Foot-Care Services for Patients with Diabetic Sensory

The Medicare National Coverage Determinations Manual, Pub. 100-03, Part 1, Section 70.2.1, describes national policy regarding Medicare guidelines for services provided for the diagnosis and treatment of diabetic sensory neuropathy with LOPS. The pertinent national policy can be referenced in the attached article.

HCPCS codes G0245, G0246 and G0247 have been developed for reporting these physician services under this coverage. Codes G0245 and G0246 have been revised to describe them more accurately as E/M services. The new codes are described as:

G0245 Initial physician evaluation of a diabetic patient with diabetic sensory neuropathy resulting in LOPS, which must include:
The diagnosis of LOPS.
A patient history.
A physical examination consisting of findings regarding at least the following elements:
Visual inspection of the forefoot, hindfoot and toe web spaces.
Evaluation of protective sensation.
Evaluation of foot structure and biomechanics.
Evaluation of vascular status and skin integrity.
Evaluation and recommendation of footwear.
Patient education.
G0246 Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in LOPS to include at least the following:
A patient history.
A physical examination consisting of findings that includes:
Visual inspection of the forefoot, hindfoot and toe web spaces.
Evaluation of protective sensation.
Evaluation of foot structure and biomechanics.
Evaluation of vascular status and skin integrity.
Evaluation and recommendation of footwear.
Patient education.
G0247 Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in LOPS to include if present, at least the following:
Local care of superficial wounds.
Debridement of corns and calluses.
Trimming and debridement of nails.
Medicare payment for routine foot-care services to patients with diabetic sensory neuropathy who do not meet the class findings described in the attached article will be limited to the provisions of the coverage in this section of the LCD.
Limitations:
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
Safe and effective.
Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the clinical trials NCD are considered reasonable and necessary).
Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
Furnished in a setting appropriate to the patient’s medical needs and condition.
Ordered and furnished by qualified personnel.
One that meets, but does not exceed, the patient’s medical needs.
At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

11X, 12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.

Revenue codes have not been identified for all procedures/services as they can be performed in a number of revenue centers within a hospital, such as emergency room (0450), operating room (0360) or clinic (0510).

CPT/HCPCS Codes

Note:

Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
11055©
Trim skin lesion
11056©
Trim skin lesions, 2 to 4
11057©
Trim skin lesions, over 4
11719©
Trim nail(s)
G0127
Trimming dystrophic nails, any number
G0245
Initial foot exam PT LOPS
G0246
Followup eval of foot PT LOPS
G0247
Routine footcare PT W LOPS
ICD-9-CM Codes that Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 11055, 11056, 11057, 11719 and G0127:
Covered for:
030.1*
Leprosy, tuberculoid leprosy (type T)
042*
Human immunodeficiency virus [HIV] disease
090.1*
Early congenital syphilis, latent (neurosyphilis)
Note: Use codes 030.1*, 042*, 090.1* with 357.4 (polyneuropathy in other diseases classified elsewhere).
250.00**–250.03**

Diabetes mellitus without mention of complication
250.10**–250.13**
Diabetes with ketoacidosis
250.20**–250.23**
Diabetes with hyperosmolarity
250.30**–250.33**
Diabetes with other coma
250.40**–250.43**
Diabetes with renal manifestations
250.50**–250.53**
Diabetes with ophthalmic manifestations
250.60**–250.63**
Diabetes with neurological manifestations
250.70**–250.73**
Diabetes with peripheral circulatory disorders
250.80**–250.83**
Diabetes with other specified manifestations
250.90**–250.93**
Diabetes with unspecified complication
265.2**
Pellagra
272.7*
Lipidoses (Fabry’s disease)
277.30*
Amyloidosis, unspecified
277.39*
Other amyloidosis
281.0**
Pernicious anemia

