Wiki Routine Foot Care and the LCDs

[jkottarathil]

Hello,

I am hoping to gain some clarification make sure that I understand the LCD correctly. The practice that I work for uses 2 different LCDs (depending on what state the patient was seen in--A57759 or A57188). When using the patient's systemic condition as the diagnosis code when billing 11721, are we only allowed to use the specific ICD-10 codes listed on the LCD? Or can we use other codes in the same category. For instance in A57759, I73.89 - Other specified peripheral vascular diseases is on the list of acceptable diagnosis codes. Could we use I73.9 - Peripheral vascular disease, unspecified instead (in the instance that the patient doesn't have I73.89 but rather I73.9) and still have it be covered?

I understand the guidelines as to when you're able to use the systemic conditions (i.e. the documentation needs to meet the requirements of a Q modifier), I am solely inquiring about the diagnosis codes you can use.

Thank you! Any insight is appreciated!

 

[MI_CODER]

I'm not familiar with the routine foot care LCDs however I do occasionally have other LCDs that I have to pay attention to. In general, if an LCD has a list of acceptable diagnoses then the insurance is only going to pay for that procedure if one of those acceptable diagnoses is listed as a primary diagnosis on the claim. In the example you provided, if I73.9 isn't an acceptable diagnosis on the LCD then your claim will get denied. If your provider is only documenting that the patient has PVD then I don't believe you could use I73.89. I73.89 is applicable to acrocyanosis, erthrocyanosis, simple acroparesthesia (Schultze's type) and vasomotor acroparesthesia (Nothnagel's type). If one of those terms isn't documented then you wouldn't be able to use I73.89. If you're having a hard time finding an acceptable diagnosis then I would query your provider and ask if they can provide a more detailed diagnosis (such as the PVD in your example). Hope this helps!

https://www.icd10data.com/ICD10CM/Codes/I00-I99/I70-I79/I73-/I73.89

https://www.aapc.com/codes/icd-10-codes/I73.89#:~:text=ICD%2D10%20code%20I73.,Diseases%20of%20the%20circulatory%20system%20.

 

[jkottarathil]

I'm not familiar with the routine foot care LCDs however I do occasionally have other LCDs that I have to pay attention to. In general, if an LCD has a list of acceptable diagnoses then the insurance is only going to pay for that procedure if one of those acceptable diagnoses is listed as a primary diagnosis on the claim. In the example you provided, if I73.9 isn't an acceptable diagnosis on the LCD then your claim will get denied. If your provider is only documenting that the patient has PVD then I don't believe you could use I73.89. I73.89 is applicable to acrocyanosis, erthrocyanosis, simple acroparesthesia (Schultze's type) and vasomotor acroparesthesia (Nothnagel's type). If one of those terms isn't documented then you wouldn't be able to use I73.89. If you're having a hard time finding an acceptable diagnosis then I would query your provider and ask if they can provide a more detailed diagnosis (such as the PVD in your example). Hope this helps!

https://www.icd10data.com/ICD10CM/Codes/I00-I99/I70-I79/I73-/I73.89

https://www.aapc.com/codes/icd-10-codes/I73.89#:~:text=ICD%2D10%20code%20I73.,Diseases%20of%20the%20circulatory%20system%20.

Thank you for your response! That it along the lines of what I was thinking...I just wanted to be sure. Have a good day!

 

[podcoder70]

I am very familiar with the foot care LCDs and Articles from the various jurisdictions. These articles list the icd10 codes that can be used to get nail and callus debridement covered. The code MUST be on the list for the service to be paid. The "unspecified" code I73.9 will get your claim denied. The second article you mention restricts coverage even further by eliminating the vascular I73 codes, only arterial risk factors are covered.

 

[Kristen Bensel]

The codes on the LCD are the codes they require to be covered. Medicare also requires a modifier to be used on those codes when the patient meets the qualifications- Q7, Q8 or Q9. The modifier is used to indicate that the routine foot care was medically necessary in the absence of a covered systemic issue.
There are a few conditions such as E11.42 that when present the modifiers are not needed, but that code would be required to be on the claim as a secondary DX for the procedure, not the primary. You will want to make sure documentation is on point for the Medicare MAC that you are dealing with.

 

[jkottarathil]

I am very familiar with the foot care LCDs and Articles from the various jurisdictions. These articles list the icd10 codes that can be used to get nail and callus debridement covered. The code MUST be on the list for the service to be paid. The "unspecified" code I73.9 will get your claim denied. The second article you mention restricts coverage even further by eliminating the vascular I73 codes, only arterial risk factors are covered.

Thank you for the response!

 

[tammystewart6611@yahoo.com]

The codes on the LCD are the codes they require to be covered. Medicare also requires a modifier to be used on those codes when the patient meets the qualifications- Q7, Q8 or Q9. The modifier is used to indicate that the routine foot care was medically necessary in the absence of a covered systemic issue.
There are a few conditions such as E11.42 that when present the modifiers are not needed, but that code would be required to be on the claim as a secondary DX for the procedure, not the primary. You will want to make sure documentation is on point for the Medicare MAC that you are dealing with.

Can you show me link where it states that if E11.42 is present you do not need at have Q modifier and E11.42 must be secondary dx?

 

[podcoder70]

Can you show me link where it states that if E11.42 is present you do not need at have Q modifier and E11.42 must be secondary dx?

Tammy, I believe what Kristen is saying is that DEPENDING ON THE MAC is what sets the rules for when a Q modifier is required and when it is not. For example, Noridian, on the west coast, only requires the Q modifier for vascular diagnosis codes. Other jurisdications, though, require it for ALL diagnosis codes for the treatment of nails and calluses to be covered. I have never understood why these MACs think that a person with neuropathy and complete LOPS would also have risk factors that qualify as a Q7/8/9...they don't! But, I don't make the rules...