Contractor Name Wisconsin Physicians Service (WPS)

Contractor Number 00951, 00952, 00953, 00954 05101, 05201, 05301, 05401, 05102, 05202, 05392, 05302, 05402 52280

Contractor Type. Carrier MAC A MAC B Intermediary - A

LCD Database ID Number

LCD Version Number

LCD Title Routine Foot Care And Debridement Of Nails

Contractor's Determination Number FT-001

AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2008 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. Current dental terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

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)

1 Part 411.15., subpart A addresses general exclusions and exclusion of particular services. CMS Publications: CMS Publication 100-2, Medicare Benefit Policy Manual, (MBPM) Chapter 15: 290 Foot care services which are exceptions to the Medicare coverage exclusion. CMS Publication 100-3, Medicare National Coverage Determination Manual, Part 1: 70.2.1 Services provided for diagnosis and treatment of diabetic peripheral neuropathy. CMS Publication 100-9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5: National Correct Coding Initiative.

Primary Geographic Jurisdiction

Carrier B: Wisconsin, Illinois, Michigan, Minnesota

Legacy A: Alaska, Alabama, Arizona, Arkansas, California - Entire State, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Iowa, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Maryland, Maine, Michigan, Minnesota, Missouri - Entire State, Mississippi, Montana, North Carolina, North Dakota, Nebraska, New Hampshire, New Jersey, New Mexico, Nevada, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Vermont, Washington, Wisconsin, West Virginia, Wyoming, District of Columbia, American Samoa, Guam, Northern Mariana Islands, Virgin Islands

MAC A: Iowa, Missouri, Nebraska, Kansas

MAC B: Iowa, Missouri, Nebraska, Kansas

Oversight Region Region V

CMS Consortium Midwest

Original Determination Effective Date 08/16/2009

Revision Effective Date

Indications and Limitations of Coverage and/or Medical Necessity Routine foot care is the paring, cutting, or trimming of corns and calluses, or debridement and trimming of toenails 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.

Medicare allows payment for routine foot care only if the conditions under "Indications and Limitations of Coverage" 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.

NOTE All claims submitted with CPT codes 11055, 11056, 11057, 11719, and G0127 must have modifier Q7, Q8, or Q9 and an ICD-9 code listed in this policy. If a claim is submitted without

2 this it will be denied. If the claim has a GA modifier the patient is responsible for denied claims or, without a GA modifier, a message will be on the remittance notice stating that the service may not be billed to the patient.

The following services are considered to be components of routine foot care and are generally excluded from coverage under both Part A and Part B, regardless of the provider rendering the service:

• 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 in the realm of self care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients; • Any services performed in the absence of localized illness, injury, or symptoms involving the foot.

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.

1. Covered Routine Foot Care CPT codes 11055, 11056, 11057, 11719, and G0127 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).

Services normally considered routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.

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.

The following 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

For purposes of applying this presumption the following findings are pertinent:

Class A findings Non-traumatic amputation of foot or integral skeletal portion thereof

Class B findings Absent posterior tibial pulse Advanced trophic changes as evidenced by any three of the following:

3 1. hair growth (decrease or increase) 2. nail changes (thickening) 3. pigmentary changes (discoloring) 4. skin texture (thin, shiny) 5. skin color (rubor or redness) Absent dorsalis pedis pulse

Class C findings Claudication Temperature changes (e.g., cold feet) Edema Paresthesias (abnormal spontaneous sensations in the feet) Burning

The presumption of coverage may be applied when the physician rendering the routine foot care has identified:

1. A Class A finding (Modifier Q7) 2. Two of the Class B findings (Modifier Q8); or 3. One Class B and two Class C findings ( Modifier Q9 ).

2. Covered Nail Debridement CPT codes 11720, 11721 NAIL DEBRIDEMENT DEFINITION: Nail debridement involves the removal of excessive nail material (i.e., the reduction of nail thickness or bulk) from clinically thickened, diseased (e.g., mycotic or dystrophic) nail plate, that may or may not also be misshapen in appearance or brittle in characteristic. (This definition has been approved by the American Podiatric Medical Association.)

Debridement of a mycotic nail, whether by electric grinder or manual method, is a temporary reduction in the length and thickness (short of avulsion) of an abnormal nail plate. This is usually performed without anesthesia. The debridement code should not be used if the only part of the nail removed is the distal nail border or other portions of nail that are not attached to the nail bed.

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).