Note: Use codes 265.2*, 272.7*, 277.30*, 277.39*, 281.0* with 357.4 (polyneuropathy in other diseases classified elsewhere).
340**
Multiple sclerosis
344.00–344.04
Quadriplegia
344.09
Other quadriplegia
344.1
Paraplegia
344.30–344.32
Monoplegia of lower limb
355.0–355.6
Mononeuritis of lower limb and unspecified site
355.71
Causalgia of lower limb
355.79
Other mononeuritis of lower limb
355.8–355.9
Unspecified inflammatory and toxic neuropathies
356.0–356.4
Hereditary peripheral neuropathy
356.8–356.9
Unspecified idiopathic peripheral neuropathy
357.0–357.1
Inflammatory and toxic neuropathy
357.2**–357.7**
Polyneuropathy in malignant disease
357.81–357.82
Other, inflammatory and toxic neuropathy
357.9
Unspecified inflammatory and toxic neuropathies
440.20–440.24
Atherosclerosis of native arteries of the extremities
440.29
Other atherosclerosis of native arteries of the extremities
440.30–440.32
Atherosclerosis of bypass graft of the extremities
440.4
Chronic total occlusion of artery of the extremities
443.1
Thromboangiitis obliterans (Buerger’s disease)
443.9
Peripheral vascular disease, unspecified
447.9
Unspecified disorders of arteries and arterioles
451.0**
Phlebitis and thrombophlebitis of superficial vessels of lower extremities
451.11**
Phlebitis and thrombophlebitis of femoral vein (deep) (superficial)
451.19**
Phlebitis and thrombophlebitis of other deep vessels of lower extremities
451.2**
Phlebitis and thrombophlebitis of lower extremities, unspecified
579.0**–579.1**

Intestinal malabsorption

585.4**–585.6**

Chronic kidney disease

Note: Use codes 579.0*–579.1* and 585.4*–585.6* with 357.4 (polyneuropathy in other diseases classified elsewhere).

For Medicare to cover routine foot care for patients with diagnoses marked by double asterisks in the list above:

The patient must be under the active care of an MD or DO to qualify for covered routine foot care.

The patient must have been seen by that physician for the specified condition within six months prior to or six weeks following the foot-care services.

For the purposes of this LCD, the coverage condition of “active care by a physician” clause above may be satisfied when appropriate care has been rendered by a Nurse Practitioner (NP), Physician Assistant (PA) or Clinical Nurse Specialist (CNS) who is licensed by the state to provide such services. References to “MD or DO” or “physician” in regard to the active care clause will include physicians (MDs and DOs), NPs, PAs and CNSs.

Medicare is establishing the following limited coverage for CPT/HCPCS codes G0245, G0246 and G0247:

Covered for:

250.60–250.63

Diabetes with neurological manifestations

357.2

Polyneuropathy in diabetes

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses that Support Medical Necessity

N/A

ICD-9-CM Codes that DO NOT Support Medical Necessity

N/A

Diagnoses that DO NOT Support Medical Necessity

Subluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons, ligaments or muscles of the foot. Surgical or non-surgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered.

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

Documentation supporting medical necessity must be legible and available to Medicare upon request.

For foot-care services covered by virtue of the presence of a qualifying covered systemic disease (asterisked and non-asterisked elsewhere in this LCD), Medicare expects the clinical record to contain a sufficiently detailed clinical description of the feet to provide convincing evidence that non-professional performance of the service is hazardous to the patient. For this purpose, documentation limited to a simple listing of class findings is insufficient. Medicare does not require the detailed clinical description to be repeated at each instance of routine foot care when an earlier record continues to accurately describe the patient’s condition at the time of the foot care. In such cases, the record should reference the location in the record of the previously recorded detailed information. Further, detailed information so referenced should be made available to Medicare upon request.

The patient’s record must include the following:

Location of each lesion treated.

Identification (by number or name) and description of all nails treated.

To distinguish debridement from trimming or clipping, Medicare expects records to contain some description of the debridement procedure beyond simple statements such as “nail(s) debrided.”

For routine foot care and debridement of multiple symptomatic nails to people who have a qualifying systemic condition, the record should demonstrate the necessity of each service considering the patient’s usual activities.

Documentation of foot-care services to residents of nursing homes not performed solely at the request of the patient or patient’s family/conservator must include a current nursing facility order (dated and signed with date of signature) for routine foot-care service issued by the patient’s supervising physician that describes the specific service necessary. Such orders must meet the following requirements:

The order must be dated and must have been issued by the supervising physician prior to foot-care services being rendered.

Telephone or verbal orders not written personally by the supervising physician must be authenticated by the dated physician’s signature within a reasonable period of time following issuance of the order.

The order must be consistent with the attending physician’s overall plan of care.

The order must be for medically necessary services to address a specific patient complaint or physical finding.

Routinely issued or “standing” facility orders for routine foot-care services and orders for non-specific foot-care services that do not meet the above requirements are insufficient.

Documentation of foot-care services to residents of nursing homes performed solely at the request of the patient or patient’s family/conservator should name the person who requested the services and should identify the requesting person’s relationship to the patient.

