LOCAL COVERAGE DETERMINATION

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Local Coverage Determination

Contractor Name
Empire Medicare Services

Contractor Number
00308

Contractor Type
Intermediary

LCD Database ID Number
L2176

A09-0004-R0

AMA CPT / ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2005 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

Primary Geographic Jurisdiction
New York - Entire State, Connecticut, Delaware

Secondary Geographic Jurisdiction
Massachusetts

Oversight Region
02

CMS Consortium
Northeast

DMERC Region LCD Covers
N/A

Original Determination Effective Date
06/01/2000

Revision Effective Date
For services performed on or after

Indications and Limitations of Coverage and/or Medical Necessity
Fungal disease of the toenails is a comparatively benign condition, but difficult to eradicate due to a high recurrence rate. A superficial variety of fungal infections produce little or no symptomatology beyond white opacities on the nails. However, deep infections may result in dystrophic nails, with subsequent pain and/or limitation of ambulation, and/or secondary infection. The definitive treatment may involve a short-term use of oral agents and/or periodic debridement of the dystrophic fungal nails with thinning of the nail plates (manual or electric).

Debridement of nails is a temporary reduction in the size or girth of any abnormal nail plate, short of avulsion. For the management of mycotic nails, it is performed most commonly without anesthesia to accomplish any or all of the objectives:

• Relief of pain
• Treatment of infection- bacterial, fungal and viral
• Exposure of subungal conditions for the purpose of treatment as well as diagnosis (biopsy, culture, etc.)

Indications
Whether by manual method or by electrical grinder, debridement is a modality used as part of a definitive antifungal treatment for onychomycosis (ICD-9-CM 110.1)

Limitations

1. 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:

1. When it is required to differentiate fungal disease from psoriatic nails.
2. When a definitive treatment for a prolonged period of time is being planned.

2. Care of mycotic infections of the nails is covered for the ambulatory patient only when the physician attending the patient's mycotic condition documents that there is clinical evidence of mycosis of the toenail. One or more of the following criteria indicates that there is clinical evidence of onychomycosis:

- hypertrophy/thickening
- lysis
- discoloration
- brittleness
- loosening of the nail plate

and

3. One or more of the following conditions exists resulting from the thickening and dystrophy of the infected toenail plate:

- marked, significant limitations on ambulation
- pain
- secondary infection

4. Care of mycotic infections of the nails is covered for the nonambulatory patient only when the physician attending the patient's mycotic condition documents that there is clinical evidence of mycosis of the toenail. One or more of the following criteria indicates that there is clinical evidence of onychomycosis:

- hypertrophy/thickening
- lysis
- discoloration
- brittleness
- loosening of the nail plate

and

5. One or more of the following conditions exist resulting from the thickening and dystrophy of the infected toenail plate:

- pain
- secondary infection

Coverage Topics
Foot Care

ICD-9-CM Codes that Support Medical Necessity

1. TRUNCATED DIAGNOSIS CODES ARE NOT ACCEPTABLE.
    
2. ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the service was performed.
    
3. It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid. Further, these ICD-9-CM codes can be used only with the conditions listed in the Indications and Limitations sections of this policy.

110.1 Dermatophytosis of nail

One of the following indicating secondary infection, pain, or difficulty in ambulation:

681.10 Cellulitis and abscess (toe)
681.11 Onychia and paronychia of toe
703.0 Ingrowing nail
729.5 Pain in limb

Diagnoses that Support Medical Necessity
NA

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

Diagnoses that DO NOT Support Medical Necessity
NA

Documentation Requirements

1. Required documentation must be submitted with all claims. (See Coding Guidelines)
    

2. Required coding must be submitted on all covered claims.
    

3. Effective 10/01/97, the modifier "Q1" (documentation on file for ambulatory or nonambulatory patients that indicates mycosis/dystrophy of the toenail causing secondary infection and/or pain which results or would result in marked limitation of ambulation and require the professional skills of a provider) is no longer required. Documentation must nevertheless exist in the patient's medical record to verify coverage criteria and be available to Medicare upon request.
    

4. Clinical photographs of the feet clearly demonstrating the presence of thick deformed fungal nails, with identification of the patient's name and date, may be requested from selected providers. If a request is made for review by Medicare, sufficient notification will be given to those selected providers to acquire pre-treatment and post-treatment photographs.
    

5. Routine identification of cultures of fungi in the toenail is medically indicated when necessary to differentiate fungal disease from psoriatic nail, or when definitive treatment for prolonged oral antifungal therapy has been planned. Documentation of cultures and the need for prolonged oral antifungal therapy must be in the patient record and available to Medicare upon request.
    

6. Services for debridement of more than five nails in a single day may be subject to special review. Documentation to support the medical necessity of such services must be in the patient's record and available to Medicare upon request.

Utilization Guidelines
NA

Sources of Information and Basis for Decision

1. Medicare Carriers Manual
    
2. Podiatry consultant
    
3. Other Medicare carrier local medical review policy

Advisory Committee Meeting Notes

1. This policy was first presented as YSurg #38 at the March 11, 1998, Carrier Advisory Committee Meeting (CAC) by Empire Medicare Services. It was not implemented in order to allow further review of comments from the provider community.
    

2. The policy was revised to expand coding guidelines and payable places of service. It was returned to the December 16, 1998, CAC as a New York State Medicare Local Medical Review policy by Empire Medicare Services.
    

3. This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups which includes representatives from the New York State Podiatric Medical Association, the New York State Society of Family Physicians, the New York State Society of Internal Medicine and the Medical Society of the State of New York.