Local Coverage Determination (LCD): Routine Foot Care (L30322)

Local Coverage Determination (LCD): Routine Foot Care (L30322) Contractor Information Contractor Name Wisconsin Physicians Service Insurance Corporation LCD Information Document Information LCD ID L30322 LCD Title Routine Foot Care AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2013 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. CMS National Coverage Policy Jurisdiction 8 Notice: Original Effective Date For services performed on or after 08/16/2009 Revision Effective Date For services performed on or after 06/01/2014 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 06/01/2012 Notice Period End Date N/A

Jurisdiction 8 comprises the states of Indiana and Michigan. WPS is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (7/16/2012 8/20/2012); and, is a consolidation of the previous legacy contractors policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination. ST Legacy A Contractor & Contract Number Legacy B Contractor & Contract Number J "8" MAC A Contractor & Contract Number J "8" MAC B Contractor & Contract Number J "8" Effective Date IN NGS: 00630 WPS: 08102 08/20/12 MI WPS: 00953 WPS: 08202 07/16/12 IN NGS: 00130 WPS: 08101 07/23/12 MI NGS: 00452 WPS: 08201 07/23/12 Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1862 (a) (1) (A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1862 (a) (13)(C) defines the exclusion for payment of routine foot care services. Code of Federal Regulations (CFR) Part 411.15., subpart A addresses general exclusions and exclusion of particular services. CMS Publications: CMS Publication 100-2, Medicare Benefit Policy Manual, (MBPM) Chapter 15: 290 Foot care services which are exceptions to the Medicare coverage exclusion. CMS Publication 100-3, Medicare National Coverage Determination Manual, Part 1: 70.2.1 Services provided for diagnosis and treatment of diabetic peripheral neuropathy.

CMS Publication 100-9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5: National Correct Coding Initiative. Coverage Guidance Coverage Indications, Limitations, 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 himself 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. NOTE Normally claims submitted with CPT codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127 must have modifier Q7, Q8, or Q9 and an ICD-9 code listed in this policy. However, if a beneficiary has peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class findings of such severity that care by a non-professional person would put the patient at risk the service would also be covered. The following services are considered to be components of routine foot care and are generally excluded from coverage under both Part A and Part B, 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. Indications: While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits. 1. Covered Routine Foot Care CPT codes 11055, 11056, 11057, 11719, and G0127, and 11720-11721. Medicare payment may be made for routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient s legs or feet). Services normally considered 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. 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. Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. Payment may be made for the debridement of a mycotic nail (whether by manual method or electrical grinder) when definitive antifungal treatment options have been reviewed and discussed with the patient at the initial visit and the physician attending the mycotic condition documents that the following criteria are met: NAIL DEBRIDEMENT DEFINITION: Nail debridement involves the removal of excessive nail material (i.e., the reduction of nail thickness or bulk) from clinically thickened, diseased (e.g., mycotic or dystrophic) nail plate, that may or may not also be misshapen in appearance or brittle in characteristic. (This definition has been approved by the American Podiatric Medical Association.) In the absence of a systemic condition, Medicare covers debridement of the nail when the following criteria are met:

In the case of ambulatory patients there exists: Clinical evidence of mycosis of the toenail, (110.1) and Marked limitation of ambulation (719.7 or 781.2), or pain (729.5 or 703.0 Note: Painful ingrown toenail),and/or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate. In the case of non-ambulatory patients there exists: Clinical evidence of mycosis of the toenail (ICD-9 code 110.1), and The patient suffers from pain (729.5 or 703.0 Note: Painful ingrown toenail) or secondary infection (681.10 or 681.11) resulting from the thickening and dystrophy of the infected toenail plate. In addition, procedures for treating toe nails are covered for the following: Onychogryphosis(703.8) (defined as long standing thickening, in which typically a curved hooked nail (ram s horn nail) occurs), and there is marked limitation of ambulation (719.7 or 781.2), pain (729.5 or 703.0 Note: Painful ingrown toenail), and/or secondary infection (681.10 or 681.11) where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe, and/or Onychauxis (703.8) (defined as thickening (hypertrophy) of the base of the nail/nail bed) and there is marked limitation of ambulation (719.7, 781.2, pain (729.5 or 703.0 Note: Painful ingrown toenail), and /or secondary infection (681.10, 681.11) that causes symptoms. 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 Class A findings Non-traumatic 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) Burning

