Local Coverage Determination (LCD) for Routine Foot Care (L24356)

Transcription

1 Local Coverage Determination (LCD) for Routine Foot Care (L24356) Contractor Name Noridian Administrative Services, LLC LCD Information Document Information LCD ID Number L24356 LCD Title Routine Foot Care Contractor's Determination Number JF B AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 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. Oversight Region Region X Original Determination Effective Date For services performed on or after 02/01/2012 Original Determination Ending Date Revision Effective Date For services performed on or after 02/27/2012 Revision Ending Date CMS National Coverage Policy Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary. Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment

2 for any claim which lacks the necessary information to process the claim. CMS Medicare Benefit Policy Manual, Pub , Section 290 Indications and Limitations of Coverage and/or Medical Necessity Routine foot care is the paring, cutting, or trimming of corns and calluses, or debridement and trimming of toenails in the absence of localized illness, injury or symptoms involving the foot. Routine foot care is usually performed by the beneficiary him or herself, or by a caregiver. Medicare allows payment for routine foot care only if the conditions under "Indications and Limitations of Coverage" are met. These conditions describe the systemic diseases and their peripheral complications that increase the danger for infection and injury if a non-professional provides these services. To avoid this danger, Medicare covers these services when performed by a professional, e.g., a physician, and no more often than every 60 days or when the billing physician documents the need for more frequent treatment. When the patient has a symptomatic foot condition, care of that condition is not "routine" and is, presuming medical necessity, covered. Separate policies have been developed for the treatment of the pathological and painful toenail, foot ulcers, symptomatic skin lesions, trigger point injections and other injections. Because providers of foot care use many different instruments to trim or debride the nondystrophic or dystrophic nail, defining trimming and debridement by the type of instrument used is impractical. Therefore, for the purpose of this policy, debridement of nails is a procedure that is needed to remove excessive material (reduce thickness and length) from a dystrophic nail but not a non-dystrophic nail. In contrast, trimming of nails is a procedure that may be directed at either type of nail. Indications: The following is quoted from the Medicare Benefit Policy Manual , Section 290: "B - Exclusions from Coverage The following foot care services are generally excluded from coverage under both Part A and Part B. (See 290.F and 290.G for instructions on applying foot care exclusions.) 1 - Treatment of Flat Foot The term "flat foot" is defined as a condition in which one or more arches of the foot have flattened out. Services or devices directed toward the care or correction of such conditions, including the prescription of supportive devices, are not covered. 2 - Routine Foot Care Except as provided above, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following: The cutting or removal of corns and calluses; The trimming, cutting, clipping, or debriding of nails; and Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other

3 service performed in the absence of localized illness, injury, or symptoms involving the foot. 3 - Supportive Devices for Feet Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. C - Exceptions to Routine Foot Care Exclusion 1 - Necessary and Integral Part of Otherwise Covered Services In certain circumstances, services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections. 2 - Treatment of Warts on Foot The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body. 3 - Presence of Systemic Condition The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from coverage). Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual's legs or feet. (See subsection A). In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions. (See 290.G for procedural instructions.) 4 - Mycotic Nails In the absence of a systemic condition, treatment of mycotic nails may be covered. The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient's mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate. The treatment of mycotic nails for a nonambulatory patient is covered only when the physician attending the patient's mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate. For the purpose of these requirements, documentation means any written information that is

4 required by the carrier in order for services to be covered. Thus, the information submitted with claims must be substantiated by information found in the patient's medical record. Any information, including that contained in a form letter, used for documentation purposes is subject to carrier verification in order to ensure that the information adequately justifies coverage of the treatment of mycotic nails. D - Systemic Conditions That Might Justify Coverage Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might justify coverage for routine foot care. Diabetes mellitus * Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis) Buerger's disease (thromboangiitis obliterans) Chronic thrombophlebitis * Peripheral neuropathies involving the feet - o Associated with malnutrition and vitamin deficiency * Malnutrition (general, pellagra) Alcoholism Malabsorption (celiac disease, tropical sprue) Pernicious anemia o Associated with carcinoma * o Associated with diabetes mellitus * o Associated with drugs and toxins * o Associated with multiple sclerosis * o Associated with uremia (chronic renal disease) * o Associated with traumatic injury o Associated with leprosy or neurosyphilis o Associated with hereditary disorders Hereditary sensory radicular neuropathy Angiokeratoma corporis diffusum (Fabry's) Amyloid neuropathy 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. E - Supportive Devices for Feet Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics. F - Presumption of Coverage In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement. For purposes of

