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Local Coverage Determination (LCD)

Routine Foot Care and Debridement of Nails

L34246

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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
L34246
Original ICD-9 LCD ID
Not Applicable
LCD Title
Routine Foot Care and Debridement of Nails
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 08/03/2023
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations, and/or Medical Necessity.
Issue - Explanation of Change Between Proposed LCD and Final LCD

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 100-2, Medicare Benefit Policy Manual, Chapter 15:

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

CMS Publication 100-3, Medicare National Coverage Determination (NCD) Manual Part 1:

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

CMS Publication 100-9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5:

    National Correct Coding Initiative.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

The Medicare program generally does not cover routine foot care. However, this determination outlines the specific conditions for which coverage may be present.

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

  • 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 in the realm of self care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients;
  • Any services performed in the absence of localized illness, injury, or symptoms involving the foot.


Indications:

While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits.

Medicare payment may be made for routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient’s legs or feet).

Treatment of warts on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.

Services normally considered routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or 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. 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, and/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  and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

In addition, procedures for treating toenails are covered for the following:

Onychogryphosis (defined as long-standing thickening, in which typically a curved hooked nail (ram's horn nail) occurs), and there is marked limitation of ambulation, pain, and/or secondary infection  where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe; and/or

Onychauxis  (defined as a thickening (hypertrophy) of the base of the nail/nail bed) and there is marked limitation of ambulation, pain, and/or secondary infection that causes symptoms.

The following physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the patient record, in order for routine foot care services to be reimbursable.

Class A findings
Non-traumatic amputation of foot or integral skeletal portion thereof

Class B findings
Absent posterior tibial pulse
Advanced trophic changes as evidenced by any three of the following:

  1. hair growth (decrease or increase)
  2. nail changes (thickening)
  3. pigmentary changes (discoloring)
  4. skin texture (thin, shiny)
  5. 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)
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.

Note: Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the appropriate ICD-10-CM code being included on the claim.

Limitations:

When the patient's condition is designated by an ICD-10-CM code that indicates the routine foot care was done based on the patient having a complicating disease, the procedures are reimbursable only if the patient is 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 or if the patient had come under a physician’s care shortly after the services were furnished.

The global surgery rules will apply to routine foot care procedure codes. 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.
Summary of Evidence

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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
View 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

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

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

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators, LL is not responsible for the continuing viability of Web site addresses listed below.

Copyright 2001, Physicians’ Current Procedural Terminology, American Medical Association

Copyright Medicode’s HCPCS 2000 and 2002

Empire Medicare Services New York and New Jersey Medical Directors.

Other Carrier Policies (Connecticut-Policy Number 94004A V1.2 revised January 13, 1998, Florida-Local Medical Review Policy revised August 14, 1998, and New York State Local Medical Review Policy-Empire/GHI/UMD-Policy Number FC001E02 revised February 25, 2000)
Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
08/03/2023 R16

R17

Revision Effective: 08/03/2023

Revision Explanation: Annual Review, no changes were made.

08/03/2023-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.
  • Other (Annual Review)
08/04/2022 R15

R16

Revision Effective: 08/04/2022

Revision Explanation: Annual Review, no changes were made

07/26/2022-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.
  • Other (Annual Review)
07/29/2021 R14

R15

Revision Effective: 07/29/2021

Revision Explanation: Annual Review, no changes were made

07/23/2021-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.
  • Other (Annual Review)
11/28/2019 R13

R14

Revision Effective: n/a

Revision Explanation: Annual Review, no changes made

07/30/2020-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.
  • Other (Annual Review, no changes made)
11/28/2019 R12

R13

Revision Effective: 11/28/2019

Revision Explanation: Removed other comments from coverage and indications section and information in associated documents section was removed and placed in the billing and coding article. 

11/20/2019-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
10/03/2019 R11

R12

Revision Effective: 10/03/2019

Revision Explanation: During the code migration information for the indications and limitations for routine foot care was accidently remove from the coverage and indication section. This information as been added back the section.

 

10/09/2019-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.
  • Typographical Error
10/01/2018 R10

R11

Revision Effective: 10/03/2019

Revision Explanation: Removed billing and coding based on CR10901. Converted to new policy template that no longer includes coding section based on CR 10901. Supplemental article is being retired and replaced with new article A57193.

