Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Routine Foot Care for Certain Medical Conditions

Policy #:07.07.01n

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

When a benefit exists, routine foot care is considered medically necessary and, therefore, covered once every 60 days when both of the following criteria are met:
  • The individual has a peripheral circulatory disorder or diminished sensation in the legs or feet as a result of one or more of the diagnoses listed below:
    • Amyotrophic lateral sclerosis (ALS)
    • Arteriosclerosis obliterans (ASO) (e.g., 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 –
      • Associated with malnutrition and vitamin deficiency*
        1. Malnutrition (general, pellagra)
        2. Alcoholism
        3. Malabsorption (celiac disease, tropical sprue)
        4. 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
        1. Hereditary sensory radicular neuropathy
        2. Amyloid neuropathy
        3. Angiokeratoma corporis diffusum (Fabry's disease)
    • Peripheral vascular disease
    • Raynaud's disease

*NOTE: When the individual's condition is one of those designated by an asterisk (*), routine procedures are covered only if the individual is under the active care of a professional provider who documents the condition.
  • The individual has one of the following:
    • A Class A finding of a nontraumatic amputation of foot or integral skeletal portion thereof
    • Two of the following Class B findings:
      • Absent posterior tibial pulse
      • Absent dorsalis pedis pulse
      • Advanced trophic changes (at least three of the following are required):
        1. Hair growth (decrease or absence)
        2. Nail changes (thickening)
        3. Pigmentary changes (discoloration)
        4. Skin texture (thin, shiny)
        5. Skin color (rubor or redness)
    • One Class B finding (see above) and two of the following Class C findings:
      • Claudication
      • Temperature changes (e.g., cold feet)
      • Edema
      • Paresthesias (abnormal spontaneous sensations in the feet)
      • Burning

Whirlpool treatment performed prior to routine foot care, to soften the nails or skin, is considered part of the routine foot care services and, therefore, is not eligible for separate reimbursement.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

For routine foot care in the presence of qualifying covered systemic conditions, the medical record must contain a sufficiently detailed description of the feet to support that non-professional performance of the service is hazardous to the individual. Furthermore, the following physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the individual’s medical record. The professional provider rendering the routine foot care has identified, in addition to a primary condition, 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 (Q9).

BILLING REQUIREMENTS

When nail trimming is performed as an individual service, report the appropriate individual service code. When routine foot care is performed as a comprehensive service, report the appropriate comprehensive Healthcare Common Procedure Coding System (HCPCS) code instead of the code for the individual services.

All codes for routine foot care services should be reported only once per visit regardless of the number of lesions or nails treated.

When reporting routine foot care services in the presence of qualifying covered systemic conditions, the applicable Q modifier (Q7, Q8, or Q9) identifying the class findings must be included on the claim.

When reporting one of the ICD-10-CM codes that fall under the "active care requirement", the date that the individual was last seen by the professional provider responsible for treating the underlying condition must be reported in line 19 of the CMS-1500 claim form or the electronic equivalent.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, when a benefit exists, routine foot care is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met. Individual member benefits must be verified as benefits for routine foot care may vary by product and group and may be excluded.

Description

Routine (i.e., palliative or cosmetic) foot care is typically performed by a professional provider (e.g., podiatrist or primary care provider) for the purposes of inspecting and treating an individual's feet for sequelae of systemic conditions including decreased circulation, skin and nail irregularities, alteration in nerve sensations, foot deformities, swelling, ulceration, or drainage.

Routine foot care includes the treatment of:
  • Corns, also known as a clavus: a thickened hard growth of skin
  • Calluses, also known as a tyloma or tylomata: a thickening of skin of the horny layer due to locations of pressure or friction
  • Plantar keratosis, hyperkeratosis, and keratotic lesions: outer layers of skin that become overgrown and thick
  • Bunions (except capsular or bone surgery thereof): inflammation from long-term pressure and irritation at the joint area located at the base of the great toe
  • Nails (except surgery for ingrown nails)

Foot care that would otherwise be considered routine (eg, cutting or removing corns/calluses, trimming, cutting, clipping, or debriding nails) is usually not routine when the individual has a systemic condition that results in severe circulatory embarrassment or areas of diminished sensation in the legs or feet. For these individuals, routine foot care procedures should be performed by a professional provider (eg, podiatrist or PCP) to minimize the risk for infection or circulatory compromise.
References

American Diabetes Association (ADA). Microvascular complications and foot care: Standards of medical care in diabetes - 2018. Diabetes Care. 2018;41(Suppl. 1):S105–S118.


