Local Coverage Article Billing and Coding

Billing and Coding: Routine Foot Care

A56680

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Contractor Information

Article Information

General Information

Article ID
A56680
Article Title
Billing and Coding: Routine Foot Care
Article Type
Billing and Coding
Original Effective Date
07/25/2019
Revision Effective Date
10/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2021 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.

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.

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

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Routine Foot Care L37643.

Coding for Mycotic Nails

Although CPT® coding does not exclusively apply CPT® codes 11720 and 11721 to mycotic nails or to the feet, Medicare assumes these are the CPT® codes usually used to code for services related to debriding mycotic nails.

Assuming services are being provided based on this indication, and the above requirements are documented, the claim should be coded with ICD-10 code B35.1 as a primary code AND L02.611- L02.612, L03.031-L03.032, L03.041-L03.042, M79.671- M79.672, M79.674-M79.675 or R26.2 as a secondary code. Systemic condition modifiers are not necessary for services performed for this indication with these diagnosis codes.

The nail debridement procedure codes (11720-11721) are considered noncovered 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.

Coding for Systemic Conditions

Foot care services are covered in the presence of certain conditions described in the CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §290 identified by the following ICD-10 codes:

Diabetes mellitus*

E08.00-E13.9

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

I70.201-I70.92
I73.00-I73.01
I73.9

Buerger’s disease (thromboangiitis obliterans)

I73.1

Chronic thrombophlebitis*

I80.00-I80.3

Peripheral neuropathies involving the feet:

    • Associated with malnutrition and vitamin deficiency*

      E56.9 and G63

      • Malnutrition (general, pellagra)*

        E46, E52, or E64.0 and G63

      • Alcoholism*

        G62.1

      • Malabsorption (celiac disease, tropical sprue)*

        K90.0 or K90.1 and G63

      • Pernicious Anemia*

        D51.0 and G63
    • Associated with carcinoma*

      G13.0

    • Associated with diabetes mellitus*

      E08.40
      E08.42
      E09.40
      E09.42
      E10.40
      E10.42
      E11.40
      E11.42
      E13.40
      E13.42

    • Associated with drugs and toxins*

      G62.0
      G62.2
      G62.82

    • Associated with multiple sclerosis*

      G35 and G63

    • Associated with uremia (chronic renal disease)*

      N18.1-N18.9 and G63

    • Associated with traumatic injury

      S86.001A-S86.009S
      S86.091A-S86.109S
      S86.191A-S86.201S
      S86.209A-S86.209S
      S86.291A-S86.309S
      S86.391A-S86.809S
      S86.891A-S86.909S
      S86.991A-S86.999S
      S89.80XA-S89.92XS
      S96.001A-S96.009S
      S96.091A-S96.109S
      S96.191A-S96.209S
      S96.291A-S96.809S
      S96.891A-S96.909S
      S96.991A-S96.999S
      S99.811A-S99.929S
      and G63

    • Associated with leprosy or neurosyphilis

      A30.0-A30.9 and G63
      A52.10-A52.3 and G63

    • Associated with hereditary disorders

      G60.0-G60.9

      • Heredity sensory radicular neuropathy

        G60.0

      • Angiokeratoma corporis diffusum (Fabry's)

        E75.21 and G63

      • Amyloid neuropathy

        E85.0-E85.9 and G63

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 or NPP who documents the condition. This must be indicated by the name and national provider identifier (NPI) of the attending physician in block 17 and 17B of the CMS-1500 or the equivalent electronic claim format. The date the patient was last seen by the attending physician should be billed in block 19. Claims for such routine services should show the complicating systemic disease in block 21 of the CMS-1500.

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

      • One (1) Class A finding using modifier Q7;
      • Two (2) Class B findings using modifier Q8; or
      • One (1) Class B and two (2) Class C findings using modifier Q9.

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

Claims without a systemic diagnosis listed will be denied as non-covered routine-type foot care services.

Services not meeting the instructions and criteria in this statement of national coverage will be denied as statutory non-covered services. For ICD-10 codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the national provider identifier (NPI) of the doctor of medicine or osteopathy.

 

Coding Information

CPT/HCPCS Codes

Group 1

(7 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
11055 Trim skin lesion
11056 Trim skin lesions 2 to 4
11057 Trim skin lesions over 4
11719 Trim nail(s) any number
11720 Debride nail 1-5
11721 Debride nail 6 or more
G0127 Trim nail(s)

CPT/HCPCS Modifiers

Group 1

(3 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
Q7 ONE CLASS A FINDING
Q8 TWO CLASS B FINDINGS
Q9 ONE CLASS B AND TWO CLASS C FINDINGS

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

Mycotic Nails- Primary Diagnosis

Group 1 Codes
CodeDescription
B35.1 Tinea unguium

Group 2

(11 Codes)
Group 2 Paragraph

Mycotic Nails- Secondary Diagnoses

Group 2 Codes
CodeDescription
L02.611 - L02.612 Cutaneous abscess of right foot - Cutaneous abscess of left foot
L03.031 - L03.032 Cellulitis of right toe - Cellulitis of left toe
L03.041 - L03.042 Acute lymphangitis of right toe - Acute lymphangitis of left toe
M79.671 - M79.672 Pain in right foot - Pain in left foot
M79.674 - M79.675 Pain in right toe(s) - Pain in left toe(s)
R26.2 Difficulty in walking, not elsewhere classified

