LCD Description:
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.
Coding Guidelines:
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. Effective January 1, 1998, CPT code M0101 (cutting or removal of corns, calluses and/or trimming of nails, application of skin creams and other hygienic and preventive maintenance care [excludes debridement of toenail(s) with onychogryposis or onychauxis], is no longer valid for Medicare purposes. To report covered services, use CPT codes 11055-11057, or 11719.
3. Appropriate modifiers must be used to indicate the affected toe(s) or foot for CPT codes 11055, 11056 and 11057:
- 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
- RT - Right foot, other than toes
- LT - Left foot, other than toes
4. All diagnoses must be coded to the highest specificity.
5. The ICD-9-CM code 277.3 has been terminated effective September 30, 2006 and the replacement ICD-9-CM codes 277.30 and 277.39 are effective for services performed on or after October 1, 2006.
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 the local coverage determination (LCD) would be denied under section 1862(a)(1)(A) of the Social Security Act.
3. A claim submitted without any of the required information, such as modifiers, class findings, etc., as outlined in the “Indications and Limitations of Coverage and/or Medical Necessity" section of the LCD will be denied for missing information.
4. A claim submitted with an ICD-9-CM diagnosis code not coded to its highest level of specificity will be returned as an incomplete claim under section 1833(e) of the Social Security Act.
Other Comments:
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 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
of the service.
2. 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, or as long as the beneficiary has not seen a foot care specialist for another reason in the interim.
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. |
