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Foot Care Services

Section: Podiatry
Effective Date: November 01, 2019
Revised Date: October 18, 2019
Last Reviewed: September 26, 2019

Description

Routine foot care – Includes the treatment of corns, callouses, clavus, tyloma or tylomata, plantar keratosis, hyperkeratosis and keratotic lesions, bunions (except capsular or bone surgery thereof), and nails (except surgery for ingrown nails and/or debridement of symptomatic, hypertrophic nails). Treatment of these conditions may pose a hazard when performed by a non-professional person on individuals with a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the legs or feet.

Debridement of mycotic nails – This service is also part of routine foot care for the temporary reduction in the size or girth of an abnormal nail plate, short of avulsion. It is performed most commonly without anesthesia to: (1) relieve pain; (2) treat infection (bacterial, fungal, or viral); (3) temporarily remove an anatomic deformity such as onychauxis (thickened nail), or certain types of onychocryptosis (ingrown nail); (4) expose subungual conditions for the purpose of treatment as well as diagnosis (biopsy, culture, etc.); (5) prevent further problems, such as subungual ulceration in an insensate individual with onychauxis.

Criteria

When the benefit exists and the individual has a peripheral circulatory disorder or peripheral neuropathic disease,  professional treatment of corns, callouses, clavus, tyloma or tylomata, plantar keratosis, hyperkeratosis and keratotic lesions, bunions (except capsular or bone surgery thereof), and nails (except surgery for ingrown nails and/or debridement of symptomatic, hypertrophic nails) may be considered medically necessary ONLY when the individual is being treated for ANY ONE of the following diagnoses:

  • Amyotrophic lateral sclerosis (ALS); or 
  • Arteriosclerosis obliterans (ASO), arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis); or 
  • Arteritis of the feet; or
  • Buerger’s disease; or 
  • Carcinoma; or 
  • Chronic indurated cellulitis; or 
  • Chronic venous insufficiency; or
  • Diabetes mellitus; or
  • Drugs and toxins; or 
  • Hereditary disorders such as but not limited to:
    • Hereditary sensory radicular neuropathy; or
    • Angiokeratoma corporis diffusum (Fabry’s); or 
    • Amyloid neuropathy.
  • Intractable edema – secondary to a specific disease (e.g., congestive heart failure (CHF), kidney disease, hypothyroidism); or
  • Leprosy; or 
  • Lymphedema – secondary to a specific disease (e.g., Milroy’s disease, malignancy); or 
  • Malnutrition and vitamin deficiency malnutrition that can be as a result of but not limited to the following:
    • Alcoholism malabsorption; or
    • Celiac Disease; or 
    • Pellagra; or 
    • Pernicious anemia; or 
    • Tropical Sprue.
  • Multiple Sclerosis; or 
  • Neurosyphilis; or
  • Peripheral vascular disease; or 
  • Post-phlebitic syndrome; or
  • Raynaud’s disease; or 
  • Stricture of artery; or 
  • Traumatic injury; or 
  • Uremia.

Services that do not meet the criteria of this policy will be considered not medically necessary.

Procedure Codes

 

S0390

Mycotic Nails
When the benefit exists, debridement of mycotic nails is considered routine foot care and may be considered medically necessary when above criteria is met.

Hypertrophic (Non-Mycotic) Nails
When the benefit exists, debridement of symptomatic hypertrophic (non-mycotic) nails may be considered medically necessary.

Debridement of hypertrophic nails is limited to once every 60 days. More frequent debridement of nails is considered not medically necessary.

Procedure Codes

11720 11721 S0390

Laser treatment of onychomycosis (mycotic nail) is considered experimental/investigational and therefore is non-covered due to unproven efficacy and safety.

Procedure Codes

17999

Pedicure services are non-covered.

Treatment of a mycotic infection that is out of the scope of routine foot care or capsular/ bone surgery, and/or debridement of non-symptomatic hypertrophic nails, may be considered medically necessary when the following criteria have been met:

  • Systemic conditions that are significant enough to result in severe circulatory insufficiency and/or areas of desensitization in the lower extremities, that are a result of but not limited to, ANY of the following:
    • Diabetes mellitus; or
    • Peripheral vascular disease; or
    • Peripheral neuropathy.
  • Evaluation/debridement of mycotic nails, in the absence of a systemic condition, when BOTH of the following conditions are met:
    • There is pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate; and
    • If ambulatory, there is pain to a degree that there is difficulty walking and/or abnormality of gait.

The individual must also meet ONE of the following:

  • A Class A finding – of a non-traumatic amputation of foot or integral skeleton portion thereof; or
  • A Class B finding – of AT LEAST TWO (2) of the following:
    • Absent posterior tibial pulse; or
    • Absent dorsalis pedis pulse; or
    • Advanced trophic changes; AT LEAST THREE (3) of the following are required:
      • Hair growth (decrease or absence); or
      • Nail changes (thickening); or
      • Pigmentary changes (discoloration); or
      • Skin texture (thin, shiny); or
      • Skin color (rubor or redness).
  • A Class C finding of ONE (1) from Class B and TWO (2) from Class C:
    • Claudication; or
    • Temperature changes (e.g., cold feet); or
    • Edema; or
    • Paresthesia; or
    • Burning.

Procedure Codes

11055 11056 11057 G0127 G0245 G0246

The following modifiers are to be used with the following procedure codes: 11055, 11056, 11057, 11719, 11720, 11721 or G0127.

  • Q7 – One (1) Class A finding.
  • Q8 – Two (2) Class B findings.
  • Q9 – One (1) Class B and two (2) Class C findings.

Submitting claims using Q7, Q8, or Q9 modifiers indicates the findings related to the individual’s condition. Failure to provide documentation supporting the use of the Q modifiers on any claim may result in denial of that claim.

Procedure Codes

11055 11056 11057 11719 11720 11721 G0127

Surgical treatment of the nail that is out of the scope of routine foot care may be considered medically necessary for the following conditions;

  • Ingrown toenails
  • Subungual abscess
  • Complicated injury of the toes or fingers involving the nail component severe enough to require removal of the nail
  • Severe or recurrent fungal nail infection that has failed to respond to usual, less invasive treatment (for example, pharmacological treatment, debridement)
  • Onychogryposis or onychauxis
  • Deformed nails that prevent wearing shoes or otherwise jeopardize the integrity of the toe.

Procedure Codes

11730 11732 11750 11765

 

Diagnosis Codes

 

Covered DX codes for procedure codes 11055, 11056, 11057, 11720, 11721, 97022, G0127, G0245, G0246, S0390 

 