5 applying this presumption the following findings are pertinent: Class A Findings Nontraumatic amputation of foot or integral skeletal portion thereof. Class B Findings Absent posterior tibial pulse; Advanced trophic changes as: hair growth (decrease or absence) nail changes (thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin color (rubor or redness) (Three required); and Absent dorsalis pedis pulse. Class C Findings Claudication; Temperature changes (e.g., cold feet); Edema; Paresthesias (abnormal spontaneous sensations in the feet); and Burning. The presumption of coverage may be applied when the physician rendering the routine foot care has identified: 1. A Class A finding; 2. Two of the Class B findings; or 3. One Class B and two Class C findings. Cases evidencing findings falling short of these alternatives may involve podiatric treatment that may constitute covered care and should be reviewed by the intermediary's medical staff and developed as necessary. For purposes of applying the coverage presumption where the routine services have been rendered by a podiatrist, the contractor may deem the active care requirement met if the claim or other evidence available discloses that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the rendition of the routine-type services. The intermediary may also accept the podiatrist's statement that the diagnosing and treating M.D. or D.O. also concurs with the podiatrist's findings as to the severity of the peripheral involvement indicated. Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections. G - Application of Foot Care Exclusions to Physician's Services The exclusion of foot care is determined by the nature of the service. Thus, payment for an excluded service should be denied whether performed by a podiatrist, osteopath, or a doctor of medicine, and without regard to the difficulty or complexity of the procedure. When an itemized bill shows both covered services and noncovered services not integrally related to the covered service, the portion of charges attributable to the noncovered services should be denied. (For example, if an itemized bill shows surgery for an ingrown toenail and

6 also removal of calluses not necessary for the performance of toe surgery, any additional charge attributable to removal of the calluses should be denied.) In reviewing claims involving foot care, the carrier should be alert to the following exceptional situations: 1. Payment may be made for incidental noncovered services performed as a necessary and integral part of, and secondary to, a covered procedure. For example, if trimming of toenails is required for application of a cast to a fractured foot, the carrier need not allocate and deny a portion of the charge for the trimming of the nails. However, a separately itemized charge for such excluded service should be disallowed. When the primary procedure is covered the administration of anesthesia necessary for the performance of such procedure is also covered. 2. Payment may be made for initial diagnostic services performed in connection with a specific symptom or complaint if it seems likely that its treatment would be covered even though the resulting diagnosis may be one requiring only noncovered care. The name of the M.D. or D.O. who diagnosed the complicating condition must be submitted with the claim. In those cases, where active care is required, the approximate date the beneficiary was last seen by such physician must also be indicated. NOTE: Section 939 of P.L removed "warts" from the routine foot care exclusion effective July 1, Relatively few claims for routine-type care are anticipated considering the severity of conditions contemplated as the basis for this exception. Claims for this type of foot care should not be paid in the absence of convincing evidence that nonprofessional performance of the service would have been hazardous for the beneficiary because of an underlying systemic disease. The mere statement of a diagnosis such as those mentioned in D above does not of itself indicate the severity of the condition. Where development is indicated to verify diagnosis and/or severity the carrier should follow existing claims processing practices which may include review of carrier's history and medical consultation as well as physician contacts. The rules in 290.F concerning presumption of coverage also apply. Codes and policies for routine foot care and supportive devices for the feet are not exclusively for the use of podiatrists. These codes must be used to report foot care services regardless of the specialty of the physician who furnishes the services. Carriers must instruct physicians to use the most appropriate code available when billing for routine foot care." End of Quote Routine foot care is also covered when the patient has had a non-traumatic amputation of a foot or integral skeletal portion thereof. Limitations: Noridian may make a presumption of coverage where the claim or other evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement. For purposes of applying this presumption, the following findings are pertinent. Class A Findings: -Non-traumatic amputation of foot or integral skeletal portion thereof