The following documentation requirements for HCPCS codes G0245, G0246 and G0247 are provided by CMS:

For codes G0245, G0246 and G0247, the medical record must include documentation of performance of all elements listed in the code descriptions.

For code G0245, the patient history should include, but is not limited to, how, when and by whom the diagnosis of LOPS was made, as well as any pertinent present and/or past history regarding the feet).

For code G0246, the patient history should include, at the least, an interval history regarding the feet since the previous evaluation.

For code G0247, the description of routine foot-care services contains similar information as other covered routine foot-care services listed above.

For codes G0245 and G0246, record the educational methods and the identity of the educator.

Abstract

Routine foot care is not a covered Medicare benefit. However, national Medicare policy allows exceptions to this exclusion under specified conditions. The purpose of the related LCD is to describe and codify the circumstances under which routine foot care is covered. The related LCD applies to foot-care services provided by all practitioners who are permitted by state license to render examination, diagnosis and treatment of foot diseases.

The Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 290, describes national policy regarding Medicare payment for routine foot-care services as given below:

Excluded Foot-Care Services

The following foot-care services are excluded from Medicare coverage:

Treatment of Subluxation of Foot

Subluxations of the foot are defined as partial dislocation or displacements of joint surfaces, tendons, ligaments, or muscles of the foot. Surgical or non-surgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered.

Treatment of Flat Foot

The term “flat foot” is defined as a condition in which one or more arches of the foot have flattened out. Services or devices directed toward the care or correction of such conditions including the prescription of supportive devices are not covered.

Supportive Devices for Feet

Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics.

Routine Foot Care

Services that normally are considered routine and not covered by Medicare include the following:

Trimming, cutting, clipping or debriding toenails.

Cutting or removal of corns, calluses and/or hyperkeratoses.

Other hygienic and preventive-maintenance care such as cleaning and soaking of the feet, application of topical medications, and the use of skin creams to maintain skin tone in either ambulatory or bedfast patients.

Any other service performed in the absence of localized illness, injury or symptoms involving the foot.

Exceptions to Routine Foot Care Exclusions

Payment may be made as an exception to the routine foot care exclusion if one of the following conditions is met. In addition, as for any other Medicare covered service, the foot-care service must be reasonable and necessary for the treatment of an illness or injury or to improve the functioning of a malformed body member.

Necessary and Integral Part of Otherwise Covered Services

In certain circumstances, services ordinarily considered to be routine (as previously defined in the LCD) 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.

Treatment of Warts on 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.

Presence of Systemic Condition

The presence of a systemic condition such as metabolic, neurologic or peripheral vascular disease may 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 (as previously defined in the LCD) may pose a hazard when performed by a non-professional person. Although not intended as a comprehensive list, the following metabolic, neurologic and vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that may justify coverage as exceptions to routine foot-care exclusions:
Diabetes mellitus*.
Arteriosclerosis obliterans ((ASO), arteriosclerosis of the extremities, occlusive and peripheral arteriosclerosis).
Buerger’s disease.
Chronic thrombophlebitis (thromboangiitis obliterans)*.
Peripheral neuropathies involving the feet associated with:
Malnutrition and vitamin deficiency *.
Malnutrition (general, pellagra).
Alcoholism.
Malabsorption (celiac disease, tropical sprue).
Pernicious anemia.
Carcinoma*.
Diabetes mellitus*.
Drugs or toxins*.
Multiple sclerosis*.
Uremia (chronic renal disease)*.
Traumatic injury.
Leprosy and neurosyphilis.
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, routine foot care is covered only if the patient is under the active care of a Medical Doctor (MD) or Doctor of Osteopathy (DO) who documents the condition and must have been seen by that physician for the specified condition within six months prior to or shortly after the routine foot-care service. These are indicated with double asterisks in the “ICD-9-CM Codes that Support Medical Necessity” section of the LCD.

Presumption of Coverage

A presumption of coverage may be made when the claim or other 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:

One of the following Class A findings.
Two of the following Class B findings.
One of the following Class B findings and two of the following Class C findings.
Class A Findings
Non-traumatic amputation of foot or integral skeletal portion thereof.
Class B Findings
Absent posterior tibial pulse.
Absent dorsalis pedis 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).
Class C Findings
Claudication.
Temperature changes (e.g., cold feet).
Edema.
Paresthesias (abnormal spontaneous sensations in the feet).
Burning.
Routine foot-care services to patients who have a coverable condition, the severity of which does not meet the class findings listed above, are excluded services with the exception of patients who have diabetic ulcers, wounds, infections and sensory neuropathy that is covered only according to the provisions of the following paragraph regarding foot-care services for patients with diabetic sensory neuropathy and Loss of Protective Sensation (LOPS).