American Academy of Orthopaedic Surgeons (AAOS). Care of the Diabetic Foot. [AAOS Web site]. Last reviewed September 2017. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00148. Accessed February 23, 2018.

American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014; vol. 37, Supplement 1 S14-S80.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. 290: Foot care. [CMS Web site]. 10/01/03. Available at: https://www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed February 23, 2018.

Company Benefit Contracts.

Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders: A clinical practice guideline. J Foot Ankle Surg. 2006;45(5 Suppl):S1-S66.

Harless LB, Satterfield VK, Dennis KJ. Role of the podiatrist. In: Bowker JH, Pfeiffer MA, eds. Levin and O'Neal's The Diabetic Foot. 6th ed. St. Louis, MO: Mosby, Inc; 2001: 682-699.

Novitas Solutions, Inc. A52996: Routine foot care (article). [Novitas Solutions Web site]. 10/01/2015. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52996&ver=5&ContrId=323&ContrVer=1&CntrctrSelected=323*1&Date=10%2f06%2f2015&DocID=A52996&bc=hAAAAAgAAAAAAA%3d%3d&. Accessed February 23, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35138: Routine foot care. [Novitas Solutions Web site]. 10/01/2015 (Revised 12/14/2017). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35138&ver=33&name=314*1&UpdatePeriod=696&bc=AQAAEAABAAAA&. Accessed February 23, 2018.

Pinzur MS, Slovenkai MP, Trepman E, Shields NN. Diabetes Committee of American Orthopaedic Foot and Ankle Society. Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int. 2005;26(1):113-119.

Rathur HM, Boulton AJ. The diabetic foot. Clin Dermatol. 2007;25(1):109-120.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

11719


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A, B, C, D, and E


HCPCS Level II Code Number(s)

G0127 Trimming of dystrophic nails, any number


G0247 Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (lops) to include if present, at least the following: (1) local care of superficial wounds, (2) debridement of corns and calluses, and (3) trimming and debridement of nails

S0390 Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific medical conditions (eg, diabetes), per visit



Revenue Code Number(s)

N/A


Misc Code

Modifiers:

Q7 One Class A finding

Q8 Two Class B findings

Q9 One class B and 2 class C findings



Coding and Billing Requirements


Cross References

Attachment A: Routine Foot Care for Certain Medical Conditions
Description: ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (A30.0 -E10.21)

Attachment B: Routine Foot Care for Certain Medical Conditions
Description: ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E10.22 - E13.3512), Continued

Attachment C: Routine Foot Care for Certain Medical Conditions
Description: ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (E13.3513 - I87.093), Continued

Attachment D: Routine Foot Care for Certain Medical Conditions
Description: ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (I87.099 - S86.891S), Continued

Attachment E: Routine Foot Care for Certain Medical Conditions
Description: ICD-10 CM Codes Eligible to be Reported for Routine Foot Care for Certain Medical Conditions (S86.892A - Z79.01), Continued




Policy History

07.07.01n
07/022018This version of the policy will become effective 07/02/2018.

The policy has been reviewed and issued to communicate the Company’s position on Routine Foot Care For Certain Medical Conditions.

The Medical Necessity requirements have been amended the medical necessity criteria as follows due to correction in LCD.

The following ICD-10 CM codes have been added to Attachment C in this policy:
E85.81 Light chain (AL) amyloidosis
E85.82 Wild-type transthyretin-related (ATTR) amyloidosis
G12.25 Progressive spinal muscle atrophy



07.07.01m
11/17/2017This policy has undergone a routine review, and the Medical Necessity requirements have been re-ordered and updated to identify conditions for which the individual must be under the active care of a professional provider.

The following Modifiers have been added to the policy:
    Q7 One Class A finding
    Q8 Two Class B findings
    Q9 One class B and 2 class C findings

The following ICD-10 CM codes have been deleted from this policy:
    E10.37X1: Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

    E10.37X2: Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

    E10.37X3: Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

    E10.37X9: Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

Billing Requirements have been added.

Language added to Required Documentation section to clarify reporting requirements related to rationale for provision of care by professional provider.
Version Effective Date: 07/02/2018
Version Issued Date: 07/02/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.