Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27486

Routine Foot Care

L27486

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.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Medicare Benefit Policy Manual – Pub. 100-02, Chapter 15, Section 290

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

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

Indications

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, trimming, or debridement of 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.

While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits. These include:

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 reimbursable. The presumption of coverage is applied when the physician rendering the routine foot care has identified either (1) the Class A finding (Q7); (2) two of the Class B findings (Q8); or (3) one Class B and two Class C findings, in addition to a primary condition (Q9).

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 three of the following:
  • hair growth (decrease or increase)
    
  • nail changes (thickening)
    
  • pigmentary changes (discoloring)
    
  • skin texture (thin, shiny)
    
  • 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

Note: Benefits for routine foot care are also available for patients 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.

Routine foot care is payable when the patient has a systemic condition resulting in severe circulatory embarrassment or areas of desensitization in the legs or feet. The diagnoses listed below represent systemic conditions that may result in the need for routine foot care:

Amyotrophic Lateral Sclerosis (ALS)

Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)

Arteritis of the feet

Buerger's disease (thromboangiitis obliterans)

Chronic indurated cellulitis

*Chronic thrombophlebitis

Chronic venous insufficiency

*Diabetes mellitus

Intractable edema-secondary to a specific disease (e.g., congestive heart failure, kidney disease, hypothyroidism)

Lymphedema-secondary to a specific disease (e.g., Milroy's disease, malignancy)

Peripheral neuropathies involving the feet

Peripheral neuropathies of the feet

*Associated with malnutrition and vitamin deficiency

• Malnutrition (general, pellagra)
• Alcoholism
• Malabsorption (celiac disease, tropical sprue)
• Pernicious anemia

*Associated with carcinoma

*Associated with diabetes mellitus

*Associated with drugs and toxins

*Associated with multiple sclerosis

*Associated with uremia (chronic kidney disease)

Associated with traumatic injury

Associated with leprosy or neurosyphilis

Associated with hereditary disorders

• Hereditary sensory neuropathy
• Angiokeratoma corporis diffusum (Fabry's)
• Amyloid neuropathy

Peripheral vascular disease

Raynaud's disease

Note:

1. When the patient's condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.
   

2. Claims indicating other diagnoses not specified above will be denied unless the medical record documentation is submitted with the claim.

Limitations

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

Routine foot care should not be paid in the absence of convincing evidence that non-professional performance of the service would be hazardous for the patient because of an underlying systemic disease.

Evaluation and management services for any of the conditions defined as routine foot care will be considered ineligible for reimbursement, with the exception of the initial E/M service performed to diagnose the patient’s condition.

Evaluation and management services provided on the same day as routine foot care by the same doctor for the same condition are not eligible for payment except if it is the initial E&M service performed to diagnose the patient's condition or if the E&M service is a significant separately identifiable service.

Additionally, whirlpool treatment performed prior to routine foot care to soften the nails or skin is not eligible for separate reimbursement.

The global surgery rules will apply to routine foot care procedure codes 11055, 11056, 11057, and 11719. As a result, an E&M service billed on the same day as a routine foot care service is not eligible for reimbursement unless the E&M service is a significant separately identifiable service, indicated by the use of modifier 25, and documented by medical records.

Foot Care

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. Routine foot care services performed more often than every 60 days will be denied unless documentation is submitted with the claim to substantiate the increased frequency. This evidence should include office records or physician notes and diagnoses characterizing the patient's physical status as being of such an acute or severe nature that more frequent services are appropriate.
   
   
5. Physical findings and services must be specific and precise (e.g., left great toe OR right foot, 4^th digit).  Documentation of co-existing systemic illness should be maintained.
   
   
6. There must be adequate documentation to demonstrate the need for routine foot care services as outlined in this determination.  This documentation may be office records, physician notes or diagnoses characterizing the patient’s physical status as being of such severity to meet the criteria for exceptions to the Medicare routine foot care exclusion.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Routine foot care services provided more often than every 60 days will be denied.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27486

07/31/2008

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