LOCAL COVERAGE DETERMINATION ARTICLE (CODING GUIDELINE)

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CONTRACTOR INFORMATION

Contractor Name
Empire Medicare Services

Contractor Number
00308

Contractor Type
Intermediary

Article Database ID Number
A23116

Article Type
General

Is the AMA/CPT and ADA/CDT Copyright Statement Required?
Yes
CPT codes, descriptions and other data only are copyright 2004 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.

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

Secondary Geographic Jurisdiction
Massachusetts

Article Publication Date
09/29/2004

Article Beginning Effective Date
06/01/2000

LCD Description:
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.)

Coding Guidelines:

1. A claim with a diagnosis of mycotic nails must also show one of the diagnosis codes which indicates secondary infection or pain. A diagnosis of mycotic nails alone is insufficient for payment. The following information must be included on the claim form:

List the most appropriate CPT code for the procedure performed:

11720-11721 (Debridement)

2. List the appropriate ICD-9-CM codes to indicate that the coverage criteria are met:

110.1 Dermatophytosis of nail

and

to indicate 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 toe

3. Appropriate modifiers must be used to indicate the affected toe(s):

-TA Left foot, great toe
-T1 Left foot, second digit
-T2 Left foot, third digit
-T3 Left foot, fourth digit
-T4 Left foot, fifth digit
-T5 Right foot, great toe
-T6 Right foot, second digit
-T7 Right foot, third digit
-T8 Right foot, fourth digit
-T9 Right foot, fifth digit

Reasons For Denial:

1. A claim submitted without a valid ICD-9-CM diagnosis code will be returned as an incomplete claim under section 1833(e) of the Social Security Act.
    

2. A claim submitted without a diagnosis code listed in the "ICD-9-CM Diagnosis Codes That Support Medical Necessity" section of this policy will be denied under section 1862 (a) (1)(A) of the Social Security Act.
    

3. A claim for debridement of mycotic nails without a qualifying diagnosis indicating secondary infection, pain, or difficulty in ambulation (for ambulatory patients) will be denied as not medically necessary.
    

4. A claim for services for mycotic nails submitted in any place of service other than one listed in the "Indications and Limitations" section of this policy will be denied.
    

5. A claim for services for mycotic nails submitted without the appropriate modifier will be returned for missing information.

1. For services that exceed the accepted standard of medical practice and may be deemed not medically necessary, the provider/supplier must provide the patient with an acceptable advance beneficiary notice of Medicare’s possible denial of payment. A waiver of liability should thus be signed when a provider/supplier does not want to accept the financial responsibility for the service.
    

2. This policy supersedes Empire Medicare Services’ policy YPath#01 and Group Health Incorporated’s policy POD 733.

CMS National Coverage Policy

1. Title XVIII of the Social Security Act, Section 1862 (a)(7). This section excludes routine physical examinations.
    
2. Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section allows coverage and payment for only those services considered medically reasonable and necessary.
    
3. Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
    
4. Medicare Carriers Manual (MCM), Section 2323. This section addresses foot care services excluded from Medicare coverage.
    
5. Medicare Carriers Manual (MCM), Section 4120.2. This section addresses coverage of routine foot care services.
    
6. Code of Federal Regulations (CFR) Part 411.15. Subpart A. This section addresses general exclusions and exclusion of particular services.
    
7. Hospital Manual (Pub. 10) 260.9. Excluded. foot care services.
    
8. Intermediary Manual Reference (Pub. 13) 3158. Excluded foot care services.
    
9. Outpatient Physical Therapy/CORF Manual (Pub. 9) 289. Foot care and supportive devices for the feet.
    
10. Rural Health Clinic and FQHC Manual (Pub. 27) 438. Foot care and supportive devices for the feet.
     
11. Skilled Nursing Facility (Pub.12) 280.8.C. Routine foot care

Coverage Topic
Foot Care

Ted J. Triana, D.O.

Fiscal Intermediary Medical Director

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