The presumption of coverage may be applied when the physician rendering the routine foot care has identified:

1. A Class A finding (Modifier Q7) 2. Two of the Class B findings (Modifier Q8); or 3. One Class B and two Class C findings ( Modifier Q9 ).

Debridement of the nails may be covered by Medicare when the medical record documents that the beneficiary has mycotic nails and a systemic condition. The claim is submitted with ICD-9 code 110.1 AND the appropriate Q modifier.

4

In the absence of a systemic condition, Medicare covers debridement of the nail when the following criteria are met: In the case of ambulatory patients there exists:

● Clinical evidence of mycosis of the toenail, (110.1 ) and ● Marked limitation of ambulation (719.7 or 781.2), or pain (729.5 or 703.0), and/or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate.

The treatment of mycotic nails for a nonambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that ● There is clinical evidence of mycosis of the toenail (ICD-9 code 110.1 ), and ● The patient suffers from pain ( 729.5 or 703.0 ) or secondary infection ( 681.10 or 681.11 ) resulting from the thickening and dystrophy of the infected toenail plate.

3. Avulsion of Nail CPT code 11730 - 11732 Surgical avulsion is the atraumatic separation and removal of all or part of the nail plate from the nail bed-matrix and the proximal fold. The procedure is most commonly performed for the treatment of chronic ingrown toenails, injury to a nail or infection of the nail. a. Treatment consists of a partial or complete removal of the nail border or complete nail by mechanical or chemical means with disturbance to the nail bed- matrix under anesthesia (local). The nail avulsion procedure codes apply to one or both lateral sides of a nail or the entire nail. Lateral sides may not be billed separately. Only one surgical procedure per nail is permitted.

b. The operative note should be of significant detail to support the procedure reported and the technique used should be described. Local anesthesia is a “bundled service” and may not be billed separately. The correct number of services per nail is one and the modifiers TA and T1-T9 should be reported to identify the toenail in which the surgical avulsion applies. Re-growth of the nail following avulsion treatment is approximately six months. c. Simple cutting of a wedge portion of the nail distal to the eponychium is considered routine trimming of nails (routine foot care) and may not be reported as a nail avulsion. 4. Excision of the nail and the nail matrix (CPT code 11750) Excision of the nail is generally performed for severely deformed or ingrown nails. This procedure may be performed using surgical, laser, electrocautery, or chemical techniques. Following administration of a local anesthetic for total nail avulsion and matrixectomy (excision of nail matrix), the nail matrix is then excised or cauterized using surgical technique, laser, electrocautery, or chemical technique.

5. Wedge excision (CPT code 11765) Wedge excision of the soft tissue with removal of the offending portion of the nail is designed to relieve pressure on the nail/soft tissue.

Generally, a wedge excision of the skin of the nail fold is performed to remove hypertrophic lateral nail folds that develop as a result of chronic ingrown toenails. Following administration of local anesthetic, an excision of a wedge of the soft tissue and ingrown nail from the involved side of the toe is accomplished, and the edges of the wound are approximated with sutures.

5 Limitations: 1. Treatment of simple onychocryptosis with removal of the offending wing or spicule of the nail is considered to be routine foot care in the absence of infection or inflammation. Trimming, cutting, clipping, or debriding of a nail, distal to the eponychium, will be regarded as routine foot care. These services should be reported under the nail trimming/debridement HCPCS code G0127 and CPT codes 11719-11721. It is not appropriate to report CPT codes 11730/11732 when performing these services.

2. When the patient's condition is designated by an ICD-9-CM code with an asterisk (*) (see ICD-9-CM Codes That Support Medical Necessity), 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 or if the patient sees their primary care physician no later than 30 days after the services were furnished.

3. The 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.

4. 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 other diseases affecting the nails.

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

5. Bill type codes only apply to providers who bill these services to the fiscal intermediary. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.

6. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

7. For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for surgical treatment of Nails services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)

Coverage topic

6 Foot care

Coding information

Bill type codes 12x Hospital-inpatient or Home Health visits (Part B only)

13x Hospital-outpatient (HHA-A also) (under OPPS 13x must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

22x SNF-inpatient or home health visits (Part B only)

74x Clinic-ORF only (eff 4/97); ORF and CMHC (10/91 - 3/97)

75x Clinic-CORF

85x Special facility or ASC surgery-rural primary care hospital (eff 10/94)

051x Clinic-general classification

0940 Other therapeutic services-general classification

Revenue codes Revenue codes only apply to providers who bill these services to the Fiscal Intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

CPT/HCPCS 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

11730 Avulsion of nail plate, partial or complete, simple; single

11732 Avulsion of nail plate, partial or complete, simple; each additional nail plate (list separately in addition to code for primary procedure) 11750 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal;

7 11765 Wedge excision of skin of nail fold (eg, for ingrown toenail)

G0127 Trimming of dystrophic nails, any number

ICD-9 codes that support medical necessity

For covered routine foot care: CPT codes: G0127, 11055, 11056, 11057, 11719 billed with the appropriate Q modifier and date last seen by 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 or if the patient sees their primary care physician no later than 30 days after the services were furnished.

