Local Coverage Determination (LCD)

Routine Foot Care and Debridement of Nails

L33636

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Contractor Information

LCD Information

Document Information

LCD ID
L33636
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 12/26/2019
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 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.

Current Dental Terminology © 2021 American Dental Association. All rights reserved.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS 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. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

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.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

The Medicare program generally does not cover routine foot care. However, this determination and the related Billing and Coding article outline the specific conditions for which coverage may be allowed.

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 mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. Please refer to the related Billing and Coding article for coverage criteria.

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 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. Refer to the related Billing and Coding article for Class 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 ICD-10-CM codes in Group 4 of the “ICD-10-CM Codes that Support Medical Necessity” section in the related Billing and Coding article. 

Limitations:

When the patient's condition is designated by an ICD-10-CM code with an asterisk (*) (see ICD-10-CM Codes That Support Medical Necessity in the related article), routine foot care 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. 

Other Comments:

Medicare does not routinely cover fungus cultures and KOH preparations performed on toenail clippings in the doctor’s office. Identification of cultures of fungi in the toenail clippings is medically necessary only:

When it is required to differentiate fungal disease from psoriatic nails.

When a definitive treatment for a prolonged period of time is being planned involving the use of a prescription medication.

 

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. National Government Services 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 DateRevision History NumberRevision History ExplanationReasons for Change
12/26/2019 R17

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A57759. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
10/01/2019 R16

LCD revised for annual ICD-10 update for 2020. ICD-10 codes I80.241, I80.242, I80.243, I80.251, I80.252 and I80.253 were added to Group 1, ICD-10 Codes that Support Medical Necessity.

  • Revisions Due To ICD-10-CM Code Changes
01/01/2019 R15

LCD revised to clarify class findings criteria, under Indications of coverage.

  • Provider Education/Guidance
10/01/2017 R14

Due to the annual ICD-10-CM code update, ICD-10-CM code E85.8 was deleted from Group 1 of the "ICD-10-CM Codes that Support Medical Necessity" section of the LCD. ICD-10-CM codes E85.81, E85.82 and E85.89 were added as the replacement codes.

DATE (10/01/2017): At this time, the 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
08/15/2017 R13

Due to an inconsistency with CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290, the following language has been removed from the "Limitations" section:


"or if the patient had come under a physician's care shortly after the services were furnished."


The italicized language included in the "Abstract" and "Indications" sections should be verbatim from CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290 and has been revised accordingly.


The number listed in the note below has been revised to reflect the addition of a Group 4.


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 ICD-10-CM codes in Group 4 of the "ICD-10-CM Codes that Support Medical Necessity" section listed below.


Added Bill Type Codes 071X and 077X.

  • Provider Education/Guidance
  • Revisions Due To Bill Type or Revenue Codes
10/01/2015 R12 ICD-10-CM code L62 which was inadvertently included in Group 1 has been removed. ICD-10-CM code L60.2 is included as covered in the LCD and provides greater specificity for reporting onychogryphosis and onychauxis. The groups of ICD-10-CM codes in the “ICD-10-CM Codes that Support Medical Necessity” section have been renumbered. ICD-10-CM codes B35.1, L60.2 and L60.3 were moved from Group 1 into Group 2 for clarity.
  • Provider Education/Guidance
10/01/2015 R11 The following explanatory note in the “CPT/HCPCS Codes” section was revised to include the exception to the class finding modifier requirement:

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:

ICD-10-CM codes E08.41, E08.43, E08.44, E10.41, E10.43, E10.44, E11.41, E11.43 and E11.44 were added to Groups 1 and 3 in the “ICD-10-CM Codes that Support Medical Necessity” section.

An asterisk (*) which denotes 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 was added to M05.872, M06.071 and M06.072 in Group 1 in the “ICD-10-CM Codes that Support Medical Necessity” section.

An asterisk (*) was added to ICD-10-CM codes G35, M05.571 and M05.572 in Group 3 in the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Provider (Part A)
10/01/2015 R10 The following explanatory note was added to the “CPT/HCPCS Codes” section:

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, to indicate the class findings and site:

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.

The following explanatory notes in Groups 1, 2 and 3 were revised for clarity to include the CPT/HCPCS codes:

Group1: Paragraph
Codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127


For ICD-10-CM code B35.1, L60.2 or L60.3 refer to Group 2 for the secondary ICD-10-CM codes required for coverage for codes 11719, 11720, 11721 and G0127.

Group 2: 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 LCD.

Group 3: Paragraph
Codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127
  • Provider Education/Guidance
10/01/2015 R9 ICD-10-CM codes E08.52, E09.52, E10.52, E11.52 and E13.52 were added to Group 1 in the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R8 Based on a practitioner request, ICD-10-CM code L60.3 was added to Group 1 as well as the explanatory notes in Groups 1 and 2 in the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R7 The following statement was added to the explanatory note in Group 1 of the of the “ICD-10-CM Codes that Support Medicare Necessity” section:

For ICD-10-CM code B35.1 or L60.2, refer to Group 2 for the secondary ICD-10-CM codes required for coverage.
  • Provider Education/Guidance
10/01/2015 R6 The following explanatory note was revised for clarity:

For treatment of mycotic nails, or onychogryphosis, or onychauxis, 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 or L60.2 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 LCD.

Based on a practitioner request, ICD-10-CM codes E08.51 and E13.51 were added to Group 1 in the “ICD-10-CM codes that Support Medical Necessity” section.

ICD-10-CM codes E08.610, E09.610 and E13.610 were added to Groups 1 and 3 in the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Provider Education/Guidance
  • Request for Coverage by a Provider (Part A)
10/01/2015 R5 Based on a practitioner request, ICD-10-CM codes E09.51, E10.51, E11.51, I70.291, I70.292 and I70.293 were added to Group 1 in the “ICD-10-CM codes that Support Medical Necessity” section.

ICD-10-CM codes E10.610 and E11.610 were added to Groups 1 and 3 in the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R4 Based on a practitioner request, ICD-10-CM codes E08.42, E09.42, E10.42, E11.42 and E13.42 were added to Groups 1 and 3 in the “ICD-10-CM Codes that Support Medical Necessity” section.

  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R3 Based on a practitioner request, ICD-10-CM codes I70.201, I70.202, I70.203 and I70.90 were added to Group 1 in the “ICD-10-CM Codes that Support Medical Necessity” section.
  • Request for Coverage by a Practitioner (Part B)
10/01/2015 R2 Minor template language change.
  • Other
10/01/2015 R1 Added ICD-10-CM code G95.0 to Group 1 in the "ICD-10-CM Codes that Support Medical Necessity" section.
  • Revisions Due To ICD-10-CM Code Changes

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
12/19/2019 12/26/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Feet
  • Toes
  • Toenails

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