CPT CODE 11721, 11055 - Foot care procedure

Procedure codes and Description

Group 1 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


Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following, regardless of the provider rendering the service:
Cutting or removal of corns and calluses;

Trimming, cutting, clipping, or debridement of nails, including debridement of mycotic nails;

Shaving, paring, cutting or removal of keratoma, tyloma, and heloma;

Other hygienic and preventive maintenance care in the realm of self-care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients;

Any other service performed 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.

However, the Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 290 describes exceptions to routine foot care exclusions. This LCD outlines such exceptions.


Indications

Routine foot care services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of routine foot care services.

Exceptions to the routine foot care exclusions include:
Necessary and integral part of otherwise covered services;

Treatment of warts on foot;

Presence of systemic conditions, such as metabolic, neurologic, or peripheral vascular disease;

Mycotic nails:
In the presence of systemic conditions as noted above in #3.

In the absence of systemic conditions:
Ambulatory patient must have marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

Non ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

Systemic Conditions
Foot care services are covered in the presence of a systemic condition based on the list of illnesses described in Chapter 15, Section 290 of the Benefit Policy Manual.

Diabetes mellitus *
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
Buerger’s disease (thromboangiitis obliterans)
Chronic thrombophlebitis *

Peripheral neuropathies involving the 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

When the patient’s condition is one of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

The active care requirement would be considered met if the claim indicates that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the service.

Presumption of Coverage

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. For purposes of applying this presumption the following findings are pertinent:

Class A Findings

Nontraumatic 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); and

Burning.

The presumption of coverage may be applied when the physician rendering the routine foot care has identified:
A Class A finding;

Two of the Class B findings; or

One Class B and two Class C findings.

In addition to a valid billing modifier, these services must include a systemic condition diagnosis listed above and in Group 1 of the diagnosis codes. All claims for routine foot care based on the presence of a systemic condition must have a billing modifier of Q7, Q8 or Q9 to be considered for payment.

Mycotic Nails

Mycotic nail debridement may be a covered service:
In the presence of a systemic disease with the class findings and appropriate Q modifier.

In the absence of systemic disease if the patient has mycotic nails and marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

In the absence of systemic disease when a non-ambulatory patient has mycotic nails and suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

For services without systemic disease and class findings, the diagnosis in Group 2 and Group 3 of the diagnosis codes below must be documented in the medical record and submitted on the claim.

The nail debridement procedure codes are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services.

Limitations
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.

The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.

Medicare allows payment for routine foot care only if the conditions under indications 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.

Services not meeting the criteria in this statement of national coverage will be denied as statutory non-covered services. For diagnosis codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the doctor of medicine or osteopathy actively managing the patients systemic condition.

Nail debridement procedures are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care they must meet the same criteria as all other routine foot care services to be considered for payment.

Foot care services that do not require a professional would be considered routine and not a Medicare benefit. Professional in this situation is defined as an M.D., D.O., D.P.M., Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant.

Loss of protective sensation (LOPS) is not the subject of this LCD. Please refer to NCD 70.2.1.



ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: For codes 11055, 11056, 11057, 11719, 11720, 11721, G0127 billed with modifier Q7, Q8 or Q9. Diagnosis codes with an asterisk also need the date last seen and name and NPI of the attending physician.

For the codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.




Group 1Codes

ICD-10 CODE DESCRIPTION

A30.0 Indeterminate leprosy

A30.1 Tuberculoid leprosy

A30.2 Borderline tuberculoid leprosy

A30.3 Borderline leprosy

A30.4 Borderline lepromatous leprosy

A30.5 Lepromatous leprosy

A30.8 Other forms of leprosy

A30.9 Leprosy, unspecified

A52.10 Symptomatic neurosyphilis, unspecified

A52.11 Tabes dorsalis

A52.12 Other cerebrospinal syphilis

A52.13 Late syphilitic meningitis

A52.14 Late syphilitic encephalitis

A52.15 Late syphilitic neuropathy

A52.16 Charcot's arthropathy (tabetic)

A52.17 General paresis

A52.19 Other symptomatic neurosyphilis

A52.2 Asymptomatic neurosyphilis

A52.3 Neurosyphilis, unspecified

D51.0* Vitamin B12 deficiency anemia due to intrinsic factor deficiency

E08.00 - E13.9* - Opens in a new window Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic
hyperglycemic-hyperosmolar coma (NKHHC) - Other specified diabetes mellitus without complications

E46* Unspecified protein-calorie malnutrition

E52* Niacin deficiency [pellagra]

E56.9* Vitamin deficiency, unspecified

E64.0* Sequelae of protein-calorie malnutrition

E75.21 Fabry (-Anderson) disease

E75.22 Gaucher disease

E75.240 Niemann-Pick disease type A

E75.241 Niemann-Pick disease type B

E75.242 Niemann-Pick disease type C

E75.243 Niemann-Pick disease type D

E75.248 Other Niemann-Pick disease

E75.249 Niemann-Pick disease, unspecified

E75.3 Sphingolipidosis, unspecified

E77.0 Defects in post-translational modification of lysosomal enzymes

E77.1 Defects in glycoprotein degradation

E77.8 Other disorders of glycoprotein metabolism

E77.9 Disorder of glycoprotein metabolism, unspecified

E85.0 Non-neuropathic heredofamilial amyloidosis

E85.1 Neuropathic heredofamilial amyloidosis


E85.2 Heredofamilial amyloidosis, unspecified

E85.3 Secondary systemic amyloidosis

E85.4 Organ-limited amyloidosis

E85.8 Other amyloidosis

E85.9 Amyloidosis, unspecified
G13.0* Paraneoplastic neuromyopathy and neuropathy


G13.1 Other systemic atrophy primarily affecting central nervous system in neoplastic disease

G35* Multiple sclerosis
G60.0* Hereditary motor and sensory neuropathy

G60.1 Refsum's disease

G60.2* Neuropathy in association with hereditary ataxia

G60.3 Idiopathic progressive neuropathy

G60.8 Other hereditary and idiopathic neuropathies

G60.9 Hereditary and idiopathic neuropathy, unspecified

G61.1 Serum neuropathy

G62.0 Drug-induced polyneuropathy

G62.1* Alcoholic polyneuropathy

G62.2 Polyneuropathy due to other toxic agents

G62.82* Radiation-induced polyneuropathy

G63* Polyneuropathy in diseases classified elsewhere

G65.0 Sequelae of Guillain-Barre syndrome

G65.1 Sequelae of other inflammatory polyneuropathy

G65.2 Sequelae of toxic polyneuropathy

I70.201 Unspecified atherosclerosis of native arteries of extremities, right leg

I70.202 Unspecified atherosclerosis of native arteries of extremities, left leg

I70.203 Unspecified atherosclerosis of native arteries of extremities, bilateral legs

I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg

I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg

I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs

I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg

I70.222 Atherosclerosis of native arteries of extremities with rest pain, left leg

I70.223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs

I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh

I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle

I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot


I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg

I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site

I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh

I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf

I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle

I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot

I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot

I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg

I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site

I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg

I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg

I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.291 Other atherosclerosis of native arteries of extremities, right leg

I70.292 Other atherosclerosis of native arteries of extremities, left leg

I70.293 Other atherosclerosis of native arteries of extremities, bilateral legs

I70.301 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg

I70.302 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg

I70.303 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs

I70.311 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg

I70.312 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, left leg

I70.313 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral
legs

I70.321 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, right leg


I70.322 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, left leg

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