249.00-249.92 Secondary diabetes mellitus 250.00-250.13 Diabetes mellitus w/o comp 250.20-250.23 Diabetes w/hyperosmolarity 250.40-250.43 Diabetes renal manifest 250.60-250.63 Diabetes neuro manifest 250.70-250.73 Diabetes circulatent manifest 250.80-250.83 Diabetes unspec manifestation 250.90-250.93 Diabetes other 265.2 Pellagra 281.0 Pernicious anemia 357.2 Polyneuropathy in diabetes 357.3 Polyneuropathy in malignant disease 357.0 Acute infective polyneuritis 357.5 Alcoholic polyneuropathy 357.6 Polyneuropathy due to drugs 357.7 Polyneuropathy due to other toxic agents 340 Multiple sclerosis 446.7 Takayasu's disease 451.0-451.9 Phlebitis/Thrombophlebitis 585.1 Chronic kidney disease, stage i 585.2 Chronic kidney disease, stage ii (mild) 585.3 Chronic kidney disease, stage iii (moderate) 585.4 Chronic kidney disease, stage iv (severe) 585.5 Chronic kidney disease, stage v 585.6 End stage renal disease 729.5 Pain limb 782.0 Skin sensation disturb 795.39 Other nonspec positive culture

CPT codes: G0127, 11055, 11056, 11057, 11719 billed with the appropriate Q modifier

030.0 Lepromatous leprosy (type l) 030.1 Tuberculoid leprosy (type t) 030.3 Indeterminate leprosy (group i) 030.8 Other specified leprosy 030.9 Leprosy unspecified

8 039.4 Madura foot 040.0 Gas gangrene 042 HIV disease 045.10 - Acute polio w/other paralysis 045.13 053.13 Postherpetic polyneuropathy 066.41-066.49 West Nile fever 088.81 Lyme disease 094.0 Tabes dorsalis 094.1 General paresis 094.2 Syphilitic meningitis 094.81 Syphilitic encephalitis 094.82 Syphilitic parkinsonism 094.9 Neurosyphilis unspecified 110.1 Dermatophytosis of nail 272.7 Lipidoses 277.30 Amyloidosis, unspecified 277.31 Familial mediterranean fever 277.39 Other amyloidosis 281.0 Pernicious anemia 289.89 Other blood diseases 323.9 Encephalitis unspec 331.0 Alzheimer's disease 332.0 Paralysis agitans 333.2 Myoclonus 333.4 Huntington's chorea 334.0-334.2 Spinocerebellar disease 335.10 Spinal muscle atrophy unspec 335.20 Amyotrophic lateral sclerosis 335.21 Progressive muscular atrophy 341.8 CNSs demyelination other 342.00-342.92 Flaccid hemiplegia 343.0-343.9 Infantile cerebral palsy 344.00-344.1 Quadraplegia/quadraparesis 344.3 Monoplegia lower limb 353.4 Lumbosacral root les other 353.8 Other nerve root/plexus disorder

9 355.0-355.5 Mononeuritis lower limb 356.0-356.9 Hereditary peripheral neuropathy 357.0-357.9 Inflammatory & toxic neuropathy 357.1 Polyneuropathy in collagen vascular disease 357.4 Polyneuropathy in other diseases classified elsewhere 357.81 Chronic inflammatory demyelinating polyneuritis 357.82 Critical illness polyneuropathy 357.89 Other inflammatory and toxic neuropathy 357.9 Unspecified inflammatory and toxic neuropathies 436 CVA 438.20-438.22 Hemiplegia unspec side 438.40.-438.42 Monoplegia lower limb 438.50-438.52 Other paralytic syndrome 440.0-440.9 Atherosclerosis 442.3 Aneurysm artery lower extremity 443.0 Raynaud's syndrome 443.1 Thromboangiitis Obliterans (Buerger's disease) 443.81-443.9 Other peripheral vascular dis 444.22 Lower extremity embolism 444.81 Iliac artery embolism 444.89 Arterial embolism other 446.0 Polyarteritis nodosa 447.8 Arterial disease other 447.9 Arterial disease unspec 453.9 Embolism and thrombosis of unspecified site 454.0-454.9 Varicose veins lower extremity 457.1 Other lymphedema 459.10-459.19 Postphlebetic syndrome 459.81-459.9 Other dis circulatory system 579.0 Celiac disease 579.1 Tropical sprue 700 Corns & callosities