The presumption of coverage may be applied when the physician rendering the routine foot care has identified: 1. A Class A finding (Modifier Q7) 2. Two of the Class B findings (Modifier Q8); or 3. One Class B and two Class C findings (Modifier Q9). 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 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 neuropathy but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the ICD-9 CM codes in list three of "ICD-9 Codes that Support Medical Necessity" listed below Coding Information Bill Type Codes: 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. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 022x Skilled Nursing - Inpatient (Medicare Part B only) 074x Clinic - Outpatient Rehabilitation Facility (ORF) 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital 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. 051X Clinic - General Classification 0940 Other Therapeutic Services - General Classification CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR 11055 CALLUS); SINGLE LESION PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR 11056 CALLUS); 2 TO 4 LESIONS PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR 11057 CALLUS); MORE THAN 4 LESIONS 11719 TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER 11720 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5 11721 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 Group 1 Paragraph: Note: ICD-9 codes must be coded to the highest level of specificity. LIST ONE: For covered routine foot care that requires date last seen by physician: CPT codes: G0127, 11055, 11056, 11057, 11719 and 11720-11721 billed with the appropriate Q modifier and date last seen by a doctor of medicine or osteopathy (MD or DO) 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 sees their primary care physician no later than 30 days after the services were furnished. Group 1 Codes: 249.00 - SECONDARY DIABETES MELLITUS WITHOUT MENTION OF 249.91 COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED -

SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION, UNCONTROLLED DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR 250.00 - UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH 250.13 KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, 250.20 - NOT STATED AS UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY, 250.23 TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED 250.40 - TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH RENAL 250.43 MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR 250.70 - UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH 250.73 PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR 250.80 - UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH 250.83 OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED 250.90 - TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED 250.93 COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED 446.7 TAKAYASU'S DISEASE 453.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE 585.5 - CHRONIC KIDNEY DISEASE, STAGE V - END STAGE RENAL DISEASE 585.6 795.39 OTHER NONSPECIFIC POSITIVE CULTURE FINDINGS V58.61 LONG-TERM (CURRENT) USE OF ANTICOAGULANTS Group 2 Paragraph: LIST TWO The following HCPCS codes do not require the date last seen by the physician on the claim when one of list of ICD-9 codes on list two is used. CPT codes: G0127, 11055, 11056, 11057, 11719 and 11720-11721 billed with the appropriate Q modifier and the following ICD-9 codes For CPT codes: 11720, 11721 ICD-9 CM code 110.1 or 703.8 must be reported as primary condition and the appropriate Q modifier showing that a coverage criterion has been met. Group 2 Codes: 039.4 MADURA FOOT 040.0 GAS GANGRENE

