Billing and Coding: Routine Foot Care and Debridement of Nails (A57759) (2022)

General Information

Article ID
A57759

Article Title
Billing and Coding: Routine Foot Care and Debridement of Nails

Article Type
Billing and Coding

Original Effective Date
12/26/2019

Revision Effective Date
08/04/2022

Revision Ending Date
N/A

Retirement Date
N/A

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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) 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 Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Routine 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.

Mycotic Nails

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 and grant the presumption of coverage. 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, 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.

Class Findings

Class A findings

Non-traumatic amputation of foot or integral skeletal portion thereof.

Class B findings

Absent 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); AND

Absent dorsalis pedis pulse.

Class C findings

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.

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 to Medicare 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, and

A 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; and

Patient 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 patient’s 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, 4th digit.)

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.

Routine identification of fungi in the toenail either by culture or similarly by either nucleic acid probes or amplified probe technique only is 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.

FAQs

How do you code nail debridement? ›

Debridement of Nail Coding Criteria

Procedure Code 11720 or 11721 are included in Medicare's covered foot care when billed with a diagnosis pertaining to debridement of nail. Refer to the Diagnosis Code List.

What is the ICD 10 code for routine nail trimming? ›

G0127 is to used when you are trimming Dystrophic Nails. 11719 is for trimming of Non-dystrophic nails. The same coverage guidelines for Medicare apply to both codes. As far as a DX code, for routine nail trimming (non-covered), look at 703.8 - Hypertrophic nails - basically, long nails.

How do you code routine foot care? ›

CPT code 11721 is defined as: Debridement of nail(s) by any method(s); 6 or more. This CPT code is billed when “At Risk,” routine foot care (RFC) is performed and also when symptomatic mycotic toenails are debrided.

How do you bill for toenail trimming? ›

For nail trimming or clippings, the CPT code is 11719 – Trimming of nondystrophic nails, any number.

What is the difference between nail debridement and nail trimming? ›

Debridement of Toenails: Nail debridement involves the significant reduction in the thickness and length of the nail to the tolerance of the patient with the aim of allowing the patient to ambulate without pain. Simple trimming of the end of the toenails by cutting or grinding is not considered debridement.

Can CPT 11721 and 11056 be billed together? ›

Yes. In the scenario you describe, both services are reportable under both CPT definitions of codes 11721 and 11056 and CMS NCCI edits and narrative guidelines.

Can you bill G0127 and 11720 together? ›

So can CPT G0127 and 11720 be billed together? Yes, there is nothing preventing a podiatrist from billing them as one. As long as the forms are done properly and error-free, with the conditions and clearly marked out, there should be no problem with billing the two treatments together.

Does Medicare pay for nail debridement? ›

Medicare will cover debridement of nail(s) by any method(s); 1 to 5 and/or debridement of nail(s) by any method(s); 6 or more no more often than every 60 days.

How do you bill for podiatry services? ›

Podiatry Billing Services Guidelines
  1. Submission of claims requires to include the diagnosis and its intensity, the name of the podiatrist, and the visit date of a patient. ...
  2. Proper utilization of codes in order to avoid claims denials. ...
  3. Avoid over-coding and follow coding procedures for filing claims.
29 May 2020

Do you Bill 11720 and 11721 together? ›

You would not bill 11719 and 11720-21 together. Mod 59 is also not appropriate.

Can 11720 and 11055 be billed together? ›

CPT® codes 11720 – 11721 and 11055 – 11057 should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe.

What is nail debridement? ›

Nail debridement involves removal of a diseased toenail bed or viable nail plate. This may be performed manually with an instrument, or with an electric grinder. Podiatrists generally provide nail debridement to patients diagnosed with onychomycosis (i.e., mycosis or mycotic toenails).

What is nail debridement? ›

Nail debridement involves removal of a diseased toenail bed or viable nail plate. This may be performed manually with an instrument, or with an electric grinder. Podiatrists generally provide nail debridement to patients diagnosed with onychomycosis (i.e., mycosis or mycotic toenails).

Does Medicare cover debridement of nails? ›

Medicare will cover debridement of nail(s) by any method(s); 1 to 5 and/or debridement of nail(s) by any method(s); 6 or more no more often than every 60 days.

How do you debride nail fungus? ›

Treatment usually begins with your dermatologist trimming your infected nail(s), cutting back each infected nail to the place where it attaches to your finger or toe. Your dermatologist may also scrape away debris under the nail. This helps get rid of some fungus.

What is the ICD-10 code for toenail removal? ›

ICD-10-PCS Code 0HBRXZZ - Excision of Toe Nail, External Approach - Codify by AAPC.

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