L29272

LCD/NCD Portal

Automated World Health

L29272

ROUTINE FOOT CARE

02/02/2009

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:

o The cutting or removal of corns and calluse

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

o 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.

o 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.

o Diabetes mellitus*

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

o Buerger’s disease (thromboangiitis obliterans)

o Chronic thrombophlebitis*

o Peripheral neuropathies involving feet

o Associated with malnutrition and vitamin deficiency*

 Malnutrition (general, pellagra)

 Alcoholism

 Malabsorption (celiac disease, tropical sprue)

 Pernicious anemia

o Associated with carcinoma*

o Associated with diabetes mellitus*

o Associated with drugs and toxins*

o Associated with multiple sclerosis*

o Associated with uremia (chronic renal disease)*

o Associated with traumatic injury

o Associated with leprosy or neurosyphilis

o Associated with hereditary disorders

 Hereditary sensory radicular neuropathy

 Angiokeratoma corporis diffusum (Fabry’s)

 Amyloid neuropathy

o 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:

o 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

o 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.

o 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

o Nontraumatic amputation of foot or integral skeletal portion thereof

• Class B Findings

o Absent posterior tibial pulse, or

o Absent dorsalis pedal pulse, or

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

o Hair growth (decrease or absence)

o Pigmentary changes (discoloration)

o Skin color (rubor and redness)

o Nail changes (thickening)

o Skin texture (thin, shiny)

• Class C Findings

o Claudication (pain in calf when walking)

o Temperature changes in the feet (e.g., cold feet)

o Edema

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

o Burning

Presumption of Coverage

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

o 1. A Class A finding

o 2. Two of the Class B findings; or

o 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.

o Q7 = One Class A finding

o Q8 = Two Class B findings

o 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.

o The neuropathy should be of such severity that care by a non-professional person would put the patient at risk.

o In such circumstances, claims for medically necessary services would be submitted without the Q7, Q8, or Q9 modifiers that indicate class findings.

o 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.

o 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:

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

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 LEPROMATOUS LEPROSY (TYPE L)

030.1 TUBERCULOID LEPROSY (TYPE T)

030.2 INDETERMINATE LEPROSY (GROUP I)

030.3 BORDERLINE LEPROSY (GROUP B)

030.8 OTHER SPECIFIED LEPROSY

030.9 LEPROSY UNSPECIFIED

094.0 TABES DORSALIS

094.1 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 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

250.70 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.71 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.72 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.73* 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 HEREDITARY PERIPHERAL NEUROPATHY

356.1 PERONEAL MUSCULAR ATROPHY

356.2 HEREDITARY SENSORY NEUROPATHY

356.3 REFSUM'S DISEASE

356.4 IDIOPATHIC PROGRESSIVE POLYNEUROPATHY

356.8 OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

356.9 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

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

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

443.0 RAYNAUD'S SYNDROME

443.1 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

579.0* CELIAC DISEASE

579.1* TROPICAL SPRUE

579.2* BLIND LOOP SYNDROME

579.3* OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

579.4* PANCREATIC STEATORRHEA

585.1 CHRONIC KIDNEY DISEASE, STAGE I

585.2 CHRONIC KIDNEY DISEASE, STAGE II (MILD)

585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)

585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)

585.5 CHRONIC KIDNEY DISEASE, STAGE V

585.6 END STAGE RENAL DISEASE

585.9* CHRONIC KIDNEY DISEASE, UNSPECIFIED

586* RENAL FAILURE UNSPECIFIED

952.00 C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.01 C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.02 C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME

952.03 C1-C4 LEVEL WITH CENTRAL CORD SYNDROME

952.04 C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.05 C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.06 C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.07 C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME

952.08 C5-C7 LEVEL WITH CENTRAL CORD SYNDROME

952.09 C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.10 T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.11 T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.12 T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME

952.13 T1-T6 LEVEL WITH CENTRAL CORD SYNDROME

952.14 T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.15 T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.16 T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.17 T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME

952.18 T7-T12 LEVEL WITH CENTRAL CORD SYNDROME

952.19 T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.2 LUMBAR SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.3 SACRAL SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.4 CAUDA EQUINA SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.8 MULTIPLE SITES OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.9 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 INJURY TO SCIATIC NERVE

956.1 INJURY TO FEMORAL NERVE

956.2 INJURY TO POSTERIOR TIBIAL NERVE

956.3 INJURY TO PERONEAL NERVE

956.4 INJURY TO CUTANEOUS SENSORY NERVE LOWER LIMB

956.5 INJURY TO OTHER SPECIFIED NERVE(S) OF PELVIC GIRDLE AND LOWER LIMB

956.8 INJURY TO MULTIPLE NERVES OF PELVIC GIRDLE AND LOWER LIMB

956.9 INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB

The following diagnoses require a Q modifier: