Local Coverage Article Billing and Coding

Billing and Coding: Routine Foot Care and Debridement of Nails

A57759

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Article ID
A57759
Article Title
Billing and Coding: Routine Foot Care and Debridement of Nails
Article Type
Billing and Coding
Original Effective Date
12/26/2019
Revision Effective Date
10/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
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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

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act:

Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862 (a) (1) (A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1862 (a) (13)(C) defines the exclusion for payment of routine foot care services.

Code of Federal Regulations:

(CFR) Part 411.15., subpart A addresses general exclusions and exclusion of particular services.

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

290 Foot care services which are exceptions to the Medicare coverage exclusion.

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Part 1:

70.2.1 Services provided for diagnosis and treatment of diabetic peripheral neuropathy.

CMS Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5:

National Correct Coding Initiative.

Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Routine Foot Care and Debridement of Nails.

National Coverage Provisions:

The following services are considered to be components of routine foot care, regardless of the provider rendering the service:

  • The cutting or removal of corns and calluses;
  • Clipping, trimming, 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, 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.

The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.

Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections.

Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present and grant the presumption of coverage. Payment may be made for the debridement of a mycotic nail (whether by manual method or by electrical grinder) when definitive antifungal treatment options have been reviewed and discussed with the patient at the initial visit and the physician attending the mycotic condition documents that the following criteria are met: In the absence of a systemic condition, the following criteria must be met:

  • In the case of ambulatory patients there exists:

Clinical evidence of mycosis of the toenail, and

Marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

  • In the case of non-ambulatory patients there exists:

Clinical evidence of mycosis of the toenail, and The patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

Class A findings

Non-traumatic amputation of foot or integral skeletal portion thereof.

Class B findings

Absent posterior tibial pulse;

Advanced trophic changes such as (three required):

  • hair growth (decrease or absence);
  • nail changes (thickening);
  • pigmentary changes (discoloration);
  • skin texture (thin, shiny);
  • skin color (rubor or redness); 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. A Class A finding;
  2. Two of the Class B findings; or
  3. One Class B and two Class C findings.

Loss of Protective Sensation (LOPS):

For coverage information on Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (LOPS), and its relation to coverage of Routine Foot Care Services, refer to Medicare National Coverage Determinations (NCD) Manual, Section 70.2.1.

According to this National Coverage Determination,

Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim. LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically. Heavily callused areas should be avoided. As suggested by the American Podiatric Medicine Association, an absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation.

The examination includes:

A patient history, and

A physical examination that must consist of at least the following elements:

Visual inspection of forefoot and hindfoot (including toe web spaces);

Evaluation of protective sensation;

Evaluation of foot structure and biomechanics;

Evaluation of vascular status and skin integrity;

Evaluation of the need for special footwear; and

Patient education.

 

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Specific Coding Guidelines:

Global surgery rules will apply to routine foot care procedure codes 11055, 11056, 11057, 11719, 11720, 11721, and G0127. As a result, an E&M service billed on the same day as a routine foot care service is not eligible for reimbursement unless the E&M service is a significant separately identifiable service, indicated by the use of modifier 25, and documented by medical records.

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation supporting the 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.

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.

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

Routine identification of cultures of fungi in the toenail is medically indicated when necessary to differentiate fungal disease from psoriatic nail, or when definitive treatment for prolonged oral antifungal therapy has been planned. If cultures are performed and billed, documentation of cultures and the need for prolonged oral antifungal therapy must be in the patient record and available to Medicare upon request.

Utilization Guidelines:

Routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be considered not medically necessary. Services for debridement of more than five nails in a single day may be subject to special review.
 

Coding Information

CPT/HCPCS Codes

Group 1

(7 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
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

CPT/HCPCS Modifiers

Group 1

(3 Codes)
Group 1 Paragraph

One of the modifiers listed below must be reported with codes 11055, 11056, 11057, 11719, G0127, and with codes 11720 and 11721 when the coverage is based on the presence of a qualifying systemic condition EXCEPT where the patient has evidence of neuropathy, but no vascular impairment, for which class findings modifiers are not required:

Modifier Q7: One (1) Class A finding Modifier Q8: Two (2) Class B findings Modifier Q9: One (1) Class B finding and two (2) Class C findings.