066.41-066.49 WEST NILE FEVER WITH ENCEPHALITIS - WEST NILE FEVER WITH OTHER COMPLICATIONS 110.1 DERMATOPHYTOSIS OF NAIL 272.7 LIPIDOSES 277.30 AMYLOIDOSIS, UNSPECIFIED 277.31 FAMILIAL MEDITERRANEAN FEVER 277.39 OTHER AMYLOIDOSIS 289.89 OTHER SPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING ORGANS 331.0 ALZHEIMER'S DISEASE 332.0 PARALYSIS AGITANS 333.2 MYOCLONUS 333.4 HUNTINGTON'S CHOREA 335.10 SPINAL MUSCULAR ATROPHY UNSPECIFIED 335.20 AMYOTROPHIC LATERAL SCLEROSIS 335.21 PROGRESSIVE MUSCULAR ATROPHY 440.0-440.9 ATHEROSCLEROSIS OF AORTA - GENERALIZED AND UNSPECIFIED ATHEROSCLEROSIS 442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY 443.0 RAYNAUD'S SYNDROME 443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) 443.81-443.9 PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE - PERIPHERAL VASCULAR DISEASE UNSPECIFIED 444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY 444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY 444.89 EMBOLISM AND THROMBOSIS OF OTHER ARTERY 446.0 POLYARTERITIS NODOSA 447.8 OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES 447.9 UNSPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF 451.0 - LOWER EXTREMITIES - PHLEBITIS AND THROMBOPHLEBITIS OF 451.9 UNSPECIFIED SITE 454.0-454.9 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER - ASYMPTOMATIC VARICOSE VEINS 459.10-459.19 POSTPHLEBETIC SYNDROME WITHOUT COMPLICATIONS - POSTPHLEBETIC SYNDROME WITH OTHER COMPLICATION 459.81-459.9 VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED - UNSPECIFIED CIRCULATORY SYSTEM DISORDER 579.0 CELIAC DISEASE 579.1 TROPICAL SPRUE 700 CORNS AND CALLOSITIES 703.8 OTHER SPECIFIED DISEASES OF NAIL 706.2 SEBACEOUS CYST 707.06 PRESSURE ULCER, ANKLE

707.07 PRESSURE ULCER, HEEL 707.14 ULCER OF HEEL AND MIDFOOT 707.15 ULCER OF OTHER PART OF FOOT 707.9 CHRONIC ULCER OF UNSPECIFIED SITE 729.5 PAIN IN LIMB 785.4 GANGRENE 893.0-893.2 OPEN WOUND OF TOE(S) WITHOUT COMPLICATION - OPEN WOUND OF TOE(S) WITH TENDON INVOLVEMENT 917.0-917.9 ABRASION OR FRICTION BURN OF FOOT AND TOE(S) WITHOUT INFECTION - OTHER AND UNSPECIFIED SUPERFICIAL INJURY OF FOOT AND TOES INFECTED 924.3 CONTUSION OF TOE 928.3 CRUSHING INJURY OF TOE(S) 945.12 ERYTHEMA DUE TO BURN (FIRST DEGREE) OF FOOT 945.21 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF TOE(S) (NAIL) 945.22 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FOOT 945.31 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF TOE(S) (NAIL) 945.32 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOOT 945.41 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TOE(S) (NAIL) WITHOUT LOSS OF TOE(S) 945.42 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOOT WITHOUT LOSS OF FOOT 945.51 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TOE(S) (NAIL) WITH LOSS OF TOE(S) 945.52 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOOT WITH LOSS OF FOOT 956.0-956.9 INJURY TO SCIATIC NERVE - INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB 959.7 OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT 976.0 POISONING BY LOCAL ANTI-INFECTIVES AND ANTI-INFLAMMATORY DRUGS 976.2 POISONING BY LOCAL ASTRINGENTS AND LOCAL DETERGENTS 976.3 POISONING BY EMOLLIENTS DEMULCENTS AND PROTECTANTS 991.2 FROSTBITE OF FOOT V07.39 NEED FOR OTHER PROPHYLACTIC CHEMOTHERAPY V12.3 PERSONAL HISTORY OF DISEASES OF BLOOD AND BLOOD-FORMING ORGANS V49.3 SENSORY PROBLEMS WITH LIMBS