Group 3

(1,021 Codes)
Group 3 Paragraph

System Conditions

Group 3 Codes
CodeDescription
A30.0 - A30.9 Indeterminate leprosy - Leprosy, unspecified
A52.10 - A52.3 Symptomatic neurosyphilis, unspecified - Neurosyphilis, unspecified
D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency
E08.00 - E13.9 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
E75.244 Niemann-Pick disease type A/B
E85.0 - E85.9 Non-neuropathic heredofamilial amyloidosis - Amyloidosis, unspecified
G13.0 Paraneoplastic neuromyopathy and neuropathy
G35 Multiple sclerosis
G60.0 - G60.9 Hereditary motor and sensory neuropathy - Hereditary and idiopathic neuropathy, unspecified
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
I70.201 - I70.92 Unspecified atherosclerosis of native arteries of extremities, right leg - Chronic total occlusion of artery of the extremities
I73.00 - I73.01 Raynaud's syndrome without gangrene - Raynaud's syndrome with gangrene
I73.1 Thromboangiitis obliterans [Buerger's disease]
I73.9 Peripheral vascular disease, unspecified
I80.00 - I80.3 Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity - Phlebitis and thrombophlebitis of lower extremities, unspecified
K90.0 Celiac disease
K90.1 Tropical sprue
N18.1 - N18.9 Chronic kidney disease, stage 1 - Chronic kidney disease, unspecified
S86.001A - S86.009S Unspecified injury of right Achilles tendon, initial encounter - Unspecified injury of unspecified Achilles tendon, sequela
S86.091A - S86.109S Other specified injury of right Achilles tendon, initial encounter - Unspecified injury of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, unspecified leg, sequela
S86.191A - S86.201S Other injury of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, right leg, initial encounter - Unspecified injury of muscle(s) and tendon(s) of anterior muscle group at lower leg level, right leg, sequela
S86.209A - S86.209S Unspecified injury of muscle(s) and tendon(s) of anterior muscle group at lower leg level, unspecified leg, initial encounter - Unspecified injury of muscle(s) and tendon(s) of anterior muscle group at lower leg level, unspecified leg, sequela
S86.291A - S86.309S Other injury of muscle(s) and tendon(s) of anterior muscle group at lower leg level, right leg, initial encounter - Unspecified injury of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, unspecified leg, sequela
S86.391A - S86.809S Other injury of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, right leg, initial encounter - Unspecified injury of other muscle(s) and tendon(s) at lower leg level, unspecified leg, sequela
S86.891A - S86.909S Other injury of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter - Unspecified injury of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg, sequela
S86.991A - S86.999S Other injury of unspecified muscle(s) and tendon(s) at lower leg level, right leg, initial encounter - Other injury of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg, sequela
S89.80XA - S89.92XS Other specified injuries of unspecified lower leg, initial encounter - Unspecified injury of left lower leg, sequela
S96.001A - S96.009S Unspecified injury of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial encounter - Unspecified injury of muscle and tendon of long flexor muscle of toe at ankle and foot level, unspecified foot, sequela
S96.091A - S96.109S Other injury of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial encounter - Unspecified injury of muscle and tendon of long extensor muscle of toe at ankle and foot level, unspecified foot, sequela
S96.191A - S96.209S Other specified injury of muscle and tendon of long extensor muscle of toe at ankle and foot level, right foot, initial encounter - Unspecified injury of intrinsic muscle and tendon at ankle and foot level, unspecified foot, sequela
S96.291A - S96.809S Other specified injury of intrinsic muscle and tendon at ankle and foot level, right foot, initial encounter - Unspecified injury of other specified muscles and tendons at ankle and foot level, unspecified foot, sequela
S96.891A - S96.909S Other specified injury of other specified muscles and tendons at ankle and foot level, right foot, initial encounter - Unspecified injury of unspecified muscle and tendon at ankle and foot level, unspecified foot, sequela
S96.991A - S96.999S Other specified injury of unspecified muscle and tendon at ankle and foot level, right foot, initial encounter - Other specified injury of unspecified muscle and tendon at ankle and foot level, unspecified foot, sequela
S99.811A - S99.929S Other specified injuries of right ankle, initial encounter - Unspecified injury of unspecified foot, sequela

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

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2021 R5

Under ICD-10 Codes that Support Medical Necessity Group 3: Codes added code E75.244. This revision is due to the Annual ICD-10 Code Update and is effective on 10/1/21.

10/01/2020 R4

Under ICD-10 Codes that Support Medical Necessity Group 3: Codes added N18.30, N18.31 and N18.32 to code range N18.1-N18.9.This revision is due to the Annual ICD-10 Code Update and is effective on October 1, 2020.

12/05/2019 R3

This article 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 and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Routine Foot Care L37643 LCD and placed in this article. Under Article Text inserted the verbiage “or NPP”.The verbiage “seen by the attending physician should be billed” was changed to “seen by the attending provider should be billed”. Under CPT/HCPCS Modifiers Group 1 Codes added modifiers Q7, Q8 and Q9.

10/01/2019 R2

Under Covered ICD-10 Codes Group 3: Codes I80.241, I80.242, I80.243, I80.249, I80.251, I80.252, I80.253 and I80.259 were added. These revisions are due to the Annual ICD-10 Updates and become effective on 10/1/2019.

07/25/2019 R1

All coding located in the Coding Information section has been removed from the related Routine Foot Care L37643 LCD and added to this article.

Associated Documents

Related Local Coverage Documents
LCDs
L37643 - Routine Foot Care
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
08/09/2021 10/01/2021 - N/A Currently in Effect You are here
08/26/2020 10/01/2020 - 09/30/2021 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Foot Care
  • Nail Care