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

(216 Codes)
Group 1 Paragraph

Codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127

Group 1 Codes
CodeDescription
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
A50.41 Late congenital syphilitic meningitis
A50.42 Late congenital syphilitic encephalitis
A50.43 Late congenital syphilitic polyneuropathy
A50.45 Juvenile general paresis
A52.11 Tabes dorsalis
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
D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency
D81.818 Other biotin-dependent carboxylase deficiency
E08.41* Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.42* Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.43* Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E08.44* Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.49* Diabetes mellitus due to underlying condition with other diabetic neurological complication
E08.51* Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene
E08.52* Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E08.59* Diabetes mellitus due to underlying condition with other circulatory complications
E08.610* Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy
E09.42* Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
E09.49* Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication
E09.51* Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene
E09.52* Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E09.59* Drug or chemical induced diabetes mellitus with other circulatory complications
E09.610* Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy
E10.41* Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42* Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43* Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44* Type 1 diabetes mellitus with diabetic amyotrophy
E10.49* Type 1 diabetes mellitus with other diabetic neurological complication
E10.51* Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52* Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.59* Type 1 diabetes mellitus with other circulatory complications
E10.610* Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E11.41* Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42* Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43* Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44* Type 2 diabetes mellitus with diabetic amyotrophy
E11.49* Type 2 diabetes mellitus with other diabetic neurological complication
E11.51* Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52* Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59* Type 2 diabetes mellitus with other circulatory complications
E11.610* Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E13.42* Other specified diabetes mellitus with diabetic polyneuropathy
E13.49* Other specified diabetes mellitus with other diabetic neurological complication
E13.51* Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene
E13.52* Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.59* Other specified diabetes mellitus with other circulatory complications
E13.610* Other specified diabetes mellitus with diabetic neuropathic arthropathy
E51.11* Dry beriberi
E51.12* Wet beriberi
E52* Niacin deficiency [pellagra]
E53.1* Pyridoxine deficiency
E53.8* Deficiency of other specified B group vitamins
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
E75.244 Niemann-Pick disease type A/B
E75.248 Other Niemann-Pick disease
E77.0 Defects in post-translational modification of lysosomal enzymes
E77.1 Defects in glycoprotein degradation
E77.8 Other disorders of glycoprotein metabolism
E85.1 Neuropathic heredofamilial amyloidosis
E85.3 Secondary systemic amyloidosis
E85.4 Organ-limited amyloidosis
E85.81 Light chain (AL) amyloidosis
E85.82 Wild-type transthyretin-related (ATTR) amyloidosis
E85.89 Other amyloidosis
G04.1 Tropical spastic paraplegia
G11.10 Early-onset cerebellar ataxia, unspecified
G11.11 Friedreich ataxia
G11.19 Other early-onset cerebellar ataxia
G12.21 Amyotrophic lateral sclerosis
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
G61.0* Guillain-Barre syndrome
G61.1* Serum neuropathy
G61.81 Chronic inflammatory demyelinating polyneuritis
G61.89 Other inflammatory polyneuropathies
G62.0* Drug-induced polyneuropathy
G62.1* Alcoholic polyneuropathy
G62.2* Polyneuropathy due to other toxic agents
G62.81 Critical illness polyneuropathy
G62.82* Radiation-induced polyneuropathy
G62.89 Other specified polyneuropathies
G63 Polyneuropathy in diseases classified elsewhere
G64 Other disorders of peripheral nervous system
G65.0 Sequelae of Guillain-Barre syndrome
G65.1 Sequelae of other inflammatory polyneuropathy
G65.2 Sequelae of toxic polyneuropathy
G70.1* Toxic myoneural disorders
G70.81* Lambert-Eaton syndrome in disease classified elsewhere
G73.1* Lambert-Eaton syndrome in neoplastic disease
G73.3* Myasthenic syndromes in other diseases classified elsewhere
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
G95.0 Syringomyelia and syringobulbia
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
I70.233 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
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
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
I70.25 Atherosclerosis of native arteries of other extremities with ulceration
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
I70.90 Unspecified atherosclerosis
I70.91 Generalized atherosclerosis
I73.00 Raynaud's syndrome without gangrene
I73.01 Raynaud's syndrome with gangrene
I73.1 Thromboangiitis obliterans [Buerger's disease]
I73.81 Erythromelalgia
I73.89 Other specified peripheral vascular diseases
I79.1 Aortitis in diseases classified elsewhere
I79.8 Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere
I80.01* Phlebitis and thrombophlebitis of superficial vessels of right lower extremity
I80.02* Phlebitis and thrombophlebitis of superficial vessels of left lower extremity
I80.03* Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral
I80.11* Phlebitis and thrombophlebitis of right femoral vein
I80.12* Phlebitis and thrombophlebitis of left femoral vein
I80.13* Phlebitis and thrombophlebitis of femoral vein, bilateral
I80.211* Phlebitis and thrombophlebitis of right iliac vein
I80.212* Phlebitis and thrombophlebitis of left iliac vein
I80.213* Phlebitis and thrombophlebitis of iliac vein, bilateral
I80.221* Phlebitis and thrombophlebitis of right popliteal vein
I80.222* Phlebitis and thrombophlebitis of left popliteal vein
I80.223* Phlebitis and thrombophlebitis of popliteal vein, bilateral
I80.231* Phlebitis and thrombophlebitis of right tibial vein
I80.232* Phlebitis and thrombophlebitis of left tibial vein
I80.233* Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.241* Phlebitis and thrombophlebitis of right peroneal vein
I80.242* Phlebitis and thrombophlebitis of left peroneal vein
I80.243* Phlebitis and thrombophlebitis of peroneal vein, bilateral
I80.251* Phlebitis and thrombophlebitis of right calf muscular vein
I80.252* Phlebitis and thrombophlebitis of left calf muscular vein
I80.253* Phlebitis and thrombophlebitis of calf muscular vein, bilateral
I80.291* Phlebitis and thrombophlebitis of other deep vessels of right lower extremity
I80.292* Phlebitis and thrombophlebitis of other deep vessels of left lower extremity
I80.293* Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral
I82.541* Chronic embolism and thrombosis of right tibial vein
I82.542* Chronic embolism and thrombosis of left tibial vein
I82.543* Chronic embolism and thrombosis of tibial vein, bilateral
I82.811* Embolism and thrombosis of superficial veins of right lower extremity
I82.812* Embolism and thrombosis of superficial veins of left lower extremity
I82.813* Embolism and thrombosis of superficial veins of lower extremities, bilateral
I82.891* Chronic embolism and thrombosis of other specified veins
I89.0 Lymphedema, not elsewhere classified
K90.0 Celiac disease
K90.1 Tropical sprue
K90.2* Blind loop syndrome, not elsewhere classified
K90.3* Pancreatic steatorrhea
K91.2* Postsurgical malabsorption, not elsewhere classified
M05.471* Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
M05.472* Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
M05.571* Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
M05.572* Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.771* Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement
M05.772* Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.871* Other rheumatoid arthritis with rheumatoid factor of right ankle and foot
M05.872* Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
M06.071* Rheumatoid arthritis without rheumatoid factor, right ankle and foot
M06.072* Rheumatoid arthritis without rheumatoid factor, left ankle and foot
M06.871* Other specified rheumatoid arthritis, right ankle and foot
M06.872* Other specified rheumatoid arthritis, left ankle and foot
M30.0 Polyarteritis nodosa
M30.2 Juvenile polyarteritis
M30.8 Other conditions related to polyarteritis nodosa
M31.4 Aortic arch syndrome [Takayasu]
M31.7 Microscopic polyangiitis
M34.83 Systemic sclerosis with polyneuropathy
N18.1* Chronic kidney disease, stage 1
N18.2* Chronic kidney disease, stage 2 (mild)
N18.30* Chronic kidney disease, stage 3 unspecified
N18.31* Chronic kidney disease, stage 3a
N18.32* Chronic kidney disease, stage 3b
N18.4* Chronic kidney disease, stage 4 (severe)
N18.5* Chronic kidney disease, stage 5
N18.6* End stage renal disease
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

