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:
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
Buerger’s disease (thromboangiitis obliterans)
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
- Malabsorption (celiac disease, tropical sprue)*
K90.0 or K90.1 and G63
- Pernicious Anemia*
D51.0 and G63
- Associated with carcinoma*
- Associated with diabetes mellitus*
- Associated with drugs and toxins*
- Associated with multiple sclerosis*
G35 and G63
- Associated with uremia (chronic renal disease)*
N18.1-N18.9 and G63
- Associated with traumatic injury
- Associated with leprosy or neurosyphilis
A30.0-A30.9 and G63
A52.10-A52.3 and G63
- Associated with hereditary disorders
- Heredity sensory radicular neuropathy
- 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.