Warning: Trimming Toe Nails Can be Hazardous
Present Convincing Evidence for Routine Foot Care Necessity
By Cindy W. Gallimore, CPC
Determining if and when routine foot care is covered under Medicare guidelines can be a challenge. We’ll help you distinguish between covered versus non-covered routine foot care services and the required documentation for billing these services, whether you are a primary care physician or a podiatrist.
Routine foot care is typically excluded from Medicare’s coverage. According to the Medicare Benefit Policy Manual, chapter 15, section 290, “Medicare Covered Podiatry Services” only include medically necessary and reasonable foot care.
Although a podiatrist provides most routine foot care, the exclusion of foot care services is determined by the nature of service and not according to who provides the service. Payment for a routine excluded service would be denied whether performed by a podiatrist or any other provider. Services normally considered routine and not covered by Medicare are:
- The cutting or removal of corns and calluses
- The trimming, cutting, clipping, or debriding of nails
- Other hygienic and preventive maintenance care
The procedure codes that could be considered routine by Medicare are:
HCPCS Level II
G0127 Trimming of dystrophic nails, any number
11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
11056 … 2 to 4 lesions
11057 … more than 4 lesions
11719 Trimming of non dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 … six or more
When routine foot care services are provided, notify the patient the services are excluded from Medicare coverage. A Medicare Advanced Beneficiary Notice should be completed and signed by the patient prior to performing services. The above CPT® codes would then be filed with either modifier GA Waiver of liability statement on file or GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit. This will allow the provider to bill the patient for rendered services.
Systemic Conditions Determine Routine Foot Care Necessity
What is medically necessary routine foot care and what are the exceptions to Medicare exclusions?
Medicare requires the presence of a systemic condition for possible coverage. Foot care otherwise considered routine may be covered when the systemic conditions result in severe circulatory compromise and diminished sensation in the individual’s legs or feet. In these circumstances, routine foot care (for example, trimming of corn and calluses, debridement of nails) may pose a hazard when provided by a non-professional. Completely document convincing evidence to show non-professional services are hazardous for the patient due to underlying systemic disease. Merely documenting a patient has a complicating condition, such as diabetes, does not constitute coverage as it doesn’t show the severity of the condition.
Medicare provides guidance on systemic conditions or complicating conditions that may justify routine foot care coverage. This is not an all-inclusive list but represents the most common underlying conditions:
- Diabetes mellitus *
- Arteriosclerosis obliterans
- Thromboangiitis obliterations (Buerger’s disease)
- Chronic thrombophlebitis *
- Peripheral neuropathies involving the feet – Associated with malnutrition and vitamin deficiency *
- Malnutrition (general, pellagra)
- 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 renal disease) *
- Associated with traumatic injury
- Associated with leprosy or neurosyphilis
- Associated with hereditary disorders
- Hereditary sensory radicular neuropathy
- Angiokeratoma corporis diffusum (Fabry’s disease)
- Amyloid neuropathy
Asterisk (*) systemic condition—requires the active care and documentation of a doctor of medicine or osteopathy for the patient’s complicating condition. Active care in this circumstance requires patient evaluation and/or treatment for the systemic condition within six months prior to receiving the foot care services.
The treatment of mycotic nails (fungal infection of the nails) may be covered in the absence of the systemic conditions listed above. The treatment for mycotic nails is only covered when there is documentation of (1) clinical evidence of mycotic infection of the toenail(s) and (2) marked limitation in ambulation (for ambulatory patients), pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.
Presumption of Coverage
Routine foot care service providers may use the “presumption of coverage” theory. Presumption of coverage stipulates that upon patient evaluation certain physical and/or clinical findings are consistent with the diagnosis and indicate severe peripheral involvement. Presumption of coverage is applied by the use of class findings.
Class A findings
- Nontraumatic amputation of foot or integral skeleton portion
Class B findings
- Absent posterior tibial pulse
- Advanced trophic changes: (three required to qualify as one class finding)
- Hair growth (increase or decrease)
- Nail changes (thickening)
- Pigmentary changes (discoloration)
- Skin texture (thin, shiny)
- Skin color (rubor, redness)
- Absent dorsalis pedis pulse
- Class C findings
- Temperature changes (e.g., cold feet)
- Paresthesias (abnormal spontaneous sensations in the feet)
To apply the presumption of coverage, the foot care service provider must identify the above class findings, and the appropriate correlating HCPCS Level II modifier must be appended to the routine foot care procedure when billed to Medicare.
