Article - Billing and Coding: Routine Foot Care and Debridement of Nails (A57759)

CMS National Coverage PolicyLanguage 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,italicizedtext 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 TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forRoutine 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 ExclusionsPresence of Systemic ConditionThe 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 individuals legs or feet. Documentation of the class findings below supports these conditions:Class FindingsClass A findingsNon-traumatic amputation of foot or integral skeletal portion thereof.Class B findingsAbsent 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); ANDAbsent dorsalis pedis pulse.Class C findingsClaudication;Temperature changes (e.g., cold feet);Edema;Paresthesias (abnormal spontaneous sensations in the feet); andBurning.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; orOne Class B and two Class C findings.Mycotic NailsTreatment 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: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; ORIn 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, andMarked 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 toMedicare 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, andA 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; andPatient 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 withinthe 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 patients 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, 4thdigit.)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 patients 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 cultureor similarly by either nucleic acid probes or amplified probe techniqueonlyis 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/LimitationsCovered 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 Doctor of Osteopathic Medicine 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.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 practitionerAll requirements of the incident to provision are met per the CMS Medicare Benefit Policy ManualProof of accredited Foot Care Nurse certification must be available for NGS on requestAll other coverage provisions outlined in this Billing and Coding Article are metProviders should be aware that this may not be allowed, based on their state scope of practice laws.