Procedure codes and Description
Group 1 Codes:
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
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following, regardless of the provider rendering the service:
Cutting or removal of corns and calluses;
Trimming, cutting, clipping, or debridement of nails, including debridement of mycotic nails;
Shaving, paring, cutting or removal of keratoma, tyloma, and heloma;
Other hygienic and preventive maintenance care in the realm of self-care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients;
Any other service performed in the absence of localized illness, injury, or symptoms involving the foot.
Routine foot care is usually performed by the beneficiary himself or herself, or by a caregiver.
However, the Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 290 describes exceptions to routine foot care exclusions. This LCD outlines such exceptions.
Indications
Routine foot care services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of routine foot care services.
Exceptions to the routine foot care exclusions include:
Necessary and integral part of otherwise covered services;
Treatment of warts on foot;
Presence of systemic conditions, such as metabolic, neurologic, or peripheral vascular disease;
Mycotic nails:
In the presence of systemic conditions as noted above in #3.
In the absence of systemic conditions:
Ambulatory patient must have marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.
Non ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.
Systemic Conditions
Foot care services are covered in the presence of a systemic condition based on the list of illnesses described in Chapter 15, Section 290 of the Benefit Policy Manual.
Diabetes mellitus *
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
Buerger’s disease (thromboangiitis obliterans)
Chronic thrombophlebitis *
Peripheral neuropathies involving the feet –
Associated with malnutrition and vitamin deficiency *
Malnutrition (general, pellagra)
Alcoholism
Malabsorption (celiac disease, tropical sprue)
Pernicious anemia
Associated with carcinoma *
Associated with diabetes mellitus *
Associated with drugs and toxins *
Associated with multiple sclerosis *
Associated with uremia (chronic renal disease) *
Associated with traumatic injury
Associated with leprosy or neurosyphilis
Associated with hereditary disorders
Hereditary sensory radicular neuropathy
Angiokeratoma corporis diffusum (Fabry’s)
Amyloid neuropathy
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 who documents the condition.
The active care requirement would be considered met if the claim indicates that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the service.
Presumption of Coverage
In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement. For purposes of applying this presumption the following findings are pertinent:
Class A Findings
Nontraumatic amputation of foot or integral skeletal portion thereof.
Class B Findings
Absent posterior tibial pulse;
Advanced trophic changes as: hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), skin color (rubor or redness) (Three required); 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:
A Class A finding;
Two of the Class B findings; or
One Class B and two Class C findings.
In addition to a valid billing modifier, these services must include a systemic condition diagnosis listed above and in Group 1 of the diagnosis codes. All claims for routine foot care based on the presence of a systemic condition must have a billing modifier of Q7, Q8 or Q9 to be considered for payment.
Mycotic Nails
Mycotic nail debridement may be a covered service:
In the presence of a systemic disease with the class findings and appropriate Q modifier.
In the absence of systemic disease if the patient has mycotic nails and marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.
In the absence of systemic disease when a non-ambulatory patient has mycotic nails and suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.
For services without systemic disease and class findings, the diagnosis in Group 2 and Group 3 of the diagnosis codes below must be documented in the medical record and submitted on the claim.
The nail debridement procedure codes are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services.
Limitations
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.
The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.
Medicare allows payment for routine foot care only if the conditions under indications are met. These conditions describe the systemic diseases and their peripheral complications that increase the danger for infection and injury if a non-professional provides these services.
Services not meeting the criteria in this statement of national coverage will be denied as statutory non-covered services. For diagnosis codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the doctor of medicine or osteopathy actively managing the patients systemic condition.
Nail debridement procedures are considered non-covered 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.
Foot care services that do not require a professional would be considered routine and not a Medicare benefit. Professional in this situation is defined as an M.D., D.O., D.P.M., Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant.
Loss of protective sensation (LOPS) is not the subject of this LCD. Please refer to NCD 70.2.1.
ICD-10 Codes that Support Medical Necessity
Group 1 Paragraph: For codes 11055, 11056, 11057, 11719, 11720, 11721, G0127 billed with modifier Q7, Q8 or Q9. Diagnosis codes with an asterisk also need the date last seen and name and NPI of the attending physician.
For the codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.
Limitations
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.
The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.
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 diagnosis 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 a systemic condition based on the list of illnesses described in Chapter 15, Section 290 of the Benefit Policy Manual and coded 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 who documents the condition. This must be indicated by the name and 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 noncovered routine-type foot care services.
Services not meeting the instructions and criteria in this statement of national coverage will be denied as statutory noncovered services. For ICD-10 codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the doctor of medicine or osteopathy.
Loss of protective sensation (LOPS) is not the subject of this LCD.
Group 1Codes
ICD-10 CODE DESCRIPTION
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
A30.9 Leprosy, unspecified
A52.10 Symptomatic neurosyphilis, unspecified
A52.11 Tabes dorsalis
A52.12 Other cerebrospinal syphilis
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
A52.2 Asymptomatic neurosyphilis
A52.3 Neurosyphilis, unspecified
D51.0* Vitamin B12 deficiency anemia due to intrinsic factor deficiency
E08.00 – E13.9* – Opens in a new window 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
E75.22 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
E75.248 Other Niemann-Pick disease
E75.249 Niemann-Pick disease, unspecified
E75.3 Sphingolipidosis, unspecified
E77.0 Defects in post-translational modification of lysosomal enzymes
E77.1 Defects in glycoprotein degradation
E77.8 Other disorders of glycoprotein metabolism
E77.9 Disorder of glycoprotein metabolism, unspecified
E85.0 Non-neuropathic heredofamilial amyloidosis
E85.1 Neuropathic heredofamilial amyloidosis
E85.2 Heredofamilial amyloidosis, unspecified
E85.3 Secondary systemic amyloidosis
E85.4 Organ-limited amyloidosis
E85.8 Other amyloidosis
E85.9 Amyloidosis, unspecified
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
G60.9 Hereditary and idiopathic neuropathy, unspecified
G61.1 Serum neuropathy
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
G65.0 Sequelae of Guillain-Barre syndrome
G65.1 Sequelae of other inflammatory polyneuropathy
G65.2 Sequelae of toxic polyneuropathy
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
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
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
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg
I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
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
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
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
I70.301 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg
I70.302 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg
I70.303 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs
I70.311 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg
I70.312 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, left leg
I70.313 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral
legs
I70.321 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, right leg
I70.322 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, left leg