V49.70 - V49.77 UNSPECIFIED LEVEL LOWER LIMB AMPUTATION STATUS - HIP AMPUTATION STATUS Group 3 Paragraph: In the absence of a systemic condition, CPT codes 11720, 11721 one of the ICD-9 codes below must be used with ICD-9 CM 110.1 or 703.8 to document the medical necessity of the service. Group 3 Codes: 681.10 UNSPECIFIED CELLULITIS AND ABSCESS OF TOE 681.11 ONYCHIA AND PARONYCHIA OF TOE 703.0 INGROWING NAIL 719.7 DIFFICULTY IN WALKING 729.5 PAIN IN LIMB 781.2 ABNORMALITY OF GAIT Group 4 Paragraph: LIST THREE The ICD-9 codes below represent those diagnoses where the patient has evidence of neuropathy, but no vascular impairment, for which class findings modifiers are not required. For these diagnoses, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) 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. Group 4 Codes: 030.0 LEPROMATOUS LEPROSY (TYPE L) 030.1 TUBERCULOID LEPROSY (TYPE T) 030.3 BORDERLINE LEPROSY (GROUP B) 030.8 OTHER SPECIFIED LEPROSY 030.9 LEPROSY UNSPECIFIED 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE 045.10-045.13 ACUTE POLIOMYELITIS WITH OTHER PARALYSIS UNSPECIFIED TYPE OF POLIOVIRUS - ACUTE POLIOMYELITIS WITH OTHER PARALYSIS POLIOVIRUS TYPE III 053.13 POSTHERPETIC POLYNEUROPATHY 088.81 LYME DISEASE 094.0 TABES DORSALIS 094.1 GENERAL PARESIS 094.2 SYPHILITIC MENINGITIS 094.81 SYPHILITIC ENCEPHALITIS 094.82 SYPHILITIC PARKINSONISM 094.9 NEUROSYPHILIS UNSPECIFIED

250.60* DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED 250.61* DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED 250.62* DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED 250.63* DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED 265.2* PELLAGRA 281.0 PERNICIOUS ANEMIA 323.9 UNSPECIFIED CAUSES OF ENCEPHALITIS, MYELITIS, AND ENCEPHALOMYELITIS 334.0-334.2 FRIEDREICH'S ATAXIA - PRIMARY CEREBELLAR DEGENERATION SYRINGOMYELIA AND SYRINGOBULBIA - SUBACUTE COMBINED 336.0 - DEGENERATION OF SPINAL CORD IN DISEASES CLASSIFIED 336.2 ELSEWHERE 336.9 UNSPECIFIED DISEASE OF SPINAL CORD 337.1 PERIPHERAL AUTONOMIC NEUROPATHY IN DISORDERS CLASSIFIED ELSEWHERE 340* MULTIPLE SCLEROSIS 341.8 OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED 342.00 - SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING 342.92 NONDOMINANT SIDE 343.0-343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED 344.00-344.1 QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA 344.30-344.9 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - PARALYSIS UNSPECIFIED 353.4 LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED 353.8 OTHER NERVE ROOT AND PLEXUS DISORDERS 355.0-355.5 LESION OF SCIATIC NERVE - TARSAL TUNNEL SYNDROME 356.0-356.9 HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY 357.0* ACUTE INFECTIVE POLYNEURITIS 357.1 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 357.81 CHRONIC INFLAMMATORY DEMYELINATING POLYNEURITIS 357.82 CRITICAL ILLNESS POLYNEUROPATHY 357.89 OTHER INFLAMMATORY AND TOXIC NEUROPATHY 357.9 UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES 358.1 MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE 358.2 TOXIC MYONEURAL DISORDERS 436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE 438.20-438.22 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.40-438.42 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 438.50-438.52 OTHER PARALYTIC SYNDROME AFFECTING UNSPECIFIED SIDE - OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE 782.0* DISTURBANCE OF SKIN SENSATION Group 4 Medical Necessity ICD-9 Codes Asterisk Explanation: **For these diagnoses, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) 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. ICD-9 Codes that DO NOT Support Medical Necessity N/A General Information Associated Information Documentation requirements The following class finding modifiers should be used with G0127, 11055, 11056, 11057, 11719, 11720, 11721, when applicable: 1. A Class A finding (Modifier Q7) 2. Two of the Class B findings (Modifier Q8); or

