Routine foot care is excluded from coverage.  Services that normally are considered routine and not covered include the following:

• The cutting or removal of corns and calluses;
• The trimming, cutting, clipping, or debriding of nails; and
• 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 feet.

This policy addresses exceptions to this exclusion.

Routine Foot Care
The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require 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.

In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions.

Claims for this type of foot care should not be paid in the absence of convincing evidence that nonprofessional performance of the service would have been hazardous for the member because of an underlying systemic disease. The mere statement of a diagnosis such as those mentioned in above does not of itself indicate the severity of the condition.

Debridement of Mycotic Nails
In the absence of a systemic condition, treatment of mycotic nails may be covered in the following circumstances;

• Ambulatory Patient:  The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents:
  
  • clinical evidence of mycosis of the toenail (110.1); and,
  • marked limitation of ambulation (719.7, 781.2) , pain (729.5) , or secondary infection (681.10, 681.11)  resulting from the thickening and dystrophy of the infected toenail plate.
    
• Non-ambulatory Patient:  The treatment of mycotic nails for a non-ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents:
  
  • clinical evidence of mycosis of the toenail (110.1); and,
  • the patient suffers from pain (719.7), or secondary infection (681.10, 681.11) resulting from the thickening and dystrophy of the infected toenail plate.

Presence of Systemic Conditions
Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might justify coverage for routine foot care.

• Amyotrophic lateral sclerosis (ALS)
• Arteritis of the feet
• Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
• Buerger’s disease (thromboangiitis obliterans)
• Chronic indurated cellulitis
• Chronic thrombophlebitis *
• Chronic venous insufficiency
• Diabetes mellitus *
• Intractable edema - secondary to a specific disease (e.g., congestive heart failure, kidney disease, hypothyroidism)
• Lymphedema - secondary to a specific disease (e.g., Milroy's disease, malignancy)
• 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
• Peripheral vascular disease
• Raynaud's Disease

When the patient’s condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

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  - One required
  • Nontraumatic amputation of foot or integral skeletal portion thereof.
    
    
• Class B Findings  - Two required
  • Absent posterior tibial pulse;
  • Advanced trophic changes as evidenced by any three of the following;:
    • hair growth (decrease or absence)
    • nail changes (thickening)
    • pigmentary changes (discoloration)
    • skin texture (thin, shiny) skin color (rubor or redness)
  • Absent dorsalis pedis pulse.
    
    
• Class C Findings – One class B and two class C required
  • 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.

For purposes of applying the coverage presumption where the routine services have been rendered by a podiatrist, the Plan may deem the active care requirement met if the claim or other evidence available discloses 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 rendition of the routine-type services. The Plan may also accept the podiatrist’s statement that the diagnosing and treating M.D. or D.O. also concurs with the podiatrist’s findings as to the severity of the peripheral involvement indicated.

The name of the M.D or D.O. who diagnosed the complicating condition must be submitted with the claim.  In those cases, where active care is required, the approximate date the member was last seen by such physician must also be indicated.

Evaluations and Management Services
The decision to perform routine foot care or debride mycotic nails is included in the payment for the procedure and should not be reported separately as an E&M service. Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the routine foot care or debridement of nail service. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

The E&M service and minor surgical procedure do not require different diagnoses. If routine foot care is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.

Reasons for Noncoverage

Whirlpool (97022) treatment performed with routine foot care (11055 – 11056, 11719) or debridement of mycotic nails (11720, 11721) is not eligible for separate reimbursement.  When one physician reports whirlpool treatment in addition to routine foot care or debridement of mycotic nails, the services are combined under procedure codes 11055 – 11056, 11719, or 11720-11721, as appropriate.  Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day.  When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Services provided for conditions other than those considered eligible are not covered.  A provider can bill the member for the denied service.

Documentation Requirements

All documentation must be maintained in the patient’s medical record and available upon request.

Documentation to Support Debridement of Mycotic Nails:  The information submitted with claims must be substantiated by documentation found in the patient’s medical record. Any information, including that contained in a form letter, used for documentation purposes is subject to carrier verification in order to ensure that the information adequately justifies coverage of the treatment of mycotic nails.

There must be adequate documentation to demonstrate the need for routine foot care services as described in this policy.  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 routine foot care exclusion.

Documentation of the co-existing systemic illness should be included in the medical record.

Physical findings and services must be specific and precise (e.g., left great toe OR right foot, 4th digit). 

Documentation supporting procedure code 11720 should include a description of at least one toenail.

Documentation supporting procedure code 11721 should include a description of at least six toenails.

Report code 11720 when debriding 1 – 5 toenails.

Report code 11721 debriding 6 – 10 toenails.

Use modifier Q7 to indicate the presence of one Class A finding.

Use modifier Q8 to indicate the presence of two Class B findings.

Use modifier Q9 to indicate the presence of one Class B and two Class C findings.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-line Manual 100-02, Chapter 15, Section 290

Diagnosis Codes that Support Medical Necessity

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Routine Foot Care (11055, 11056, 11057, 11719, 11720, 11721 and G0127)

*NOTE: When the patient's condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

Debridement of Mycotic Nails (11720, 11721)

*NOTE: ICD-9-CM code 110.1 must appear on each claim in addition to one of the other above ICD-9-CM codes that indicates secondary infection, pain, or difficulty in ambulation.