10 703.8 Other specified diseases of nail 707.9 Unspec disease nail 706.2 Sebaceous cyst 707.06 Chronic ulcer skin, ankle 707.07 Chronic ulcer skin, heel 707.14 Ulcer heel/midfoot 707.15 Ulcer other 785.4 Gangrene 893.0-893.2 Open wound toe 917.0-917.9 Open wound toe 924.3 Contusion toe 928.3 Crushing injury toe 945.11 1st deg burn toe 945.12 1st deg burn toe 945.21 2nd deg burn toe 945.22 2nd deg burn foot 945.31 3rd deg burn toe 945.32 3rd deg burn foot 945.41 Deep 3rd deg burn toe 945.42 Deep 3rd deg burn foot 945.51 3rd deg burn w/loss toe 945.52 3rd deg burn w/loss foot 956.0-956.9 Anaphylactic shock food 959.7 Lower leg injury unspec 976.0 Poison local anti infect 976.2 Poison loc astringent/detergent 976.3 Poison emol/demul/protect 991.1 Frostbite hand 991.2 Frostbite foot V07.39 Prophylactic chemotherapy V12.3 History blood disease V12.50-v12.59 History circulatory disorder

11 V49.3 Sensory problems w/limbs V49.70-v49.77 Lower limb amputation status V58.61 Encounter long anticoag use

CPT codes: 11720, 11721 ICD-9 CM code 110.1 must be reported as primary condition and the appropriate Q modifier showing that coverage criteria has been met. In the absence of a systemic condition, one of the ICD-9 codes below must be used with ICD-9 CM 110.1 to document the medical necessity of the service.

681.10 Unspecified cellulitis and abscess of toe 681.11 Onychia and paronychia of toe 703.0 Ingrowing nail 719.7 Difficulty in walking 729.5 Pain in limb 781.2 Abnormality of gait

NOTE: Since 110.1 is only covered when the beneficiary has 'painful' onychomycosis, a secondary diagnosis always has to be used when 11720 and 11721 are billed.

ICD-9 codes that support medical necessity for treatment of nail avulsion, CPT codes 11730, 11732 110.1 Dermatophytosis nail 112.3 Candidiasis skin & nails 681.11 Onychia toe 703.0 Ingrowing nail 703.8 Other diseases nail 757.5 Nail anomalies other 893.0 Open wound toe 893.1 Open wound toe complicated 893.2 Open Wound Of Toe(S) With Tendon Involvement 917.0-917.9 Abrasion foot/toe 924.3 Contusion toe

For MI/MN providers only 816.12 Fx distal phalanx hand open 681 Unspecified Cellulitis And Abscess Of Finger

12 681.02 Onychia And Paronychia Of Finger

883.0 Open wound finger

883.1 Open wound finger complicated

883.2 Open Wound Of Fingers With Tendon Involvement

915.1- Abrasion finger 915.9 923.3 Contusion finger

927.3 Crushing Injury Of Finger(S)

944.31 Full-Thickness Skin Loss Due To Burn (Third Degree (NOS) Of Single Digit (Finger (Nail)) Other Than Thumb 944.41 Deep Necrosis Of Underlying Tissues Due To Burn (Deep Third Degree) Of Single Digit (Finger (Nail)) Other Than Thumb Without Loss Of Finger

ICD-9 codes that support medical necessity for treatment of CPT code 11750 or CPT code 11765

110.1 Dermatophytosis Of Nail 681 Unspecified Cellulitis And Abscess Of Finger 681.02 Onychia And Paronychia Of Finger 681.11 Onychia And Paronychia Of Toe 681.9 Cellulitis And Abscess Of Unspecified Digit 703 Ingrowing Nail 703.8 Other Specified Diseases Of Nail 757.5 Specified Congenital Anomalies Of Nails 785.4 Gangrene

