Contractor Name 

National Government Services, Inc.  

Contractor Number 

00308 

Contractor Type 

FI 

LCD ID Number 

L648 

LCD Title 

Routine Foot Care 

Contractor's Determination Number 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 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 

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. CMS Manual, Publication 100-2, Chapter 15, Section 290. This section addresses foot care services excluded from Medicare coverage and coverage of routine foot care services.

5. Code of Federal Regulations (CFR) Part 411.15. Subpart A. This section addresses general exclusions and exclusion of particular services.

6. CMS Annual Code Update for October 2005.

7. Change Request (CR) 4009, dated August 12, 2005. October 2005 Non-Outpatient Prospective Payment System Code Editor (non-OPPS).

8. Change Request (CR) 3888, dated June 24, 2005. Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 

9. Change Request (CR) 5142, dated June 23, 2006. Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

10. Change Request (CR) 5244, dated September 1, 2006. October 2006 Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) Specifications Version 7.3

11. Change Request (CR) 5256, dated September 18, 2006. October 2006 Non-Outpatient Prospective Payment System Outpatient Code Editor (Non-OPPS OCE) Specifications Version 22.0. 

Primary Geographic Jurisdiction 

Connecticut
Delaware
New York - Entire State
 

Secondary Geographic Jurisdiction 

Oversight Region 

Region II
 

Original Determination Effective Date 

For services performed on or after 06/01/2000  

Original Determination Ending Date 

Revision Effective Date 

For services performed on or after 02/01/2008  

Revision Ending Date 

Indications and Limitations of Coverage and/or Medical Necessity 

The Medicare program generally does not cover routine foot care. However, this determination outlines specific conditions which may be coverable.

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 or trimming of normal or 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:
1. 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).

2. 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.

3. 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.

4. 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. (Treatment of mycotic nails for patients without systemic illnesses may also be covered and are defined in a separate Local Coverage Determination [LCD] for Debridement of Mycotic Nails.)

5. 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 coverable:

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 threeof the following:

1. hair growth (decrease or increase)
2. nail changes (thickening)
3. pigmentary changes (discoloring)
4. skin texture (thin, shiny)
5. skin color (rubor or redness)

·  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 the following:

1. a Class A finding;
2. two (2) Class B findings; or
3. one (1) Class B and two (2) Class C Findings.

Cases with findings falling short of these alternatives may involve podiatric treatment that may constitute covered care and may be reviewed by the intermediary's medical staff.

Note: Benefits for routine foot care are also available for patient's 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 diabetes with peripheral neuropathy, but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by ICD-9-CM codes 250.60 - 250.63 or 357.2

Limitations:
1. When the patient's condition is designated by an ICD-9-CM diagnosis code with an asterisk(*), (see ICD-9-CM Codes That Support Medical Necessity section), routine foot care procedures are coverable 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.

2. Claims submitted for more than five services in one day for the same beneficiary may be subject to special review. 

Coverage Topic 

Foot Care
 

Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes 

ICD-9 Codes that Support Medical Necessity 

Diagnoses that Support Medical Necessity 

ICD-9 Codes that DO NOT Support Medical Necessity 

250.00
250.01
250.02
250.03

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

Diagnoses that DO NOT Support Medical Necessity 

Documentation Requirements 

1. Required documentation must be submitted for all routine foot care claims. (See Coding Guidelines)

2. Required coding must be submitted on all covered claims

3. 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.

4. ICD-9-CM diagnosis codes supporting the medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.

5. Loss of protective sensation (LOPS) must 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.

6. The documentation must show that five sites have been tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines.

7. As suggested by the American Podiatric Medicine Association, an absence of sensation at two or more sites out of five 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. 

Appendices 

Utilization Guidelines 

Sources of Information and Basis for Decision 

1. Other Medicare carriers medical policy: (Group Health Incorporated, United HealthCare Medicare Part B)

2. Podiatry consultant 

Advisory Committee Meeting Notes 

1. 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.
 