* For these diagnoses, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) or qualified non-physician practitioner for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service.

Group 2

(3 Codes)
Group 2 Paragraph

Refer to Group 3 for the secondary ICD-10-CM codes required for coverage for codes 11719, 11720, 11721 and G0127.

Group 2 Codes
CodeDescription
B35.1 Tinea unguium
L60.2 Onychogryphosis
L60.3 Nail dystrophy

Group 3

(16 Codes)
Group 3 Paragraph

For treatment of mycotic nails, or onychogryphosis, or onychauxis (codes 11719, 11720, 11721 and G0127), in the absence of a systemic condition or where the patient has evidence of neuropathy, but no vascular impairment, for which class findings modifiers are not required, ICD-10 CM code B35.1, L60.2 or L60.3 respectively, must be reported as primary, with the diagnosis representing the patient’s symptom reported as the secondary ICD-10-CM code. Refer to the “Indications and Limitations of Coverage and/or Medical Necessity” section of the related LCD.

Secondary Diagnoses to be reported with B35.1, L60.2 or L60.3 for treatment of mycotic nails, onychogryphosis, and onychauxis to indicate medical necessity:

Group 3 Codes
CodeDescription
L02.611 Cutaneous abscess of right foot
L02.612 Cutaneous abscess of left foot
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.041 Acute lymphangitis of right toe
L03.042 Acute lymphangitis of left toe
L60.0 Ingrowing nail
M79.671 Pain in right foot
M79.672 Pain in left foot
M79.674 Pain in right toe(s)
M79.675 Pain in left toe(s)
R26.0 Ataxic gait
R26.1 Paralytic gait
R26.2 Difficulty in walking, not elsewhere classified
R26.81 Unsteadiness on feet
R26.89 Other abnormalities of gait and mobility

Group 4

(98 Codes)
Group 4 Paragraph

Codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127

The ICD-10-CM codes below represent those diagnoses where the patient has evidence of neuropathy, but no vascular impairment, for which class findings modifiers are not required.

