MEDICAL POLICY: Routine Foot Care Services

POLICY........ PG-0246 EFFECTIVE......01/01/09 LAST REVIEW... 03/11/14 MEDICAL POLICY: Routine Foot Care Services GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement. DESCRIPTION Foot Care involves all aspects of preventative and corrective care of the foot and ankle. This includes examination and diagnostic services associated with routine foot care performed in the absence of a localized illness, symptoms, or injury. These routine foot care services are defined and reported with the following procedure codes: 11055, 11056, 11057, 11719, 11720, 11721, G0127, and G0247. Services that are considered routine foot care include, but are not limited to, any of the following: Cutting or removal of corns and calluses Clipping, trimming, or debridement of nails, including debridement of mycotic 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 POLICY Routine foot care is non-covered for HMO, PPO, Individual Marketplace, Elite, & Advantage. Non-Routine Foot Care that meets medically indicated criteria does not require prior authorization. Foot care becomes non-routine and medically necessary for specific medical conditions referred to as Exceptions to Routine Foot Care Exclusion: 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. The presence of a systemic condition, 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). Treatment of warts on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body. Treatment of mycotic nails may be covered in the absence of a systemic condition if the following criteria are met: o Clinical evidence of mycosis of the toenail, and o Patient has marked limitation of ambulation, pain, and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate Procedures for treating toenails are covered for the following: o o Onychogryphosis (defined as long-standing thickening, in which typically a curved hooked nail (ram's horn nail) occurs), and there is marked limitation of ambulation, pain, and/or secondary infection where the nail plate is causing symptomatic indentation of or minor laceration of the affected distal toe Onychauxis (defined as a thickening (hypertrophy) of the base of the nail/nail bed) and there is marked limitation of ambulation, pain, and/or secondary infection that causes symptoms

-2- Medicare defined the conditions and placed them into classes (identified by specific modifiers) which may assist in the reporting of the medical conditions currently present in the member, supporting the medical necessity for foot care. These modifiers are recognized as valid; however, have no claims processing value 1. Class A (modifier Q7) findings one required Non-traumatic amputation of foot or integral skeletal portion 2. Class B (modifier Q8) findings two required Absent posterior tibial pulse Advanced trophic changes as evidenced by any three of the following: o Hair growth (decrease or absence) o Nail changes (thickening) o Pigmentary changes (discoloration) o Skin texture changes (thin, shiny) o Skin color changes (rubor or redness); and Absent dorsalis pedis pulse 3. Class C (modifier Q9) findings one Class B and two Class C findings required Claudication Temperature changes Paresthesias Burning Edema HMO, PPO, Individual Marketplace, Elite, Advantage Routine foot care is non-covered for any of these members. Podiatry services become medically necessary and not routine, when the routine service is performed for a medically approved condition as listed above and will be allowed six times a year (once every 60 calendar days). Procedures are reimbursable only if the patient is under the active care of a doctor of medicine or osteopathy (MD or DO) or qualified non-physician practitioner 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 had come under a physician s care shortly after the services were furnished. While the modifiers for foot conditions will be recognized as valid, these services will only be allowed when the diagnosis supporting medical necessity is included. Routine foot care, removal and/or trimming of corns, calluses and/or nails, and preventive maintenance in specific medical conditions (procedure code S0390), is considered a non-covered service. The provider should report the correct procedure code for the service performed. This service will be denied for all product lines. For Advantage members, procedures 11719, G0127, G0245, G0246, G0247, and S0390 are non-covered per Medicaid Appendix DD. Secondary Diagnoses listed below to be reported with ICD-9 codes 110.1 and 703.8 for treatment of mycotic nails, onychogryphosis, and onychauxis to indicate medical necessity: 681.10 Unspecified cellulitis and abscess of toe 681.11 Onychia and paronychis of toe 703.0 Ingrowing nail 719.7 Difficulty in walking 729.5 Pain in limb 781.2 Abnormality of gait EFFECTIVE 10/01/2015 Secondary Diagnoses listed below to be reported with ICD-10 codes B35.1, L60.1, L60.2, L60.3 and L60.8 for treatment of mycotic nails, onychogryphosis, and onychauxis to indicate medical necessity: L03.039 Cellulitis of unspecified toe L03.049 Acute lymphangitis of unspecified toe L60.0 Ingrowing nail M79.609 Pain in unspecified limb R26.0 Ataxic gait R26.1 Paralytic gait

