Archive
API

Local Coverage Determination (LCD)

Routine Foot Care

L37643

Expand All | Collapse All
Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L37643
Original ICD-9 LCD ID
Not Applicable
LCD Title
Routine Foot Care
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 01/29/2018
Revision Effective Date
For services performed on or after 12/05/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
12/14/2017
Notice Period End Date
01/28/2018
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862 (a)(13)(C) defines the exclusion for payment of routine foot care.

42 CFR Section 411.15 (l) Particular services excluded from coverage.

CMS Internet- Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §290 Foot Care

CMS Internet- Only Manual, Pub 100-03, Medicare National Coverage Determination Manual, Chapter 1, §70.2.1 Services Provided for the Diagnosis and Treatment of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Background

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;
  • 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, 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.

There are exceptions to routine foot care exclusions. This local coverage determination (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 routine foot care exclusions include:

  1. Routine foot care that is necessary and an integral part of an otherwise covered service;

  2. Treatment of warts on foot;

  3. The presence of systemic conditions, such as metabolic, neurologic, or peripheral vascular disease;

  4. Mycotic nails:
  • In the presence of systemic conditions as noted above in #3.
  • In the absence of systemic conditions:
    • An ambulatory patient must have marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.
    • A non-ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of an infected toenail plate.

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:

  1. One Class A finding;
  2. Two of the Class B findings; or
  3. One Class B and two Class C findings.

Limitations

1.Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days.

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

Loss of protective sensation (LOPS) is not the subject of this LCD.
Summary of Evidence

N/A
Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Expand All | Collapse All

Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Expand All | Collapse All

Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Expand All | Collapse All

Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

  1. All indications must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.

  2. Documentation supporting 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.

  3. Physical findings and services must be precise and specific (e.g., left great toe, or right foot, 4th digit.) Documentation of co-existing systemic illness should be maintained.

  4. There must be adequate medical documentation to demonstrate the need for routine foot care services as outlined in this LCD. 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.

  5. For each service encounter for debridement of mycotic nails, the medical record should contain a description of each debrided nail that reflects clinical descriptors consistent with mycotic nails . If appropriate the clinical descriptor may encompass multiple nails with the same findings. (e.g., the nail for toes 1, 3, 5 are yellow, brittle, thickened, etc.)

  6. When the documentation does not meet the criteria for the service rendered, or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

Utilization Guidelines

Routine foot care services are considered medically necessary once (1) in 60 days.
Sources of Information

N/A

 
Bibliography

Other Medicare Contractor’s Local Coverage Determinations.

 

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
12/05/2019 R5

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Routine Foot Care A56680 article. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
07/25/2019 R4

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been moved into the related Billing and Coding: Routine Foot Care A56680 article and removed from the LCD.

Under CMS National Coverage Policy “Chapter 1” was added to “CMS Internet- Only Manual, Pub 100-03, Medicare National Coverage Determination Manual, §70.2.1 Services Provided for the Diagnosis and Treatment of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy).” Punctuation was corrected throughout the LCD. 

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
12/13/2018 R3

Grammar and punctuation were corrected, words were capitalized or changed to lower case and acronyms were inserted where appropriate throughout the policy.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Provider Education/Guidance
  • Public Education/Guidance
02/26/2018 R2 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R1

The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.

  • Other
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56680 - Billing and Coding: Routine Foot Care
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/27/2019 12/05/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Foot Care
  • Nail care

Read the LCD Disclaimer

Submit Feedback/Ask a Question