A30.0 A30.1 A30.2 A30.3 A30.4 A30.5 A50.1
A50.40 A50.41 A50.42 A50.43 A50.45 A52.11 A52.13
A52.14 A52.15 A52.16 A52.17 A52.19 A52.2 B20
B35.1 D51.0 D81.818 D81.819 E08.11 E08.21 E08.22
E08.29 E08.311 E08.319 E08.3211 E08.3212 E08.3213 E08.3291
E08.3292 E08.3293 E08.3311 E08.3312 E08.3313 E08.3391 E08.3392
E08.3393 E08.3411 E08.3412 E08.3413 E08.3491 E08.3492 E08.3493
E08.3511 E08.3512 E08.3513 E08.3521 E08.3522 E08.3523 E08.3531
E08.3532 E08.3533 E08.3541 E08.3542 E08.3543 E08.3551 E08.3552
E08.3553 E08.3591 E08.3592 E08.3593 E08.36 E08.37X1 E08.37X2
E08.37X3 E08.39 E08.40 E08.41 E08.42 E08.43 E08.44
E08.49 E08.51 E08.52 E08.59 E08.610 E08.618 E08.620
E08.621 E08.622 E08.628 E08.630 E08.638 E08.641 E08.649
E08.65 E08.69 E08.8 E08.9 E09.00 E09.01 E09.10
E09.11 E09.21 E09.22 E09.29 E09.311 E09.319 E09.3211
E09.3212 E09.3213 E09.3291 E09.3292 E09.3293 E09.3311 E09.3312
E09.3313 E09.3391 E09.3392 E09.3393 E09.3411 E09.3412 E09.3413
E09.3491 E09.3492 E09.3493 E09.3511 E09.3512 E09.3513 E09.3521
E09.3522 E09.3523 E09.3531 E09.3533 E09.3541 E09.3542 E09.3543
E09.3551 E09.3552 E09.3553 E09.3591 E09.3592 E09.3593 E09.36
E09.37X1 E09.37X2 E09.37X3 E09.39 E09.40 E09.41 E09.42
E09.43 E09.44 E09.49 E09.51 E09.52 E09.59 E09.610
E09.618 E09.620 E09.621 E09.622 E09.628 E09.630 E09.638
E09.641 E09.649 E09.65 E09.69 E09.8 E09.9 E10.10
E10.11 E10.21 E10.22 E10.29 E10.311 E10.319 E10.3211
E10.3212 E10.3213 E10.329 E10.3291 E10.3292 E10.3293 E10.3311
E10.3312 E10.3313 E10.3391 E10.3392 E10.3393 E10.3411 E10.3412
E10.3413 E10.3491 E10.3492 E10.3493 E10.3511 E10.3512 E10.3513
E10.3521 E10.3522 E10.3523 E10.3531 E10.3532 E10.3533 E10.3541
E10.3542 E10.3543 E10.3551 E10.3552 E10.3553 E10.3591 E10.3592
E10.3593 E10.36 E10.39 E10.40 E10.41 E10.42 E10.43
E10.44 E10.49 E10.51 E10.52 E10.59 E10.610 E10.618
E10.620 E10.621 E10.622 E10.628 E10.630 E10.638 E10.641
E10.649 E10.65 E10.69 E10.8 E10.9 E11.00 E11.01
E11.21 E11.22 E11.29 E11.311 E11.319 E11.3211 E11.3212
E11.3213 E11.3291 E11.3292 E11.3293 E11.3311 E11.3312 E11.3313
E11.3391 E11.3392 E11.3393 E11.3411 E11.3412 E11.3413 E11.3491
E11.3492 E11.3493 E11.3511 E11.3512 E11.3513 E11.3521 E11.3522
E11.3523 E11.3531 E11.3532 E11.3533 E11.3541 E11.3542 E11.3543
E11.3551 E11.3552 E11.3553 E11.3591 E11.3592 E11.3593 E11.36
E11.37X1 E11.37X2 E11.37X3 E11.39 E11.40 E11.41 E11.42
E11.43 E11.44 E11.49 E11.51 E11.52 E11.59 E11.610
E11.618 E11.620 E11.621 E11.622 E11.628 E11.630 E11.638
E11.641 E11.649 E11.65 E11.69 E11.8 E11.9 E13.00
E13.01 E13.10 E13.11 E13.21 E13.22 E13.29 E13.311
E13.319 E13.3211 E13.3212 E13.3213 E13.3291 E13.3292 E13.3293
E13.3311 E13.3312 E13.3313 E13.3391 E13.3392 E13.3393 E13.3411
E13.3412 E13.3413 E13.3491 E13.3492 E13.3493 E13.3511 E13.3512
E13.3513 E13.3521 E13.3522 E13.3523 E13.3531 E13.3532 E13.3533
E13.3541 E13.3542 E13.3543 E13.3551 E13.3552 E13.3553 E13.3591
E13.3592 E13.3593 E13.36 E13.37X1 E13.37X2 E13.37X3 E13.39
