED CAUSES OF ENCEPHALITIS, MYELITIS, AND ENCEPHALOMYELITIS |
| 334.0 - 334.2 | FRIEDREICH'S ATAXIA - PRIMARY CEREBELLAR DEGENERATION |
| 336.0 - 336.2 | SYRINGOMYELIA AND SYRINGOBULBIA - SUBACUTE COMBINED DEGENERATION OF SPINAL CORD IN DISEASES CLASSIFIED ELSEWHERE |
| 336.9 | UNSPECIFIED DISEASE OF SPINAL CORD |
| 337.1 | PERIPHERAL AUTONOMIC NEUROPATHY IN DISORDERS CLASSIFIED ELSEWHERE |
| 340* | MULTIPLE SCLEROSIS |
| 341.8 | OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM |
| 342.00 - 342.92 | FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE |
| 343.0 - 343.9 | CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED |
| 344.00 - 344.1 | QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA |
| 344.30 - 344.9 | MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - PARALYSIS UNSPECIFIED |
| 353.4 | LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED |
| 353.8 | OTHER NERVE ROOT AND PLEXUS DISORDERS |
| 355.0 - 355.5 | LESION OF SCIATIC NERVE - TARSAL TUNNEL SYNDROME |
| 356.0 - 356.9 | HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY |
| 357.0* | ACUTE INFECTIVE POLYNEURITIS |
| 357.1 | POLYNEUROPATHY IN COLLAGEN VASCULAR DISEASE |
| 357.2* | POLYNEUROPATHY IN DIABETES |
| 357.3* | POLYNEUROPATHY IN MALIGNANT DISEASE |
| 357.4 | POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE |
| 357.5* | ALCOHOLIC POLYNEUROPATHY |
| 357.6* | POLYNEUROPATHY DUE TO DRUGS |
| 357.7* | POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS |
| 357.81 | CHRONIC INFLAMMATORY DEMYELINATING POLYNEURITIS |
| 357.82 | CRITICAL ILLNESS POLYNEUROPATHY |
| 357.89 | OTHER INFLAMMATORY AND TOXIC NEUROPATHY |
| 357.9 | UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES |
| 358.1 | MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE |
| 358.2 | TOXIC MYONEURAL DISORDERS |
| 436 | ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE |
| 438.20 - 438.22 | HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE |
| 438.40 - 438.42 | MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE |
| 438.50 - 438.52 | OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE - OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE |
| 782.0* | DISTURBANCE OF SKIN SENSATION |
| * For these diagnoses, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service. | |
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
The following class finding modifiers should be used with G0127, 11055, 11056, 11057, 11719, 11720, 11721, when applicable:
1. A Class A finding (Modifier Q7)
2. Two of the Class B findings (Modifier Q8); or
3. One Class B and two Class C findings (Modifier Q9).
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this 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.
Physical findings and services must be precise and specific (e.g., left great toe, or right foot, 4 th digit.) Documentation of co-existing systemic illness should be maintained.
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.
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to Medicare upon request.
1. A Class A finding (Modifier Q7)
2. Two of the Class B findings (Modifier Q8); or
3. One Class B and two Class C findings (Modifier Q9).
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this 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.
Physical findings and services must be precise and specific (e.g., left great toe, or right foot, 4 th digit.) Documentation of co-existing systemic illness should be maintained.
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.
Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to Medicare upon request.
Appendices
Utilization Guidelines
Routine foot care
services are considered medically necessary once (1) in 60 days. More
frequent services will be considered not medically necessary.
* - an asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or the contractor medical director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the carrier advisory committee(s), which includes representatives of various medical specialty societies.
This LCD replaces all previous foot care LCDs including FT-001, FT-501 and FT-501
See routine foot care and debridement of nails: billing/coding guidelines.
* - an asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or the contractor medical director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the carrier advisory committee(s), which includes representatives of various medical specialty societies.