3. One Class B and two Class C findings (Modifier Q9). The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation supporting the medical necessity, such as physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement must be maintained in the patient record. Physical findings and services must be precise and specific (e.g., left great toe, or right foot, 4 th digit.) Documentation of co-existing systemic illness should be maintained. There must be adequate medical 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. Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to Medicare upon request. Utilization guidelines Routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be considered not medically necessary. Sources of Information and Basis for Decision Advisory Committee Meeting Notes Meeting date: Wisconsin: 01/16/2009 Illinois: 01/28/2009 Michigan: 01/07/2009 Minnesota: 01/22/2008 J-5 MAC (IA,KS,MO, NE) 02/12/2009 Open Meeting Date 12/17/2008 Any Carrier Advisory Committee (CAC) related information, including Start Date and End Date of Comment Period, reflects the last time this LCD passed through the Comment and Notice process. Formal comment is not required for LCDs being adopted as part of the MAC transition. Start Date Of Comment Period 02/12/2009 End Date Of Comment Period 03/30/2009

Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 06/01/2014 R4 09/07/2013 R3 10/22/2012 R2 Revision History Number Revision History Explanation 06/01/2014 Removed diagnosis code 991.1 and references to hand services because this LCD only applies to foot care. Annual review removed duplicate paragraphs. The WPS Carrier Contract Numbers 00951(WI), 00952(IL), and 00954(MN) were removed from this LCD. Effective 09/07/2013, the Jurisdiction 6 Part B MAC contractor for Illinois, Wisconsin, and Minnesota is National Government Services (NGS). 06/01/2013 Annual review done 05/13/2013 no change in coverage. 10/22/2012: In accordance with Section 911 of the Medicare Modernization Act of 2003 and CMS Change Request 8059, contractor numbers in this LCD policy were updated due to the transition from WPS Fiscal Intermediary Contract Number 52280 to WPS Part A MAC Contractor Number 05901. No other changes were made to this LCD policy. Reason(s) for Change Other Change in Assigned States or Affiliated Contract Numbers Other (Annual review) 10/22/2012 R1 08/20/2012: This LCD was revised to add the Jurisdiction 8 (J-8) Indiana Part B MAC Contract Number 08102. The CMS Statement of Work for the J8 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This WPS policy is being promulgated to the J8 MAC as the most clinically appropriate LCD within this jurisdiction. No coverage changes were made to this LCD for this revision. 07/23/2012: This LCD was revised to add the Jurisdiction 8 (J-8) Indiana and Michigan Part A MAC Contract Numbers 08101 and 08201. Automated Edits to Enforce Reasonable & Necessary Requirements

The CMS Statement of Work for the J8 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This WPS policy is being promulgated to the J8 MAC as the most clinically appropriate LCD within this jurisdiction. No coverage changes were made to this LCD for this revision. 07/16/2012: This LCD was revised to add the Jurisdiction 8 (J-8) Michigan Part B MAC Contract Number 08202 and remove the legacy Michigan Part B Carrier Contract Number 00953. The CMS Statement of Work for the J8 Medicare Administrative Contract (MAC) requires that the contractor retain the most clinically appropriate LCD within the jurisdiction. This WPS policy is being promulgated to the J8 MAC as the most clinically appropriate LCD within this jurisdiction. No coverage changes were made to this LCD for this revision. *01/01/2010, Removed statement, per MBPM, Chapter 15, 290 - "or qualified non-physician practitioner", *12/01/2009, Removed all information except that which is directly related to routine foot care, added third list of ICD-9 codes where the patient has evidence of neuropathy, but no vascular impairment for which class finding modifies are not required; 07/01/2009, one, this LCD merges all other LCDs regarding Food Care including FT-001, FT-501 and FT- 502 - Symptomatic, Pathological Nail and Its Treatment 11/24/2009 added updated version of the coding and billing guidelines. The change was UPIN to NPI. The current version of coding and billing is now Coding and Billing Guidelines 01/01/10 Version 2.