E13.40 E13.41 E13.42 E13.43 E13.44 E13.49 E13.51
E13.52 E13.59 E13.610 E13.618 E13.620 E13.621 E13.622
E13.628 E13.630 E13.638 E13.641 E13.649 E13.65 E13.69
E13.8 E13.9 E52 E53.0 E53.1 E53.8 E53.9
E75.21 E75.22 E75.240 E75.241 E75.242 E75.243 E75.248
E75.249 E75.3 E77.0 E77.1 E77.8 E77.9 E85.1
E85.2 E85.3 E85.4 E85.81 E85.82 E85.89 E85.9
G12.21 G12.23 G12.24 G12.25 G13.0 G13.1 G35
G60.0 G60.1 G60.2 G60.3 G60.8 G60.9 G61.0
G61.1 G61.81 G61.89 G61.9 G62.0 G62.1 G62.2
G62.81 G62.82 G62.89 G62.9 G63 G64 G65.0
G65.1 G65.2 G90.09 G99.0 I70.201 I70.202 I70.203
I70.208 I70.209 I70.211 I70.212 I70.213 I70.218 I70.219
I70.221 I70.222 I70.223 I70.228 I70.229 I70.231 I70.232
I70.233 I70.234 I70.235 I70.238 I70.239 I70.241 I70.242
I70.243 I70.244 I70.245 I70.248 I70.25 I70.261 I70.262
I70.263 I70.268 I70.269 I70.291 I70.292 I70.293 I70.298
I70.299 I70.90 I70.91 I73.00 I73.01 I73.1 I73.81
I73.89 I73.9 I77.1 I77.6 I79.1 I79.8 I80.00
I80.01 I80.02 I80.03 I80.10 I80.11 I80.12 I80.13
I80.201 I80.202 I80.203 I80.209 I80.221 I80.222 I80.223
I80.229 I80.231 I80.232 I80.233 I80.239 I80.291 I80.292
I80.293 I80.299 I80.3 I87.001 I87.002 I87.003 I87.009
I87.011 I87.012 I87.013 I87.019 I87.021 I87.022 I87.023
I87.029 I87.031 I87.032 I87.033 I87.039 I87.091 I87.092
I87.093 I87.099 I87.1 I87.2 I87.301 I87.302 I87.303
I87.309 I87.311 I87.312 I87.313 I87.319 I87.321 I87.322
I87.323 I87.329 I87.331 I87.332 I87.333 I87.339 I87.391
I87.392 I87.393 I87.399 I87.9 I89.0 I99.9 K90.0
K90.1 K90.9 L02.415 L02.416 L02.419 L02.611 L02.612
L02.619 L02.91 L03.031 L03.032 L03.039 L03.041 L03.042
L03.049 L03.115 L03.116 L03.119 L03.125 L03.126 L03.129
L03.90 L03.91 L60.0 M05.50 M05.511 M05.512 M05.519
M05.521 M05.522 M05.529 M05.531 M05.532 M05.539 M05.541
M05.542 M05.549 M05.551 M05.552 M05.559 M05.561 M05.562
M05.569 M05.571 M05.572 M05.579 M05.59 M34.83 N18.1
N18.2 N18.3 N18.4 N18.5 N18.6 N18.9 O24.011
O24.012 O24.013 O24.019 O24.02 O24.03 O24.111 O24.112
O24.113 O24.119 O24.12 O24.13 O24.311 O24.312 O24.313
O24.319 O24.32 O24.33 O24.811 O24.812 O24.813 O24.819
O24.82 O24.83 O24.911 O24.912 O24.913 O24.919 O24.92
O24.93 Q82.0 R60.0 R60.1 R60.9 S86.001A S86.002A
S86.009A S86.091A S86.092A S86.099A S86.101A S86.102A S86.109A
S86.191A S86.192A S86.199A S86.201A S86.202A S86.209A S86.291A
S86.292A S86.299A S86.301A S86.302A S86.309A S86.391A S86.392A
S86.399A S86.801A S86.802A S86.809A S86.891A S86.892A S86.899A
S86.901A S86.902A S86.909A S86.991A S86.992A S86.999A S89.80XA
S89.81XA S89.82XA S89.90XA S89.91XA S89.92XA S96.001A S96.002A
S96.009A S96.091A S96.092A S96.099A S96.101A S96.102A S96.109A
S96.191A S96.192A S96.199A S96.201A S96.202A S96.209A S96.291A
S96.292A S96.299A S96.801A S96.802A S96.809A S96.891A S96.892A
S96.899A S96.901A S96.902A S96.909A S96.991A S96.992A S96.999A
S99.811A S99.812A S99.819A S99.821A S99.822A S99.829A S99.911A
S99.912A S99.919A S99.921A S99.922A Z79.01