Services that are not codifiable using a Q modifier are not payable by Medicare except in those cases for which the review of medical records demonstrates that the patient’s condition meets exception criteria to the exclusion from Medicare payment for routine foot care. Individual consideration of such claims should be requested during the claim redetermination process.

Foot-Care Services for Patients with Diabetic Sensory Neuropathy and LOPS

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 patient 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 (NIDDKD). Five sites should be tested on the plantar surface of each foot, according to the NIDDKD guidelines. The areas must be tested randomly since the LOPS 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 of five tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with LOPS.

Part A Program Instructions

Reasons for Denial

Services performed at a frequency that exceeds the patient’s need.

Services performed for diagnoses not listed as covered in the LCD.

All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD.

The medical record does not verify that the service described by the CPT/HCPCS code and attached modifiers was provided.

The service does not follow the guidelines of the LCD.

The service is considered:

Investigational.

For cosmetic purposes.

For routine screening.

A program exclusion.

Otherwise not covered.

Never reasonable and necessary.

LCD Individual Consideration Instructions

Medical records that demonstrate the patient’s condition meets exception criteria to the exclusion from Medicare payment for routine foot care must be submitted when requesting a redetermination. The redetermination submission must have “LCD INDIVIDUAL CONSIDERATION REQUEST” indicated on the request form to receive individual consideration.

Coding Guidelines

Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.

Claims must be submitted with a diagnosis code in the appropriate ICD-9-CM field and ICD-9-CM codes must be coded to the highest level of specificity for that date of service. Claims without this information will be rejected as unprocessable. Rejected claims must be submitted as new claims and not as reviews.

Claims for routine foot-care services must be submitted with the following information:

For routine foot-care services covered by reason of the presence of systemic disease, report the following:

An appropriate primary diagnosis(es) to describe the foot condition (i.e., corn or callus) requiring foot-care services.

An appropriate secondary diagnosis code(s) relating to the systemic disease (identified under the “ICD-9-CM Codes that Support Medical Necessity” section of the LCD).

The appropriate class-finding modifier:

Q7 – one Class A finding.

Q8 – two Class B findings.

Q9 – one Class B and two Class C findings.

The National Provider Identifier (NPI) number of the MD or DO providing active care to the patient for double asterisked conditions (from the “ICD-9-CM Codes that Support Medical Necessity” section of the related LCD). For the purposes of the LCD, the coverage condition of “active care by a physician” clause above may be satisfied when appropriate care has been rendered by a Nurse Practitioner (NP), Physician Assistant (PA) or Clinical Nurse Specialist (CNS) who is licensed by the state to provide such services. References to “MD or DO” or “physician” in regard to the active care clause will include physicians (MDs and DOs), NPs, PAs and CNSs.

For all claims for foot-care services, report a foot/toe location modifier (when appropriate). The following are valid HCPCS modifiers:

Left foot – LT.

First toe, left foot – TA.

Second toe, left foot – T1.

Third toe, left foot – T2.

Fourth toe, left foot – T3.

Fifth toe, left foot – T4.

Right foot – RT.

First toe, right foot – T5.

Second toe, right foot – T6.

Third toe, right foot – T7.

Fourth toe, right foot – T8.

Fifth toe, right foot – T9.

Report separately identifiable and medically necessary Evaluation and Management (E/M) services on the same day of service as routine foot-care services and nail debridement with CPT modifier 25. It is inappropriate to report an E/M code in instances where the only service provided to the patient on that date of service was a routine foot-care service.

Report only one of CPT codes 11055–11057 for each date of service. Total the number of keratotic lesions debrided and select the most appropriate CPT code. Example: if one lesion is debrided on the right foot and two lesions are debrided on the left foot, code 11056 (two to four lesions) would be the most appropriate CPT code.

It is inappropriate to report shaving, paring or curettement of corns, calluses and hyperkeratoses using any shaving, paring, biopsy or debridement code other than the codes listed in the LCD.

Rebundling combinations are listed in the latest version of the CCI.

Medicare would not expect to see hydrotherapy billed on a date of service when corns/calluses are pared and no other covered physical therapy services are provided.