04/19/2010 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto. 8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 74 was changed 8/1/2010 - The description for Bill Type Code 75 was changed 8/1/2010 - The description for Bill Type Code 85 was changed 8/1/2010 - Bill Type Code 51 was deleted 8/1/2010 - Bill Type Code 94 was deleted 10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901). 11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: 11056 descriptor was changed in Group 1 11057 descriptor was changed in Group 1 11720 descriptor was changed in Group 1 11721 descriptor was changed in Group 1

02/21/2011 In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901). 02/01/2011, LCD reviewed, no updates 03/01/2011, corrected typo hair growth (decrease or increase) changed to hair growth (decrease or absence); 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update. 10/01/2011, 2012 ICD-9 update 11/01/2011, seven, removed ICD-9 codes V12.50-V12.59 typo inappropriate cardiac diagnosis 05/01/2012, eight, annual review, added revenue codes - no impact to claims processing; 11/25/2012 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: 11719 descriptor was changed in Group 1 Associated Documents Attachments Billing & Coding Guidelines opens in new window (PDF - 152 KB ) Related Local Coverage Documents N/A Related National Coverage Documents

N/A Public Version(s) Updated on 05/21/2014 with effective dates 06/01/2014 - N/A Updated on 08/26/2013 with effective dates 09/07/2013-05/31/2014 Updated on 05/22/2013 with effective dates 10/22/2012-09/06/2013 Updated on 11/25/2012 with effective dates 10/22/2012 - N/A Updated on 10/09/2012 with effective dates 10/22/2012 - N/A Some older versions have been archived. Please visit the MCD Archive Site opens in new window to retrieve them. Keywords N/A Read the LCD Disclaimer opens in new window

Billing and Coding Guidelines Routine Foot Care Effective Date 01/01/2010 Revision Effective Date: 06/01/2014 CMS National Coverage Policy Italicized Language is from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs (42 CFR 405.860[b] and 42 CFR 426 [Subpart D Title XVIII of the Social Security Act Section 1862 (a) (1) (A) Section 1862 (a) (13)(C) Code of Federal Regulations (CFR) Part 411.15., subpart A CMS Publications: CMS Publication 100-2, Medicare Benefit Policy Manual, Chapter 15: 290 CMS Publication 100-3, Medicare National Coverage Determination Manual, Part 1: 70.2.1 CMS Publication 100-9, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 Coding Information 1. Report the appropriate procedure code and modifiers for the service(s) performed. a. When reporting foot/nail care report the applicable Q modifier. b. These services should be reported with quantity of one in the quantity/units field. 2. Report the ICD-9 code for which the service(s) is performed in the first position in the diagnosis field of the CMS 1500 claim form or electronic equivalent; report the systemic condition(s) in the remaining positions. Where the systemic condition is marked with an (*) (see below) and the services were rendered by a podiatrist, include the 8-digit (MM/DD/CCYY) date the patient was last seen and the NPI of his/her attending (MD/DO) physician who diagnosed the complicating condition in item 19 of the CMS 1500 claim form or electronic equivalent field. Diabetes mellitus* Chronic Thrombophlebitis* Peripheral neuropathies involving 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 renal disease)* Hereditary sensory radicular neuropathy Angiokeratoma corporis diffusum (fabry's) Amyloid neuropathy 1