 

Covered Dx codes for procedure codes 11730, 11732, 11750 and 11765

B35.1 L03.031 L03.032 L40.0 L40.1 L40.2 L40.3
L40.4 L40.8 L60.0 L60.1 L60.2 L60.3 L60.4
L60.5 L60.8 L62 Q84.3 Q84.4 Q84.5 Q84.6
S61.101A S61.101D S61.101S S61.102A S61.102D S61.102S S61.111A
S61.111D S61.111S S61.112A S61.112D S61.112S S61.121A S61.121D
S61.121S S61.122A S61.122D S61.122S S61.131A S61.131D S61.131S
S61.132A S61.132D S61.132S S61.141A S61.141D S61.141S S61.142A
S61.142D S61.142S S61.151A S61.151D S61.151S S61.152A S61.152D
S61.152S S91.201A S91.201D S91.201S S91.202A S91.202D S91.202S
S91.204A S91.204D S91.204S S91.205A S91.205D S91.205S S91.211A
S91.211D S91.211S S91.212A S91.212D S91.212S S91.214A S91.214D
S91.214S S91.215A S91.215D S91.215S S91.221A S91.221D S91.221S
S91.222A S91.222D S91.222S S91.224A S91.224D S91.224S S91.225A
S91.225D S91.225S S91.231A S91.231D S91.231S S91.232A S91.232D
S91.232S S91.234A S91.234D S91.234S S91.235A S91.235D S91.235S
S91.241A S91.241D S91.241S S91.242A S91.242D S91.242S S91.244A
S91.244D S91.244S S91.245A S91.245D S91.245S S91.251A S91.251D
S91.251S S91.252A S91.252D S91.252S S91.254A S91.254D S91.254S
S91.255A S91.255D S91.255S T25.331A T25.331D T25.331S T25.332A
T25.332D T25.332S T25.731A T25.731D T25.731S T25.732A T25.732D
T25.732 S61.300A S61.300D S61.300S S61.301A S61.301D S61.301S
S61.302A S61.302D S61.302S S61.303A S61.303D S61.303S S61.304A
S61.304D S61.304S S61.305A S61.305D S61.305S S61.306A S61.306D
S61.306S S61.307A S61.307D S61.307S S61.310A S61.310D S61.310S
S61.311A S61.311D S61.311S S61.312A S61.312D S61.312S S61.313A
S61.313D S61.313S S61.314A S61.314D S61.314S S61.315A S61.315D
S61.315S S61.316A S61.316D S61.316S S61.317A S61.317D S61.317S
S61.320A S61.320D S61.320S S61.321A S61.321D S61.321S S61.322A
S61.322D S61.322S S61.323A S61.323D S61.323S S61.324A S61.324D
S61.324S S61.325A S61.325D S61.325S S61.326A S61.326D S61.326S
S61.327A S61.327D S61.327S S61.330A S61.330D S61.330S S61.331A
S61.331D S61.331S S61.332A S61.332D S61.332S S61.333A S61.333D
S61.333S S61.334A S61.334D S61.334S S61.335A S61.335D S61.335S
S61.336A S61.336D S61.336S S61.337A S61.337D S61.337S S61.340A
S61.340D S61.340S S61.341A S61.341D S61.341S S61.342A S61.342D
S61.342S S61.343A S61.343D S61.343S S61.344A S61.344D S61.344S
S61.345A S61.345D S61.345S S61.346A S61.346D S61.346S S61.347A
S61.347D S61.347S S61.350A S61.350D S61.350S S61.351A S61.351D
S61.351S S61.352A S61.352D S61.352S S61.353A S61.353D S61.353S
S61.354A S61.354D S61.354S S61.355A S61.355D S61.355S S61.356A
S61.356D S61.356S S61.357A S61.357D S61.357S S90.211A S90.211D
S90.211S S90.212A S90.212D S90.212S S90.221A S90.221D S90.221S
S90.222A S90.222D S90.222S

 

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