 

09/18/2018-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.
  • Revisions Due To Code Removal
10/01/2018 R9

Annual Review, no changes made.
  • Other (Annual Review)
10/01/2018 R8

R9

Revision Effective: 10/01/2018

Revision Explanation: New code E75.26 was added to group 1 and 3 from 2019 ICD-10 annual review.

09/18/2018-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.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R7

R8

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

07/30/2018-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.
  • Other (Annual review)
10/01/2017 R6

R7

Revision Effective: 10/01/2017

Revision Explanation: During ICD-10 annual review E85.8 was deleted and replaced with E85.81, E85.82, and E85.89 in groups 1 and 3.

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.

 

R6

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

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.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R5 R5
Revision Effective: 10/01/2016
Revision Explanation: During annual ICD-10 update codes E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359 were deleted and replaced with the following codes: E08.3211, E08.3212, E08.3213, E08.3291, E08.3292, E08.3293, E08.3311, E08.3312, E08.3313, E08.3391, E08.3392, E08.3393, E08.3411, E08.3412, E08.3413, E08.3491, E08.3492, E08.3493, E08.3511, E08.3512, E08.3513, E08.3521, E08.3522, E08.3523, E08.3531, E08.3532, E08.3533, E08.3541, E08.3542, E08.3543, E08.3551, E08.3552, E08.3553, E08.3591, E08.3592, E08.3593, E08.37X1, E08.37X2, E08.37X3, E09.3211, E09.3212, E09.3213, E09.3291, E09.3292, e09.3293, E09.3311, E09.3312, e09.3313, E09.3391, E09.3392, E09.3393, E09.3411, E09.3412, E09.3413, E09.3491, E09.3492, E09.3493, E09.3511, E09.3512, E09.3513, E09.3521, E09.3522, E09.3523, E09.3531, E09.3532, E09.3533, E09.3541, E09.3542, E09.3543, E09.3551, E09.3552, E09.3553, E09.3591, e09.3592, E09.3593, E09.37X1, E09.37X2, E09.37X3, E10.3211, E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.3311, E10.3312, E10.3313, E10.3391, E10.3392, E10.3393, E10.3411, E10.3412, E10.3413, E10.3491, E10.3492, E10.3493, E10.3511, E10.3512, e10.3513, E10.3521, E10.3522, E10.3523, E10.3531, E10.3532, E10.3533, E10.3541, E10.3542, E10.3543, E10.3551, E10.3552, E10.3553, E10.3591, E10.3592, E10.3593, E10.37X1, E10.37X2, E10.37X3, E11.3211, e11.3212, E11.3213, E11.3291, E11.3292, E11.3293, E11.3311, E11.3312, E11.3313, E11.3391, E11.3392, E11.3393, E11.3411, E11.3412, E11.3413, E11.3491, E11.3492, E11.3493, E11.3511, e11.3512, E11.3513, E11.3521, E11.3522, E11.3523, E11.3531, E11.3532, E11.3533, E11.3541, E11.3542, E11.3543, E11.3551, E11.3552, E11.3553, E11.3591, E11.3592, E11.3593, E11.37X1, E11.37X2, E11.37X3, E13.3211, E13.3212, E13.3213, E13.3291, E13.3292, E13.3293, E13.3311, E13.3312, E13.3313, E13.3391, E13.3392, E13.3393, E13.3411, E13.3412, e13.3413, E13.3491, E13.3492, e13.3493, E13.3511, E13.3512, E13.3513, E13.3521, E13.3522, E13.3523, E13.3531, E13.3532, E13.3533, E13.3541, E13.3542, E13.3543, E13.3551, E13.3552, E13.3553, E13.3591, e13.3592,E13.3593,E13.37X1,E13.37X2,E13.37X3
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R4 R4
Revision Effective: N/A
Revision Explanation: Annual review corrected formatting listing class finding to move the heading for Class C from end of class B findings to over the list for class C.
  • Other (annual review and formatting)
10/01/2015 R3 R3
Revision Effective:10/01/2015
Revision Explanation: Removed ICD-9 code left in text in error as well as L60.8 and L62 since it was removed from group 2.
  • Typographical Error
10/01/2015 R2 R2
Revision Effective:10/01/2015
Revision Explanation: In indications section L60.0 should have been L60.2.
  • Typographical Error
10/01/2015 R1 R1
Revision Effective:10/01/2015
Revision Explanation: In group 2 ICD-10 code L60.8 and L62 were included in error.
  • Typographical Error
N/A

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
07/25/2023 08/03/2023 - N/A Currently in Effect You are here
07/26/2022 08/04/2022 - 08/02/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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