Group 4 Codes
CodeDescription
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
A50.43 Late congenital syphilitic polyneuropathy
A50.45 Juvenile general paresis
A52.11 Tabes dorsalis
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
D81.818 Other biotin-dependent carboxylase deficiency
E08.41* Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.42* Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.43* Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E08.44* Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.49* Diabetes mellitus due to underlying condition with other diabetic neurological complication
E08.610* Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy
E09.42* Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy
E09.49* Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication
E09.610* Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy
E10.41* Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42* Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43* Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44* Type 1 diabetes mellitus with diabetic amyotrophy
E10.49* Type 1 diabetes mellitus with other diabetic neurological complication
E10.610* Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E11.41* Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42* Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43* Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44* Type 2 diabetes mellitus with diabetic amyotrophy
E11.49* Type 2 diabetes mellitus with other diabetic neurological complication
E11.610* Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E13.42* Other specified diabetes mellitus with diabetic polyneuropathy
E13.49* Other specified diabetes mellitus with other diabetic neurological complication
E13.610* Other specified diabetes mellitus with diabetic neuropathic arthropathy
E51.11* Dry beriberi
E51.12* Wet beriberi
E52* Niacin deficiency [pellagra]
E53.1* Pyridoxine deficiency
E53.8* Deficiency of other specified B group vitamins
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
E75.244 Niemann-Pick disease type A/B
E75.248 Other Niemann-Pick disease
E77.0 Defects in post-translational modification of lysosomal enzymes
E77.1 Defects in glycoprotein degradation
E77.8 Other disorders of glycoprotein metabolism
E85.1 Neuropathic heredofamilial amyloidosis
G04.1 Tropical spastic paraplegia
G11.10 Early-onset cerebellar ataxia, unspecified
G11.11 Friedreich ataxia
G11.19 Other early-onset cerebellar ataxia
G12.21 Amyotrophic lateral sclerosis
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
G61.0* Guillain-Barre syndrome
G61.1* Serum neuropathy
G61.81 Chronic inflammatory demyelinating polyneuritis
G61.89 Other inflammatory polyneuropathies
G62.0* Drug-induced polyneuropathy
G62.1* Alcoholic polyneuropathy
G62.2* Polyneuropathy due to other toxic agents
G62.81 Critical illness polyneuropathy
G62.82* Radiation-induced polyneuropathy
G62.89 Other specified polyneuropathies
G63 Polyneuropathy in diseases classified elsewhere
G64 Other disorders of peripheral nervous system
G65.0 Sequelae of Guillain-Barre syndrome
G65.1 Sequelae of other inflammatory polyneuropathy
G65.2 Sequelae of toxic polyneuropathy
G70.1* Toxic myoneural disorders
G73.3* Myasthenic syndromes in other diseases classified elsewhere
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
G95.0 Syringomyelia and syringobulbia
M05.571* Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
M05.572* Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M34.83 Systemic sclerosis with polyneuropathy
Group 4 Medical Necessity ICD-10-CM Codes Asterisk Explanation

* For these diagnoses, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) or qualified non-physician practitioner for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service.

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

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ICD-10-PCS Codes

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Additional ICD-10 Information

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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.

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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.

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Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2021 R3

Based on annual ICD-10 updates for 2022, ICD-10 code E75.244 was added to Group 1 and Group 4 covered diagnoses.

10/01/2020 R2

Based on annual ICD-10 updates for 2021, ICD-10 codes G11.1 and N18.3 were deleted and replaced by G11.10, G11.11, G11.19 for Groups 1 and 4, and N18.30, N18.31 and N18.32 for Group 1 covered diagnoses.

03/19/2020 R1

Article revised to clarify coverage for debridement of mycotic nails and to remove the following documentation requirements:

For debridement of mycotic nails, each service encounter, the medical record should contain a description of each nail which requires debridement. This should include, but is not limited to, the size (including thickness) and color of each affected nail. In addition, the local symptomatology caused by each affected nail resulting in the need for debridement must be documented. For CPT code 11720 documentation of at least one nail will be accepted. For CPT code 11721 complete documentation must be provided for at least 6 nails.

 

Associated Documents

Related Local Coverage Documents
LCDs
L33636 - Routine Foot Care and Debridement of Nails
Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
09/23/2021 10/01/2021 - N/A Currently in Effect You are here
09/24/2020 10/01/2020 - 09/30/2021 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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