Report excluded routine foot-care services using modifier GY.

Use code G0247 for routine foot care by a physician of a patient with diabetic sensory neuropathy resulting in LOPS and who does not meet class findings requirements as listed in previous sections of the LCD.

Code G0247 must be billed for the same date of service and on the same claim with either G0245 or G0246 to be considered for payment.

All coverage criteria must be met before Medicare can reimburse this service.

The diagnosis code(s) must be representative of the patient’s condition. When billing for this service in a non-covered situation (e.g., does not meet requirements of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.

Modifiers:

GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the utilization guidelines of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.)

GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.)

GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit.

See also Bill Type and Revenue Codes sections below.

Part B Program Instructions

Reasons for Denial

Services performed at a frequency that exceeds the patient’s need.

Services performed for diagnoses not listed as covered in the LCD.

All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD.

The medical record does not verify that the service described by the CPT/HCPCS code and attached modifiers was provided.

The service does not follow the guidelines of the LCD.

The service is considered:

Investigational.

For cosmetic purposes.

For routine screening.

A program exclusion.

Otherwise not covered.

Never reasonable and necessary.

LCD Individual Consideration Instructions

Coding Guidelines

Refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.

Claims for routine foot-care services must be submitted with the following information:

For routine foot-care services covered by reason of the presence of systemic disease, report the following:

An appropriate primary diagnosis(es) to describe the foot condition (i.e., corn or callus) requiring foot-care services.

An appropriate secondary diagnosis code(s) relating to the systemic disease (identified under the “ICD-9-CM Codes that Support Medical Necessity” section of the LCD).

The appropriate class-finding modifier:

Q7 – one Class A finding.

Q8 – two Class B findings.

Q9 – one Class B and two Class C findings.

The NPI number of the MD or DO providing active care to the patient for double asterisked conditions (from the “ICD-9-CM Codes that Support Medical Necessity” section of the related LCD). For the purposes of the LCD, the coverage condition of “active care by a physician” clause above may be satisfied when appropriate care has been rendered by an NP, PA or CNS who is licensed by the state to provide such services. References to “MD or DO” or “physician” in regard to the active care clause will include physicians (MDs and DOs), NPs, PAs and CNSs.

For all claims for foot-care services, report a foot/toe location modifier (when appropriate). The following are valid HCPCS modifiers:

Left foot – LT.

First toe, left foot – TA.

Second toe, left foot – T1.

Third toe, left foot – T2.

Fourth toe, left foot – T3.

Fifth toe, left foot – T4.

Right foot – RT.

First toe, right foot – T5.

Second toe, right foot – T6.

Third toe, right foot – T7.

Fourth toe, right foot – T8.

Fifth toe, right foot – T9.

Report separately identifiable and medically necessary E/M services on the same day of service as routine foot-care services and nail debridement with CPT modifier 25. It is inappropriate to report an E/M code in instances where the only service provided to the patient on that date of service was a routine foot-care service.

It is inappropriate to report shaving, paring or curettement of corns, calluses and hyperkeratoses using any shaving, paring, biopsy or debridement code other than the codes listed in the LCD.

Rebundling combinations are listed in the latest version of the CCI.

Medicare would not expect to see hydrotherapy billed on a date of service when corns/calluses are pared and no other covered physical therapy services are provided.

Report excluded routine foot-care services using modifier GY.

Code G0247 must be billed for the same date of service and on the same claim with either G0245 or G0246 to be considered for payment.

All coverage criteria must be met before Medicare can reimburse this service.

Modifiers:

GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit.

Bill Type and Revenue Codes below do not apply to Part B.

Bill Type Codes

11X, 12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.

Revenue Codes

CPT/HCPCS Codes

Note:

11055©

Trim skin lesion

11056©

Trim skin lesions, 2 to 4

11057©

Trim skin lesions, over 4

11719©

Trim nail(s)

G0127

Trimming dystrophic nails, any number

G0245

Initial foot exam PT LOPS

G0246

Followup eval of foot PT LOPS

G0247

Routine footcare PT W LOPS

Other Comments

For the purposes of the LCD, the coverage condition of “active care by a physician” clause above may be satisfied when appropriate care has been rendered by an NP, PA or CNS who is licensed by the state to provide such services. References to “MD or DO” or “physician” in regard to the active care clause will include physicians (MDs and DOs), NPs, PAs and CNSs.

Comment Summary

Draft LCD Comment and Notice Summary Report

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