7 Class B Findings: -Absent posterior tibial pulse -Absent dorsalis pedis pulse -Advanced trophic changes, such as: (three required) hair growth decreased or absent nail changes (thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin color (rubor or redness) Class C Findings: -Claudication -Temperature changes (e.g., cold feet) -Edema -Paresthesias (abnormal spontaneous sensations in the feet) -Burning The presumption of coverage may be applied when the physician rendering the routine foot care has identified: (1) a Class A finding; the Q7 Modifier, (2) two of the Class B findings; the Q8 Modifier, or (3) one Class B and two Class C findings; the Q9 Modifier For purposes of applying the coverage presumption where the routine services have been rendered by a podiatrist, Noridian may deem the active care requirements (note under Indications and Limitations of Coverage and/or Medical Necessity) met if the claim or other evidence available discloses that the patient has seen an MD or DO for treatment and/or evaluation of the complicating disease process during the six-month period prior to the rendition of the routine-type service. Except for the patient with a non-traumatic amputation of a foot or part thereof, if the patient does not have one of the systemic conditions (listed above) with peripheral complications, then routine foot care is not covered. A communication from the Central Office of CMS (formerly HCFA) dated March 19, 1999 stated that, "This [the condition justifying payment for routine foot care] does not include immunosuppression and coagulation defects. These are non-covered conditions for RFC [routine foot care]. Nor do we cover RFC for patients on high-dose steroids, transplant patients, or those with artificial hip, knee, or vascular graft." Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review. Coding Information Bill Type Codes:

8 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. Revenue Codes: 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 Not Applicable CPT/HCPCS Codes PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE G0127 TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER ICD-9 Codes that Support Medical Necessity Note: Diagnosis codes are based on the current ICD-9-CM codes that are effective at the time of LCD publication. Any updates to ICD-9-CM codes will be reviewed by NAS; and coverage should not be presumed until the results of such review have been published/posted. These are the only ICD-9-CM codes that support medical necessity: DERMATOPHYTOSIS OF NAIL 700 CORNS AND CALLOSITIES OTHER SPECIFIED DISEASES OF NAIL UNSPECIFIED DISEASE OF NAIL Systemic Conditions: The following diagnoses require a Q modifier: * SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, NOT STATED AS, OR UNSPECIFIED * SECONDARY DIABETES MELLITUS WITHOUT MENTION OF

9 COMPLICATION, SECONDARY DIABETES MELLITUS WITH KETOACIDOSIS, NOT * STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH KETOACIDOSIS, * SECONDARY DIABETES MELLITUS WITH HYPEROSMOLARITY, NOT * STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH HYPEROSMOLARITY, * SECONDARY DIABETES MELLITUS WITH OTHER COMA, NOT * STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH OTHER COMA, * SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS, * NOT STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS, * SECONDARY DIABETES MELLITUS WITH OPHTHALMIC * MANIFESTATIONS, NOT STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH OPHTHALMIC * MANIFESTATIONS, SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL * MANIFESTATIONS, NOT STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL * MANIFESTATIONS, SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY * DISORDERS, NOT STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY * DISORDERS, SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED * MANIFESTATIONS, NOT STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED * MANIFESTATIONS, SECONDARY DIABETES MELLITUS WITH UNSPECIFIED * COMPLICATION, NOT STATED AS, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH UNSPECIFIED * COMPLICATION, * DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE

10 II OR UNSPECIFIED TYPE, NOT STATED AS DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE * I [JUVENILE TYPE], NOT STATED AS DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE * II OR UNSPECIFIED TYPE, DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE * I [JUVENILE TYPE], DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, * NOT STATED AS DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], NOT * STATED AS DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, * DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], * DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED * TYPE, NOT STATED AS DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], NOT * STATED AS DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED * TYPE, DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], * DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT * STATED AS DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], NOT * STATED AS DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, * DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], * DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR * UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE * TYPE], NOT STATED AS DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR * UNSPECIFIED TYPE, DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE * TYPE], DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR * UNSPECIFIED TYPE, NOT STATED AS * DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE

