Routine Foot Care and Debridement of Nails

Jurisdiction: J15 MAC Part B. States: Kentucky, Ohio. Type: Active LCD

Abstract: The Medicare program generally does not cover routine foot care. However, this determination outlines the specific conditions for which coverage may be present. The following services are considered to be components of routine foot care, 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. 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). Treatment of warts on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body. 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. Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. 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 following criteria are met: 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, and/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 and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate. In addition, procedures for treating toenails are covered for the following: Onychogryphosis (defined as long-standing thickening, in which typically a curved hooked nail (ram's horn nail) occurs), and there is marked limitation of ambulation, pain, and/or secondary infection where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe; and/or Onychauxis (defined as a thickening (hypertrophy) of the base of the nail/nail bed) and there is marked limitation of ambulation, pain, and/or secondary infection that causes symptoms. 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. 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: hair growth (decrease or increase) nail changes (thickening) pigmentary changes (discoloring) 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) Burning 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; or One Class B and two Class C findings. Note: Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the appropriate ICD-10-CM code being included on the claim. Limitations: When the patient's condition is designated by an ICD-10-CM code that indicates the routine foot care was done based on the patient having a complicating disease, the 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 had come under a physician’s care shortly after the services were furnished. The global surgery rules will apply to routine foot care procedure codes. 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.