L28986-LCD

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Local Coverage Determination (LCD) for Strapping (L28986)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number

09101

Contractor Type

MAC - Part A

LCD Information

Document Information

LCD ID Number L28986

LCD Title Strapping

Contractor's Determination Number A29540

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

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.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

CMS Manual System, Pub. 100-03, Chapter 1, Part 4, Section 270.4

Indications and Limitations of Coverage and/or Medical Necessity Strapping (Procedure codes 29540 and 29550)

Strapping of the ankle, foot and/or toe(s) consists of the application of nonmedicated, adhesive gauze dressings, applied by overlapping wraps of gauze to exert pressure and hold a structure in place for the purpose of providing structural support, immobilization or compression for the ankle, foot and/or toe(s).

Medicare will consider Strapping of the ankle, foot and/or toe(s) medically reasonable and necessary for the following symptomatic conditions:

• Strains, sprains, dislocations, tendinitis and certain fractures not accompanied by ulceration. Unna boot (Procedure code 29580)

Unna boot is a paste bandage which consists of gauze that has been impregnated with zinc oxide, gelatin, glycerin, and sometimes calamine. The bandage is applied to the leg from the toe to the knee by overlapping wraps of impregnated gauze. The Unna boot forms a semirigid soft cast which should be left in place for 4 to 7 days. The Unna boot bandage restricts the volume of the leg, controls edema, and encourages more normal prograde venous blood flow with reduction in the subcutaneous blood pressure. The net effect is improved healing of venous stasis ulcers of the lower extremities.

Medicare will consider the use of the Unna boot bandage medically reasonable and necessary for the following indications:

- To treat venous vascular insufficiency;

- For the treatment of ulcers with and without inflammation of the lower extremities which are caused by increased venous pressure, venous insufficiency or capillary dysfunction; and

- For the management of sprains, strains, dislocations and minor fractures.

Unna boot application is not indicated for use with ulcers resulting from arterial disease or diabetes.

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

021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

074x Clinic - Outpatient Rehabilitation Facility (ORF)

075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital

Revenue 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.

042X Physical Therapy - General Classification 043X Occupational Therapy - General Classification 0510 Clinic - General Classification

0761 Specialty Services - Treatment Room

CPT/HCPCS Codes

29540 STRAPPING; ANKLE AND/OR FOOT

29550 STRAPPING; TOES

29580 STRAPPING; UNNA BOOT

ICD-9 Codes that Support Medical Necessity

For CPT codes 29540 and 29550, the following diagnoses are considered medically reasonable and necessary:

718.37 RECURRENT DISLOCATION OF ANKLE AND FOOT JOINT

718.87 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING ANKLE AND FOOT

719.27 VILLONODULAR SYNOVITIS INVOLVING ANKLE AND FOOT

726.70 - 726.79 opens in new window

ENTHESOPATHY OF ANKLE AND TARSUS UNSPECIFIED - OTHER ENTHESOPATHY OF ANKLE AND TARSUS

727.06 TENOSYNOVITIS OF FOOT AND ANKLE

728.71 PLANTAR FASCIAL FIBROMATOSIS

733.93 STRESS FRACTURE OF TIBIA OR FIBULA

733.94 STRESS FRACTURE OF THE METATARSALS

733.95 STRESS FRACTURE OF OTHER BONE

735.1 HALLUX VALGUS (ACQUIRED)

735.2 HALLUX VARUS (ACQUIRED)

735.3 HALLUX MALLEUS

735.4 OTHER HAMMER TOE (ACQUIRED)

735.5 CLAW TOE (ACQUIRED)

735.8 OTHER ACQUIRED DEFORMITIES OF TOE

736.70 UNSPECIFIED DEFORMITY OF ANKLE AND FOOT ACQUIRED

736.79 OTHER ACQUIRED DEFORMITIES OF ANKLE AND FOOT

824.0 FRACTURE OF MEDIAL MALLEOLUS CLOSED

824.2 FRACTURE OF LATERAL MALLEOLUS CLOSED

825.0 FRACTURE OF CALCANEUS CLOSED

825.20 - 825.29 opens in new window

FRACTURE OF UNSPECIFIED BONE(S) OF FOOT (EXCEPT TOES) CLOSED - OTHER FRACTURE OF TARSAL AND METATARSAL BONES CLOSED

826.0 CLOSED FRACTURE OF ONE OR MORE PHALANGES OF FOOT

837.0 CLOSED DISLOCATION OF ANKLE

838.00 - 838.09 opens in new window

845.00 - 845.19 opens in

CLOSED DISLOCATION OF FOOT UNSPECIFIED PART - CLOSED DISLOCATION OF OTHER PART OF FOOT

new window UNSPECIFIED SITE OF ANKLE SPRAIN - OTHER FOOT SPRAIN

924.20 - 924.21 opens in

new window CONTUSION OF FOOT - CONTUSION OF ANKLE

924.3 CONTUSION OF TOE

959.7 OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT For CPT code 29580, the following diagnoses are considered medically reasonable and necessary:

