Billing and Coding: Routine Foot Care and Debridement of Nails

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.  
  
_

**_Exceptions to Routine Foot Care Exclusions_**

Presence of Systemic Condition

The presence of a systemic condition such as metabolic, neurologic, or
peripheral vascular disease requiring scrupulous foot care by a professional
that in the absence of such condition(s) would be considered routine (and,
therefore, excluded from coverage).

Accordingly, foot care that would otherwise be considered routine may be
covered when systemic condition(s) result in severe circulatory embarrassment
or areas of diminished sensation in the individual's legs or feet.
Documentation of the class findings below supports these conditions:

**Class Findings**

**_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._

**Mycotic Nails**

Treatment of mycotic nails or onychogryphosis, or onychauxis (codes 11719,
11720, 11721 and G0127 may be covered under the exceptions to the routine foot
care exclusion when one of the situations below is present:

  1. Systemic conditions with adequate documentation of class findings as outlined above, and the use of the appropriate modifier, indicating the presence of qualifying systemic illnesses causing a peripheral neuropathy. 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 criteria are met; OR
  2. 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._

**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.

In addition, the beneficiary may have complicated diagnosis(es) that require
them to be under the care of a primary physician for the disease that is
causing the beneficiary to seek provider based routine foot care. For the
asterisked conditions below, the name of the primary physician (must be a D.O.
or M.D.) who made the diagnosis, and the approximate date of the last visit
should be included in the record and entered on the appropriate claim forms or
electronic equivalent when billing Medicare per the Benefit Policy Manual
noted above. Please refer to the CMS website for instructions for billing Part
A and Part B claims.

**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.

The clinical documentation must clearly show that the patient's condition
warrants a provider rendering these services in accordance with the above
instruction, and failure to provide such professional services would be
hazardous to the beneficiary due to their underlying medical condition(s).
**The billed diagnoses should be supported with clinical findings**. Failure
to properly document the reasoning for the care rendered may result in denial
of the claim.

**There should be documentation of co-existing systemic illness. The physical
examination and findings must be precise and specific, with documentation of
the location, appearance, characteristics and symptoms of the nails and/or
lesion(s). The procedure note must describe what, how and where the procedures
were performed and correlate these treatments to the lesions documented on the
physical examination. The procedure note may reference the physical
examination when describing the treatment(s) given during the procedure
**(e.g., _left great toe, or right foot, 4 th digit._)

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 fungi in the toenail either by culture **or
similarly by either nucleic acid probes or amplified probe technique** only is
medically indicated only when necessary to differentiate fungal disease from
psoriatic nail, or when definitive treatment for prolonged oral antifungal
therapy has been planned and there must be adequate documentation in the file.
If cultures or nucleic acid probes or amplified probe techniques are performed
and billed, documentation of cultures or nucleic acid probes or amplified
probe techniques 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/_** ** _Limitations_**

  1. 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. 
  2. The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.
  3. 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.
  4. 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 Doctor of Osteopathic Medicine actively managing the patient's systemic condition.
  5. 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.
  6. 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.
  7. **Effective for dates of service on or after December 1, 2023** , a Registered Nurse that holds foot care certification such as Certified Foot Care Nurse (CFCN) or Certified Foot Care Specialist (CFCS) or other similar certifications or independent training by supervising professionals may perform covered foot care services when all the following requirements are met:  

    * Services are performed under direct supervision of a physician or other practitioner
    * All requirements of the "incident to" provision are met per the CMS Medicare Benefit Policy Manual
    * Proof of accredited Foot Care Nurse certification must be available for NGS on request
    * All other coverage provisions outlined in this Billing and Coding Article are met