Q7 One class A finding
Q8 Two class B findings
Q9 One class B & two class C findings
It is important to maintain complete, accurate documentation of the class findings for presumption of coverage. A podiatrist may also keep a statement on file from the treating MD or DO concurring with the podiatrist’s findings indicating severe peripheral involvement.
When billing Medicare for covered routine foot care services for a patient with an “Asterisk” systemic disease, the claim must include:
The MD or DO treating the systemic disease (line 19 of CMS 1500)
The NPI of the MD or DO treating the systemic disease (line 19 of CMS 1500)
The date last seen by the MD or DO (line 19 of CMS 1500)
The routine foot care diagnosis (ICD-9-CM) – the primary diagnosis
The systemic disease diagnosis (ICD-9-CM) – the secondary diagnosis
Either CPT® code 11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion, 11056 2 to 4 lesions, 11057 more than 4 lesions, 11719 Trimming of nondystrophic nails, any number, 11720 Debridement of nail(s) by any method(s); one to five, 11721 six or more, or HCPCS Level II G0127 Trimming of dystrophic nails, any number The appropriate Q modifier (for class findings)
Loss of Protective Sensation (LOPS)
Peripheral neuropathy is the most common factor leading to amputation in people with diabetes. Medicare began covering foot care services for patients with documented diabetic peripheral neuropathy with LOPS in 2002. Peripheral neuropathy primarily affects diabetic patients’ sensory nerve fibers. It generally begins in the toes and progresses proximally; the beginning of LOPS. With its progression, patients are unable to feel minor trauma from mechanical, thermal, or chemical sources.
The diagnosis of LOPS must use established guidelines, such as the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. The sensory testing must use the 5.07 monofilament, testing at least five different sites randomly on each foot. This sensation evaluation must be performed at each LOPS visit. The American Academy of Podiatric Medicine has guidelines suggesting that the absence of sensation at two or more of the five sites tested on either foot be documented to diagnose peripheral neuropathy with LOPS.
Medicare will cover an evaluation (examination and treatment) for patients with documented diabetic peripheral neuropathy with LOPS no more often than every six months if they have not seen another foot care specialist for other reason in the interim. The HCPCS Level II codes for billing LOPS are:
Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must include: (1) the diagnosis of LOPS, (2) a patient history, (3) a physical examination that consists of at least the following elements: (a) visual inspection of the forefoot, hindfoot and toe web spaces, (b)evaluation of a protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, and (e) evaluation and recommendation of footwear and (4) patient education
Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include at least the following: (1) a patient history, (2) a physical examination that includes: (a) visual inspection of the forefoot, hindfoot and toe web spaces, (b) evaluation of protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, and (e) evaluation and recommendation of footwear, and (3) patient education
Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include, the local care of superficial wounds (i.e. superficial to muscle and fascia) and at least the following if present: (1) local care of superficial wounds, (2) debridement of corns and calluses, and (3) trimming and debridement of nails
HCPCS Level II code G0247 must be billed on the same date of service with either G0245 or G0246 for payment consideration.
Providers must report one of the following diagnosis codes with the above HCPCS Level II codes in support of the services:
250.6x Diabetes mellitus; diabetes with neurological manifestations;
250.60 type II or unspecified type, not stated as uncontrolled 250.61 type I [juvenile type], not stated as uncontrolled
250.62 type II or unspecified type, uncontrolled
250.63 type I [juvenile type], uncontrolled
357.2 Inflammatory and toxic neuropathy; polyneuropathy in diabetes
The majority of patients don’t qualify for covered routine foot care services. Patients who do qualify, however, can greatly benefit from these services by reducing the future risk of more invasive procedures or possible amputation. When billing for these routine foot care services, providers should be vigilant in their examinations and documentation. Educating your patients by reinforcing the importance of routine primary care provider (PCP) follow up treatment of systemic disease is essential. With regular visits to their PCP and foot care specialist, these patients can look forward to a future with feet and toes intact.
Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 290
Program Memorandum Carriers; Transmittal B-02-091 (DHHS & CMS)
Provider Education Article: Requirement for Payment of Medicare Claims for Foot and Nail Care Services
CMS Manual System, Pub. 100-04 Medicare Claims Processing; Transmittal 498 (DHHS & CMS)
Billing of the Diagnosis and Treatment of Peripheral Neuropathy with Loss of Protective Sensation in People with Diabetes
Medicare Learning Network (CMS); MLN Matters Number: SE0707
Overview of Medicare Podiatry Services