883.1 Open Wound Of Fingers Complicated 883.2 Open Wound Of Fingers With Tendon Involvement 893.1 Open Wound Of Toe(S) Complicated 893.2 Open Wound Of Toe(S) With Tendon Involvement 923.3 Contusion Of Finger 924.3 Contusion Of Toe 927.3 Crushing Injury Of Finger(S) 928.3 Crushing Injury Of Toe(S)

13 944.31 Full-Thickness Skin Loss Due To Burn (Third Degree NOS) Of Single Digit (Finger (Nail)) Other Than Thumb 944.41 Deep Necrosis Of Underlying Tissues Due To Burn (Deep Third Degree) Of Single Digit (Finger (Nail)) Other Than Thumb Without Loss Of Finger 945.31 Full-Thickness Skin Loss Due To Burn (Third Degree NOS) Of Toe(S) (Nail) 945.41 Deep Necrosis Of Underlying Tissues Due To Burn (Deep Third Degree) Of Toe(S) (Nail) Without Loss Of Toe(S) 991.2 Frostbite Of Foot

Diagnoses that support medical necessity Not listed above

Diagnoses that support medical necessity Ones listed above

Documentation requirements The following class finding modifiers should be used with G0127, 11055, 11056, 11057, 11719, 11720, 11721, when applicable:

1. A Class A finding (Modifier Q7) 2. Two of the Class B findings (Modifier Q8); or 3. One Class B and two Class C findings ( Modifier Q9 ).

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this 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.

Physical findings and services must be precise and specific (e.g., left great toe, or right foot, 4 th digit .) Documentation of co-existing systemic illness should be maintained.

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.

For debridement of mycotic nails, each service encounter, the medical record should contain a description of each nail which requires debridement. This should include, but is not limited to, the size (including thickness) and color of each affected nail. In addition, the local symptomatology caused by each affected nail resulting in the need for debridement must be documented. For CPT code 11720 documentation of at least one nail will be accepted. For CPT code 11721 complete documentation must be provided for at least 6 nails.

14 Routine identification of cultures of fungi in the toenail is medically indicated when necessary to differentiate fungal disease from other nail diseases, or when definitive treatment for prolonged antifungal therapy has been planned. If cultures are performed and billed, documentation of cultures and the need for prolonged antifungal therapy must be in the patient record and available to Medicare upon request.

In general, surgical treatment of the nails requires the use of local anesthesia. The patient's medical record should also indicate the type and quantity of the local anesthetic injected. For nail avulsions, if injectable anesthesia was not used, the reason must be clearly documented in the patient's medical record.

If the patient requires code 11730-11732 for a second treatment of paronychia, the patient medical record must reflect the reason for persistent or recurrent infections and those measures being taken to avoid reinfection or the reason a more permanent procedure cannot be performed.

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made 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.

Nail avulsions generally offer only temporary relief for ingrown nails. The nail often grows back to its original thickness and the offending margin again may become problematic, resulting in the necessity for another nail avulsion. For the treatment of recurrent ingrown nails, a partial or complete excision of the nail and nail matrix may be the preferred course of treatment. If there is a recurrence, a subsequent nail avulsion should not be required for at least three (3) months/90 days. More frequent services may be subject to review.

For the same nail, on the same day, it is only necessary to perform one of the following procedures:

• Partial or complete avulsion (CPT codes 11730-11732), • Excision (CPT code 11750), • Wedge resection (CPT code 11765), or • Incision and drainage (CPT codes 10060 and 10061).

Both avulsion and routine trimming/debridement will not be allowed on the same nail on the same day.

Advisory Committee Meeting Notes Meeting date: Wisconsin: 01/16/2009 Illinois: 01/28/2009 Michigan: 01/07/2009 Minnesota: 01/22/2008 J-5 MAC 02/12/2009 (IA,KS,MO, NE)

15 Start Date Of Comment Period 02/12/2009

End Date Of Comment Period 03/30/2009

Start Date Of Notice Period (Published) 07/01/2009

Revision History Number/Explanation 07/01/2009, one, this LCS merges all other LCDs regarding Food Care including FT-001, FT-501 and FT-502;

Last Reviewed On 07/01/2009

Notes * - an asterisk indicates a revision to that section of the policy. This policy does not reflect the sole opinion of the contractor or the contractor medical director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the carrier advisory committee(s), which includes representatives of various medical specialty societies.

This LCD replaces all previous foot care LCDs including FT-001, FT-501 and FT-501

See routine foot care and debridement of nails: billing/coding guidelines.

16

17