L29272-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Routine Foot Care (L29272)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29272

LCD Title Routine Foot Care

Contractor's Determination Number 11055

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

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.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 02/02/2009

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the 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 §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: Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 290

Medicare Benefit Policy Manual, Pub. 100-02, Chapter 16, Section 30

Indications and Limitations of Coverage and/or Medical Necessity

Foot care services that normally are considered routine and not covered by Medicare include the following:

• The cutting or removal of corns and calluses;

• The trimming, cutting, clipping, or debriding of nails; and

• Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

In certain circumstances, services ordinarily considered to be 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.

The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a podiatrist or other physician. In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions, and may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet.

In the absence of a systemic condition, treatment/debridement of symptomatic mycotic nails may be covered. Please refer to the local LCD for Nail Debridement (11720).

The following non-comprehensive list of metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might justify coverage for routine foot care.

• Diabetes mellitus*

• Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)

• Buerger’s disease (thromboangiitis obliterans)

• Chronic thrombophlebitis*

• Peripheral neuropathies involving feet

- Associated with malnutrition and vitamin deficiency*

§ Malnutrition (general, pellagra)

§ Alcoholism

§ Malabsorption (celiac disease, tropical sprue)

§ Pernicious anemia

- Associated with carcinoma*

- Associated with diabetes mellitus*

- Associated with drugs and toxins*

- Associated with multiple sclerosis*

- Associated with uremia (chronic renal disease)*

- Associated with traumatic injury

- Associated with leprosy or neurosyphilis

- Associated with hereditary disorders

§ Hereditary sensory radicular neuropathy

§ Angiokeratoma corporis diffusum (Fabry’s)

§ Amyloid neuropathy

See corresponding * ICD-9 codes.

Active Care Requirements for Asterisked Conditions:

When the patient’s condition is one of those listed above designated by an asterisk (*), and a podiatrist renders the service, the following must be met and indicated on the claim form:

• The name of the attending physician (M.D., D.O., or non-physician practitioner [PA or NP]) who is actively treating the patient’s condition, and

• The date the patient was last seen by the M.D., D.O., or non-physician practitioner (PA or NP) who is actively treating the condition (this date must be within six months), or the patient had come under such care shortly after the services were furnished usually as a result of a referral.

Also, for non-asterisked conditions, the name of the M.D., D.O., or non-physician practitioner (PA or NP) who diagnosed the complicating condition must be on the claim form.

Physical/Clinical Class Findings

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. In patients where the presumption of coverage is based on arterial impairment, regardless of the cause, the following class findings are pertinent and must be documented for all underlying conditions.

Class A Findings

Nontraumatic amputation of foot or integral skeletal portion thereof Class B Findings

Absent posterior tibial pulse, or Absent dorsalis pedal pulse, or

Three of the following advanced tropic changes are required to meet one class B finding:

- Hair growth (decrease or absence)

- Pigmentary changes (discoloration)

- Skin color (rubor and redness)

- Nail changes (thickening)

- Skin texture (thin, shiny) Class C Findings

Claudication (pain in calf when walking) Temperature changes in the feet (e.g., cold feet) Edema

Parathesias (abnormal spontaneous sensations in the feet, e.g., tingling) Burning

Presumption of Coverage

A presumption of coverage will be applied by Medicare when the physician rendering the routine foot care has identified:

1. A Class A finding

2. Two of the Class B findings; or

3. One Class B and two Class C findings

Claims submitted for routine foot care should use the appropriate modifiers (Q7, Q8, or Q9) to indicate the findings they have made on the patient’s condition.

• Q7 = One Class A finding

• Q8 = Two Class B findings

• Q9 = One Class B and two Class C findings

Routine foot care may be available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should be of such severity that care by a non- professional person would put the patient at risk. In such circumstances, claims for medically necessary services would be submitted without the Q7, Q8, or Q9 modifiers that indicate class findings. The medical record must document the patient has an absence of sensation at two or more sites out of five tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament to support the diagnosis of peripheral neuropathy with loss of protective sensation. This testing may be performed by the attending physician, non-physician practitioner, or the podiatrist.

Other Indications and Limitations of Coverage and/or Medical Necessity:

Services or devices directed toward the care or correction of flat foot, including the prescription of supportive devices, are not covered.

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.

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.

99999 Not Applicable

CPT/HCPCS Codes

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

030.0 - 030.9 LEPROMATOUS LEPROSY (TYPE L) - LEPROSY UNSPECIFIED

94.1 TABES DORSALIS

94.2 GENERAL PARESIS

094.9 NEUROSYPHILIS UNSPECIFIED

250.40 DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.50 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.60 - 250.63*

250.70 - 250.73*

DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE

I [JUVENILE TYPE], UNCONTROLLED

DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED

263.9* UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

265.0* BERIBERI

265.2* PELLAGRA

266.1 * VITAMIN B6 DEFICIENCY

266.2 * OTHER B-COMPLEX DEFICIENCIES

272.7 LIPIDOSES

277.30 AMYLOIDOSIS, UNSPECIFIED

277.39 OTHER AMYLOIDOSIS

281.0* PERNICIOUS ANEMIA

281.3* OTHER SPECIFIED MEGALOBLASTIC ANEMIAS NOT ELSEWHERE CLASSIFIED

286.9* OTHER AND UNSPECIFIED COAGULATION DEFECTS

334.0 FRIEDREICH'S ATAXIA

340* MULTIPLE SCLEROSIS

356.0 - 356.9

357.0 - 357.7*

HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

ACUTE INFECTIVE POLYNEURITIS - POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS

358.1 * MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE

358.2 * TOXIC MYONEURAL DISORDERS

440.20 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED

440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION

440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN

440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

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440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

443.1 RAYNAUD'S SYNDROME

443.2 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY

446.0 POLYARTERITIS NODOSA

446.7* TAKAYASU'S DISEASE

451.0* PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES

451.11* PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL)

451.19* PHLEBITIS AND THROMBOPHLEBITIS OF OTHER

579.1 * CELIAC DISEASE

579.2 * TROPICAL SPRUE

579.3 * BLIND LOOP SYNDROME

579.4 * OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

579.5 * PANCREATIC STEATORRHEA

585.1 - 585.9* CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED

586* RENAL FAILURE UNSPECIFIED

952.00 - 952.9

C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED - UNSPECIFIED SITE OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

953.2 INJURY TO LUMBAR NERVE ROOT

953.3 INJURY TO SACRAL NERVE ROOT

953.5 INJURY TO LUMBOSACRAL PLEXUS

953.8 INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS

956.0 - 956.9

INJURY TO SCIATIC NERVE - INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB

See corresponding * underlying conditions.

The following diagnoses require a Q modifier:

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

440.20 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED

440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION

440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN

440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

443.1 RAYNAUD'S SYNDROME

443.2 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY

446.0 POLYARTERITIS NODOSA

446.7* TAKAYASU'S DISEASE

See corresponding * underlying conditions.

The following diagnoses related to peripheral neuropathy do not require a Q modifier:

030.0 - 030.9 LEPROMATOUS LEPROSY (TYPE L) - LEPROSY UNSPECIFIED

94.1 TABES DORSALIS

94.2 GENERAL PARESIS

094.9 NEUROSYPHILIS UNSPECIFIED

250.40 DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.50 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.60 - 250.63*

DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

263.9* UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

265.0* BERIBERI

265.2* PELLAGRA

266.1 * VITAMIN B6 DEFICIENCY

266.2 * OTHER B-COMPLEX DEFICIENCIES

272.7 LIPIDOSES

277.30 AMYLOIDOSIS, UNSPECIFIED

277.39 OTHER AMYLOIDOSIS

281.0* PERNICIOUS ANEMIA

281.3* OTHER SPECIFIED MEGALOBLASTIC ANEMIAS NOT ELSEWHERE CLASSIFIED

286.9* OTHER AND UNSPECIFIED COAGULATION DEFECTS

334.0 FRIEDREICH'S ATAXIA

340* MULTIPLE SCLEROSIS

356.0 - 356.9

357.0 - 357.7*

HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

ACUTE INFECTIVE POLYNEURITIS - POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS

358.1 * MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE

358.2 * TOXIC MYONEURAL DISORDERS

451.0* PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES

451.11* PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL)

451.19* PHLEBITIS AND THROMBOPHLEBITIS OF OTHER

579.1 * CELIAC DISEASE

579.2 * TROPICAL SPRUE

579.3 * BLIND LOOP SYNDROME

579.4 * OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

579.5 * PANCREATIC STEATORRHEA

585.1 - 585.9* CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED

586* RENAL FAILURE UNSPECIFIED

952.00 - 952.9

C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED - UNSPECIFIED SITE OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

953.2 INJURY TO LUMBAR NERVE ROOT

953.3 INJURY TO SACRAL NERVE ROOT

953.5 INJURY TO LUMBOSACRAL PLEXUS

953.8 INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS

956.0 - 956.9 INJURY TO SCIATIC NERVE - INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB

See corresponding * underlying conditions.

The following diagnosis related to anticoagulation therapy does not require a Q modifier: 286.9* OTHER AND UNSPECIFIED COAGULATION DEFECTS

See corresponding * underlying conditions.

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

The provider must document in the medical record the appropriate signs and symptoms as outlined in Class Findings A, B, and/or C along with the complicating condition(s). In addition, when services are performed by a podiatrist, the medical record must contain the name of the treating and/or diagnosing physician. If the complicating condition is one that is asterisked, the date the patient was last seen by the treating physician must also be included on the claim.

For diagnoses of peripheral neuropathy that do not require a Q modifier, and the presumption of coverage is based on loss of protective sensation, documentation must be available in the medical record of an absence of sensation at two or more sites out of five tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament to support the diagnosis of peripheral neuropathy with loss of protective sensation. This test may be performed by the attending physician, non-physician practitioner, or the podiatrist.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Akhtar, N., Chazin, H., Eisenschenk, S., Fine-Edelstein, J., Gorson, K., & Jacobs, D. (2004). Neuropathy. Neurology Channel. Retrieved Oct. 20, 2004, from www.helathcommunities.com

Curtin Health Science, Department of Podiatry. Podiatry Encyclopedia, 2001. Retrieved from internet 04/16/2004. From www.podiatry.curtin.edu.au/encyclopedia/#podology.

W.B. Saunders Company.

Harari, A.E., & Rush, M.D., (2003). Diabetic Foot Care. Emedicine Consumer Health. Retrieved Oct. 20, 2004 from www.emedicinehealth.com

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 advisory groups, which includes representatives from numerous societies.

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:02/02/2009

LCR B2009-

December 2008 Bulletin

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

For Florida (00590) this LCD (L29272) replaces LCD L6405 as the policy in notice. This document (L29272) is effective on 02/02/2009.

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

Reason for Change Typographical Correction