Start Date of Comment Period 

02/18/2000 

End Date of Comment Period 

04/03/2000 

Start Date of Notice Period 

05/01/2000 

Revision History Number 

12 

Revision History Explanation 

Revision #12
Reasons - As a result of the annual HCPCS update,the descriptions for CPT codes 11056 and 11057 have been revised in the "CPT/HCPCS Codes" section.
Although this revision was done on 02/01/2008, the changes described above are effective for dates of service on or after 01/01/2008.

Under the "Sources of Information and Basis for Decision" section, removed Medicare Carriers Manual as a source.

Revision #11
Reasons - Effective for dates of service on or after 10/01/2007, ICD-9-CM code 440.4 was added to the "ICD-9-CM Codes that Support Medical Necessity" section.
Although this revision was done on 01/01/2008, the changes described above are effective for dates of service on or after 10/01/2007.

Revision #10
Reasons - Under the "CMS National Coverage Policy" section, added #s 9, 10 and 11.

Under the "Indications and Limitations of Coverage and/or Medical Necessity" section, added the 1st paragraph. Updated the 1st paragraph under the "Indications" section and numbered it #1. Added #s 2-4. Second paragraph is now #5. Updated the 2nd bullet under the Class B Findings section. Under the Class C Findings section, removed the paragraph (under the bullets) and added a Note:

Under the "Limitations" section, updated #1.

Under the "ICD-9-CM Codes that Support Medical Necessity" section, ICD-9-CM code 277.3 has been deleted. Added new ICD-9-CM codes 277.30 and 277.39

Under the "Documentation Requirements" section, updated #4.

Revision #9
Reasons - Under the "ICD-9-CM Codes that Support Medical Necessity" section, added ICD-9-CM code 443.82 in the section entitled "Other Peripheral Vascular Disease" to coordinate with Empire Part B.

Revision #8
Reasons - Under the "CMS National Coverage Policy" section, added #s 6, 7 and 8.

Under the "ICD-9-CM Codes that Support Medical Necessity" section, replaced the truncated ICD-9-CM code 585. Also added the following ICD-9-CM codes to coordinate with Empire Part B: Under the ICD-9-CM section enttitled Peripheral neuropathies involving the feet, associated with: 110.1, 335.20, 356.0, 356.3, 356.4, 356.8, 356.9, 357.1, 357.7, 357.81, 357.82, 357.89, 357.9 and 447.6.  

Revision #7
Effective Date - 09/01/2004
Reasons - Under the "CMS National Coverage Policy" section, removed #s 6 - 10 and updated #4.

Under the "ICD-9-CM Codes that Support Medical Necessity" section, update several descriptors (per CMS)

Revision #6
Effective Date - 08/01/2002
Reasons - Bill Type 23x removed from policy per verification from CMS. MNU 2002-7, July 2002, page 4

Revision Number #5
Effective Date - 07/01/2002
Reasons - The policy is being revised to reflect Medicare's coverage guidelines regarding peripheral neuropathy with loss of protective sensation in people with diabetes. (Effective for services furnished on or after July 1, 2002).

Revision #4
Effective Date - 02/01/2002
Reasons - CPT/HCPCS code G0127 removed from policy because it does not apply to intermediaries.

Revision #3
Effective Date - 01/18/2001
Reasons - ICD-9 codes 707.14 and 707.15 added to "Codes That Support Medical Necessity'.

Revision #2
Effective Date - 10/06/2000
Reasons - The following statement was included in the policy: 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. Cases with findings falling short of these alternatives may involve podiatric treatment that may constitute covered care and may be reviewed by the intermediary's medical staff.

Revision #1
Effective Date - 04/06/2000
Reasons - Codes 11720 and 11721 were added to "CPT/HCPCS Codes" section. 

Reason for Change 

HCPCS/ICD9 Descriptor Change
 

Last Reviewed On Date 

01/07/2008 

Related Documents 

Article(s)
A22445 - Routine Foot Care - Medical Policy Article

LCD Attachments