11 TYPE], NOT STATED AS DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR * UNSPECIFIED TYPE, DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE * TYPE], DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR * UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I * [JUVENILE TYPE], NOT STATED AS DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR * UNSPECIFIED TYPE, DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I * [JUVENILE TYPE], DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II * OR UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I * [JUVENILE TYPE], NOT STATED AS DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II * OR UNSPECIFIED TYPE, DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I * [JUVENILE TYPE], DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR * UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I * [JUVENILE TYPE], NOT STATED AS DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR * UNSPECIFIED TYPE, DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I * [JUVENILE TYPE], DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR * UNSPECIFIED TYPE, NOT STATED AS DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE * TYPE], NOT STATED AS DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR * UNSPECIFIED TYPE, DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE * TYPE], ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES

12 WITH REST PAIN ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES 440.4* CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) PERIPHERAL VASCULAR DISEASE UNSPECIFIED The asterisk (*) designates those code ranges that allow coverage only if the patient is under the active care of a doctor of medicine or osteopathy. * 2008 ICD-9-CM Updates diagnosis code was added to the policy, effective 10/1/2007. The following diagnoses do not require a Q modifier: 340* MULTIPLE SCLEROSIS QUADRIPLEGIA UNSPECIFIED QUADRIPLEGIA C1-C4 COMPLETE QUADRIPLEGIA C1-C4 INCOMPLETE QUADRIPLEGIA C5-C7 COMPLETE QUADRIPLEGIA C5-C7 INCOMPLETE OTHER QUADRIPLEGIA PARAPLEGIA MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE LESION OF SCIATIC NERVE MERALGIA PARESTHETICA OTHER LESION OF FEMORAL NERVE LESION OF LATERAL POPLITEAL NERVE LESION OF MEDIAL POPLITEAL NERVE TARSAL TUNNEL SYNDROME LESION OF PLANTAR NERVE CAUSALGIA OF LOWER LIMB OTHER MONONEURITIS OF LOWER LIMB

13 355.8 MONONEURITIS OF LOWER LIMB UNSPECIFIED MONONEURITIS OF UNSPECIFIED SITE HEREDITARY PERIPHERAL NEUROPATHY PERONEAL MUSCULAR ATROPHY HEREDITARY SENSORY NEUROPATHY REFSUM'S DISEASE IDIOPATHIC PROGRESSIVE POLYNEUROPATHY OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY ACUTE INFECTIVE POLYNEURITIS POLYNEUROPATHY IN COLLAGEN VASCULAR DISEASE 357.2* POLYNEUROPATHY IN DIABETES 357.3* POLYNEUROPATHY IN MALIGNANT DISEASE 357.4* POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE 357.5* ALCOHOLIC POLYNEUROPATHY 357.6* POLYNEUROPATHY DUE TO DRUGS 357.7* POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS CHRONIC INFLAMMATORY DEMYELINATING POLYNEURITIS CRITICAL ILLNESS POLYNEUROPATHY OTHER INFLAMMATORY AND TOXIC NEUROPATHY UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES 451.0* PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) * (SUPERFICIAL) * PHLEBITIS AND THROMBOPHLEBITIS OF OTHER 451.2* PHLEBITIS AND THROMBOPHLEBITIS OF LOWER EXTREMITIES UNSPECIFIED The asterisk (*) designates those code ranges that allow coverage only if the patient is under the active care of a doctor of medicine or osteopathy. Diagnoses that Support Medical Necessity All ICD-9-CM diagnosis codes listed in this policy under ICD-9-CM Codes that Support Medical Necessity above. ICD-9 Codes that DO NOT Support Medical Necessity All ICD-9-CM diagnosis codes not listed in this policy under ICD-9-CM Codes that Support Medical Necessity above. ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity All ICD-9-CM diagnosis codes not listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.