This LCD replaces all previous foot care LCDs including FT-001, FT-501 and FT-501
See routine foot care and debridement of nails: billing/coding guidelines.
Sources of Information and Basis for Decision
Advisory Committee Meeting Notes
Meeting date:
Wisconsin: 01/16/2009
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2008
J-5 MAC (IA,KS,MO, NE) 02/12/2009
Open Meeting Date
12/17/2008
Wisconsin: 01/16/2009
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2008
J-5 MAC (IA,KS,MO, NE) 02/12/2009
Open Meeting Date
12/17/2008
Start Date of Comment Period
02/12/2009
End Date of Comment Period
03/30/2009
Start Date of Notice Period
01/01/2010
Revision History Number
X
Revision History Explanation
*01/01/2010, Removed
statement, per MBPM, Chapter 15, 290 - "or qualified non-physician
practitioner",
*12/01/2009, Removed all information except that which is directly related to routine foot care, added third list of ICD-9 codes where the patient has evidence of neuropathy, but no vascular impairment for which class finding modifies are not required; 07/01/2009, one, this LCD merges all other LCDs regarding Food Care including FT-001, FT-501 and FT-502 - Symptomatic, Pathological Nail and Its Treatment
11/24/2009 added updated version of the coding and billing guidelines. The change was UPIN to NPI. The current version of coding and billing is now Coding and Billing Guidelines 01/01/10 Version 2.
04/19/2010€”In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 22 was changed
8/1/2010 - The description for Bill Type Code 74 was changed
8/1/2010 - The description for Bill Type Code 75 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - Bill Type Code 51 was deleted
8/1/2010 - Bill Type Code 94 was deleted
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
11056 descriptor was changed in Group 1
11057 descriptor was changed in Group 1
11720 descriptor was changed in Group 1
11721 descriptor was changed in Group 1
02/21/2011 €” In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
02/01/2011, LCD reviewed, no updates
03/01/2011, corrected typo hair growth (decrease or increase) changed to hair growth (decrease or absence);
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
10/01/2011, 2012 ICD-9 update
11/01/2011, seven, removed ICD-9 codes V12.50-V12.59 typo inappropriate cardiac diagnosis
05/01/2012, eight, annual review, added revenue codes - no impact to claims processing;
*12/01/2009, Removed all information except that which is directly related to routine foot care, added third list of ICD-9 codes where the patient has evidence of neuropathy, but no vascular impairment for which class finding modifies are not required; 07/01/2009, one, this LCD merges all other LCDs regarding Food Care including FT-001, FT-501 and FT-502 - Symptomatic, Pathological Nail and Its Treatment
11/24/2009 added updated version of the coding and billing guidelines. The change was UPIN to NPI. The current version of coding and billing is now Coding and Billing Guidelines 01/01/10 Version 2.
04/19/2010€”In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 22 was changed
8/1/2010 - The description for Bill Type Code 74 was changed
8/1/2010 - The description for Bill Type Code 75 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - Bill Type Code 51 was deleted
8/1/2010 - Bill Type Code 94 was deleted
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
11056 descriptor was changed in Group 1
11057 descriptor was changed in Group 1
11720 descriptor was changed in Group 1
11721 descriptor was changed in Group 1
02/21/2011 €” In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
02/01/2011, LCD reviewed, no updates
03/01/2011, corrected typo hair growth (decrease or increase) changed to hair growth (decrease or absence);
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
10/01/2011, 2012 ICD-9 update
11/01/2011, seven, removed ICD-9 codes V12.50-V12.59 typo inappropriate cardiac diagnosis
05/01/2012, eight, annual review, added revenue codes - no impact to claims processing;
Reason for Change
Maintenance (annual review with new changes, formatting, etc.)
Related Documents
This LCD has no Related Documents.
LCD Attachments
Coding and Billing Guidelines 01/01/10 Version 3 (PDF - 52 KB )
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Page Last Updated: Thursday, 03-May-2012 14:50:44 CDT
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