451.0 PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES

451.11 - 451.19 opens in new window

PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) - PHLEBITIS AND THROMBOPHLEBITIS OF OTHER

451.2 PHLEBITIS AND THROMBOPHLEBITIS OF LOWER EXTREMITIES UNSPECIFIED

454.1 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER

454.2 VARICOSE VEINS OF LOWER EXTREMITIES WITH INFLAMMATION

454.3 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION

454.8 VARICOSE VEINS OF LOWER EXTREMITIES WITH OTHER COMPLICATIONS

459.81 VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED 707.10 - 707.19 opens in

new window UNSPECIFIED ULCER OF LOWER LIMB - ULCER OF OTHER PART OF LOWER LIMB

733.93 STRESS FRACTURE OF TIBIA OR FIBULA

733.94 STRESS FRACTURE OF THE METATARSALS

733.95 STRESS FRACTURE OF OTHER BONE

824.0 - 824.9 opens in new FRACTURE OF MEDIAL MALLEOLUS CLOSED - UNSPECIFIED FRACTURE OF ANKLE

OPEN

825.0 FRACTURE OF CALCANEUS CLOSED

825.20 - 825.29 opens in new window

FRACTURE OF UNSPECIFIED BONE(S) OF FOOT (EXCEPT TOES) CLOSED - OTHER FRACTURE OF TARSAL AND METATARSAL BONES CLOSED

826.0 CLOSED FRACTURE OF ONE OR MORE PHALANGES OF FOOT

837.0 - 837.1 opens in new

window CLOSED DISLOCATION OF ANKLE - OPEN DISLOCATION OF ANKLE

838.00 - 838.19 opens in new window

845.00 - 845.19 opens in

CLOSED DISLOCATION OF FOOT UNSPECIFIED PART - OPEN DISLOCATION OF OTHER PART OF FOOT

new window UNSPECIFIED SITE OF ANKLE SPRAIN - OTHER FOOT SPRAIN

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.

Documentation should support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

Appendices

Utilization Guidelines Strapping (Procedure codes 29540 and 29550)

It is not generally expected that strapping of the ankle, foot and/or toe(s) would be done more often than weekly. However, there are circumstances that warrant application of straps several times per week, such as, whirlpool treatments which require removal and reapplication of the straps.

Hydrotherapy (whirlpool) treatment for decubitus ulcers is a covered service under Medicare for patients when treatment is reasonable and necessary. Some other methods of treating decubitus ulcers, the safety and effectiveness of which have not been established, are not covered under the Medicare program. Some examples of these types of treatments are: ultraviolet light, low intensity direct current, topical application of oxygen, and topical dressings with Balsam of Peru in castor oil.

Unna boot (Procedure code 29580)

It is not expected that Unna boot application would be done more often than once or twice per seven days.

Sources of Information and Basis for Decision

American College of Foot and Ankle Surgeons. (2004). ACFAS Clinical Practice Guidelines [On-line]. Available: www.acfas.org

Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery. (2003). Heel spur syndrome. {On-line]. Available: http://www.guideline.gov/summary/summary.aspx?doc_id=4245

Sadovsky, R. (2003). Managing lower extremity venous ulcers. American Family Physician. [On-line]. Available: www.aafp.org/afp/20030815/tips/12.html

Schroeder, B. (2002). American College of Foot and Ankle Surgeons: Diagnosis and Treatment of Heel Pain. [Electronic version]. American Family Physician, April 15, 2002

Wolfe, M.W., Uhl, T.L., Mattacola, C.G., and McCluskey, L. (2001). Management of ankle sprains. American Family Physician. [On-line]. Available: www.aafp.org/afp/20010101/93.html

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with the advisory groups, which includes representatives from numerous socieites.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28986) replaces LCD L1470 as the policy in notice. This document (L28986) is effective on 02/16/2009.

Added language from the National Coverage Decision 270.4 related to whirlpool therapy for decubitus ulcers.

8/10/2009 - The description for Revenue code 0761 was changed

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 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 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 - The description for Revenue code 0420 was changed 8/1/2010 - The description for Revenue code 0421 was changed 8/1/2010 - The description for Revenue code 0422 was changed 8/1/2010 - The description for Revenue code 0423 was changed 8/1/2010 - The description for Revenue code 0424 was changed 8/1/2010 - The description for Revenue code 0429 was changed 8/1/2010 - The description for Revenue code 0430 was changed 8/1/2010 - The description for Revenue code 0431 was changed 8/1/2010 - The description for Revenue code 0432 was changed 8/1/2010 - The description for Revenue code 0433 was changed 8/1/2010 - The description for Revenue code 0434 was changed 8/1/2010 - The description for Revenue code 0439 was changed

8/1/2010 - The description for Revenue code 0510 was changed 8/1/2010 - The description for Revenue code 0761 was changed

Reason for Change