14 General Information Documentations Requirements The clinical chart must clearly describe the findings that are claimed by the Q modifiers. For the neuropathies, the chart must record the physical findings of severe loss of sensation to the degree that non-professional services might pose a danger to the patient. For chronic thrombophlebitis, the chart must record the significant physical findings (e.g., edema, superficial varicosities or skin discoloration). The medical record must be made available to Medicare upon request. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act. When requesting an individual consideration through the written redetermination (formerly appeal) process, providers must include all relevant medical records and literature that supports the request. At a minimum two (2) Phase II studies (human feasibility studies suggesting efficacy, pilots) or one (1) Phase III study (primary evidence of safety and efficacy, pivotal) must be submitted for the Medical Director s review. Appendices Utilization Guidelines Sources of Information and Basis for Decision Other carrier policies Podiatric consultants Jeffrey M. Robbins, DPM, Primary Podiatric Medicine, (Philadelphia, PA, W. B. Saunders, 1994) NAS Carrier Advisory Committee Members Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies. The Section titled "Does the 'CPT 30% Rule' Apply?" needs clarification. This rule comes from the AMA (American Medical Association), the organization that holds the copyrights for all CPT codes. The rule states that if, in a given section (e.g., surgery) or subsection (e.g., surgery, integumentary) of CPT Manual, more than 30% of the codes are listed in the LCD, then the short descriptors must be used rather than the long descriptors found in the CPT Manual. This policy is subject to the reasonable and necessary guidelines and the limitation of liability provision.

15 This medical policy consolidates and replaces all previous policies and publications on this subject by Noridian Administrative Services (NAS) and its predecessors for Medicare Part B. Start Date of Comment Period End Date of Comment Period Start Date of Notice Period 11/01/2006 Revision History Number JF B Revision History Explanation JF B This LCD is the outcome for the consolidation of LCDs for JF implementation. 02/01/2012: Idaho MAC B (Contract #02202) was added to this LCD. 02/27/2012: The following states and contractor numbers were added to the LCD: Alaska MAC B (Contract #02102); Oregon MAC B (Contract #02302); and Washington MAC B (Contract #02402). Reason for Change Other Related Documents This LCD has no Related Documents. LCD Attachments Coding Guidelines opens in new window (PDF - 12 KB ) All Versions Updated on 03/08/2012 with effective dates 02/27/ N/A Some older versions have been archived. Please visit the MCD Archive Site opens in new window to retrieve them. Read the LCD Disclaimer opens in new window Footer Links Get Help with File Formats and Plug-Ins opens in new window Submit Feedback opens in new window Department of Health & Human Services Medicare.gov

16 USA.gov Web Policies & Important Links Privacy Policy Freedom of Information Act No Fear Act Centers for Medicare & Medicaid Services, 7500 Security Boulevard Baltimore, MD 21244

17 Coding Guidelines Routine Foot Care 1. One of the following combinations of CPT/HCPCS codes and ICD-9-CM codes is necessary to allow payment for routine foot care: Some CPT/HCPCS codes also require a Q modifier, and, with this, the combination would be sufficient to allow payment. A requires primary diagnosis (700) PLUS a secondary diagnosis (one of the systemic diagnoses) B. G0127, 11720, require primary diagnoses (110.1, or 703.9) PLUS a secondary diagnosis (one of the systemic diagnoses) C requires a primary diagnosis (one of the systemic diagnoses) 2. One of the Q modifiers must modify the CPT/HCPCS code billed, except for the diagnoses of neuropathy and chronic thrombophlebitis. For those systemic conditions identified by an asterisk, the claim must include the approximate date that the patient last saw the primary care physician, even if the primary care physician rendered the service billed. 3. Because Class B and C findings that justify a Q8 or Q9 modifier do not match the findings of severe peripheral neuropathy (total or near total loss of sensation in the feet) or chronic thrombophlebitis, a Q modifier is not necessary with these diagnoses. 4. Use Item 19 on the CMS-1500 claim form or electronic equivalent to report the date last seen and the UPIN (or NPI) of the primary care physician. 5. If, for the purpose of denial, the provider wishes to bill Medicare for non-covered routine foot care services, ICD-9-CM code V50.8 elective surgery for purposes other than remedying health states, other, should be the only diagnosis billed. The patient is responsible for payment and the limiting charges do not apply. 6. Any claim for a procedure code listed in CPT/HCPCS Codes above must be submitted with a valid ICD-9-CM diagnosis code. 7. All ICD-9-CM diagnosis codes must be coded to the highest level of specificity. 8. A claim for a procedure code listed in CPT/HCPCS Codes above submitted without a valid ICD-9-CM diagnosis code will be returned as an incomplete claim under 1833(e). 9. It is understood that any diagnosis or Q modifier submitted must be justified in the patient record. Subsequent determination that the medical record is lacking such justification will result in a retroactive denial under 1862 (a)(1)(