Long term oral anticoagulant therapy (e.g. Coumadin, Dicoumaral, etc.)* 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. 3. When billing for services, requested by the beneficiary for denial, that are statutorily excluded by Medicare (i.e. Routine foot care), report an ICD-9 code that best describes the patients condition and the GY modifier (items or services statutorily excluded or does not meet the definition of any Medicare benefit) 4. When billing for services, requested by the beneficiary for denial, that would be considered not reasonable and necessary, report an ICD-9 code that best describes the patients condition and the GA modifier if an ABN signed by the beneficiary is on file or the GZ modifier (items or services expected to be denied as not reasonable) when there is no ABN for the service on file. 5. For patients on long term oral anticoagulant therapy, report the ICD-9 related to the performed service in the first position, the drug ICD-9 (V58.61) in the second position and the condition being treated with the anticoagulant in the third position of item 21 of the CMS 1500 claim form or electronic equivalent. 6. It is inappropriate and incorrect to report an E&M code when routine foot care or a nail trimming/debridement service is the service actually performed. 7. The following class finding modifiers should usually be used with G0127, 11055, 11056, 11057, 11719, and when appropriate, CPT codes 11720, 11721. A Class A finding (Modifier Q7) Two of the Class B findings (Modifier Q8); or One Class B and two Class C findings (Modifier Q9). 8. 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 neuropathy but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the ICD-9 CM codes in list three of ICD-9 Codes that Support Medical Necessity listed in the LCD. 9. A diagnosis of onychomycosis can allow 11720 or 11721 if it has either a Q modifier (but does not need a MD or DO last seen) or if it has one of the 6 ICD-9 codes listed in the special section for onychomycosis, i.e. difficulty with walking (681.10, 681.11, 703.0, 719.7, 729.5, 781.2). 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 service performed in the absence of localized illness, injury, or symptoms involving the foot. 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

2 - 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. 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. Coding Information Date Last Seen by Attending Physician (for those ICD-9 CM codes which fall under the active care requirement): CPT codes 11055, 11056, 11057, 11719, and G0127 or 11720, 11721. The approximate date when the beneficiary was last seen by the M.D., D.O. who diagnosed the complicating condition (attending physician) must be reported in an 8-digit (MM/DD/YYYY) format in Item 19 of the CMS-1500 claim form or the electronic equivalent or if the patient sees their primary care physician no later than 30 days after the services were furnished. For claims submitted to the fiscal intermediary: Hospital Inpatient Claims: The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB- 04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission. The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67. For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.) Hospital Outpatient Claims: The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82). The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. RHC/FQHC encounters billed on TOBs 071x or 073x do not require HCPCS coding. Home health claims billed on 12X or 22X TOBs do not require HCPCS coding. Modifiers: 3

Level two modifiers (indicating digit or limb) are entered in Field Locator 44 UB-04 claim form or the electronic equivalent. Modifiers identifying indication for treatment (Q7, Q8, or Q9) are entered in Field Locator 44 UB-04 claim form or the electronic equivalent when applicable to validate medical necessity. Modifiers: Ta Left foot, great toe T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, forth digit T4 Left foot, fifth digit T5 Right foot, great toe T6 Right foot, second digit T7 Right foot, third digit T8 Right foot, forth digit T9 Right foot, fifth digit Notes Italicized font represents CMS national policy language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national policy language/wording. Providers, through their associations/societies, should contact CMS to request changes to national policy through the Medicare Coverage Policy Process. Original Effective Date 08/16/2009 Publication Date 06/01/2012 Revision Date/Number/Explanation 06/01/2014 removed references to hands that do not apply to this LCD. 06/01/2012, This guideline is effective for J-8 providers in Michigan MAC B 07/16/12, Michigan MAC A 07/23/12, Indiana MAC A 07/23/12 and Indiana MAC B 08/20/12 01/01/2010, Removed statement, per MBPM, Chapter 15, 290 - or qualified non-physician practitioner, 12/01/2009, Removed language from LCD that was not directly related to routine foot care, added language regarding coverage of peripheral neuropathy and billing with a diagnosis of onychomycosis; 10/15/2009, corrected typo G0045-G0047 corrected to G0245- G0247; 07/01/2009, one, this LCS merges all other LCDs regarding Food Care including FT-001, FT-501 and FT- 502. 4