-3- R26.2 Difficulty in walking, not elsewhere classified R26.89 Other abnormalities of gait and mobility R26.9 Unspecified abnormalities of gait and mobility CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. CPT CODES 11055 Paring or cutting of benign hyperkeratotic skin lesion (e.g., corn or callus); single lesion 11056 Paring or cutting of benign hyperkeratotic skin lesion (e.g., corn or callus); two to four lesions 11057 Paring or cutting of benign hyperkeratotic skin lesion (e.g., corn or callus); more than four lesions 11719 Trimming of non-dystrophic 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 HCPCS CODES G0127 Trimming of dystrophic nails, any number G0245 Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy, LOPS G0246 Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy, LOPS G0247 Routine foot care, diabetic patient with diabetic sensory neuropathy, LOPS S0390 Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific medical conditions (e.g., diabetes), per visit ICD-9 CODES 030.0-030.9 Leprosy 090.40 Juvenile neurosyphilis, unspecified 090.41 Congenital syphilitic encephalitis 090.42 Congenital syphilitic meningitis 094.0 Tabes dorsalis 094.1 General paresis 094.2 Syphilitic meningitis 094.3 Asymptomatic neurosyphilis 094.81 Syphilitic encephalitis 094.82 Syphilitic Parkinsonism 094.83 Syphilitic disseminated retinochoroiditis 094.84 Syphilitic optic atrophy 094.85 Syphilitic retrobulbar neuritis 094.86 Syphilitic acoustic neuritis 094.87 Syphilitic ruptured cerebral aneurysm 094.89 Other specified neurosyphilis 094.9 Neurosyphilis, unspecified 110.1 Dermatophytosis of nail 249.00-249.91 Secondary diabetes mellitus 250.00-250.93 Diabetes mellitus 263.9 Unspecified protein-calorie malnutrition 265.0 Beriberi 265.2 Pellagra 266.1 Vitamin B6 deficiency 266.2 Other B-complex deficiencies 272.7 Lipidoses 277.30 Amyloidosis, unspecified 277.39 Other amyloidosis 281.0 Pernicious anemia 332.0 Paralysis agitans 333.2 Myoclonus 333.4 Huntington's chorea 334.0 Friedreich's ataxia 334.1 Hereditary spastic paraplegia 334.2 Primary cerebellar degeneration 335.10 Spinal muscular atrophy, unspecified

335.20 Amyotrophic lateral sclerosis 335.21 Progressive muscular atrophy 337.00 Idiopathic peripheral autonomic neuropathy, unspecified 337.09 Other idiopathic peripheral autonomic neuropathy 337.1 Peripheral autonomic neuropathy in disorders classified elsewhere 340 Multiple sclerosis 341.8 Other demyelinating diseases of central nervous system 342.00-342.92 Hemiplegia and hemiparesis 343.0-343.9 Infantile cerebral palsy 344.00-344.09 Quadriplegia 344.1 Paraplegia 344.30 Monoplegia of lower limb affecting unspecified side 344.31 Monoplegia of lower limb affecting dominant side 344.32 Monoplegia of lower limb affecting nondominant side 353.4 Lumbosacral root lesions, not elsewhere classified 353.8 Other nerve root and plexus disorders 355.0-355.5 Mononeuritis of lower limb 356.0-356.9 Hereditary and idiopathic peripheral neuropathy 357.0-357.9 Inflammatory and toxic neuropathy 358.1 Myasthenic syndromes in diseases classified elsewhere 358.2 Toxic myoneural disorders 436 Acute, but ill-defined, cerebrovascular disease 438.20 Hemiplegia affecting unspecified side 438.21 Hemiplegia affecting dominant side as late effect of cerebrovascular disease 438.22 Hemiplegia affecting nondominant side as late effect of cerebrovascular disease 438.40 Monoplegia of lower limb affecting unspecified side 438.41 Monoplegia of lower limb affecting dominant side as late effect of cerebrovascular disease 438.42 Monoplegia of lower limb affecting nondominant side as late effect of cerebrovascular disease 438.50 Other paralytic syndrome affecting unspecified side 438.51 Other paralytic syndrome affecting dominant side as late effect of cerebrovascular disease 438.52 Other paralytic syndrome affecting nondominant side as late effect of cerebrovascular disease 440.0-440.9 Atherosclerosis 442.3 Aneurysm of artery of lower extremity 443.0 Raynaud's syndrome 443.1 Thromboangiitis obliterans [Buerger's disease] 443.81 Peripheral angiopathy in diseases classified elsewhere 443.82 Erythromelalgia 443.89 Other peripheral vascular disease 443.9 Peripheral vascular disease, unspecified 444.01 Saddle embolus of abdominal aorta 444.09 Other arterial embolism and thrombosis of abdominal aorta 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 446.7 Takayasu's disease 447.1 Stricture of artery 447.6 Arteritis, unspecified 447.8 Other specified disorders of arteries and arterioles 447.9 Unspecified disorders of arteries and arterioles 451.0-451.9 Phlebitis and thrombophlebitis 453.52 Chronic venous embolism and thrombosis of deep vessels of distal lower extremity 453.6 Venous embolism and thrombosis of superficial vessels of lower extremity 453.79 Chronic venous embolism and thrombosis of other specified veins 453.9 Embolism and thrombosis of unspecified site 454.0-454.9 Varicose veins of lower extremities 457.1 Other lymphedema 459.10-459.9 Postphlebetic syndrome 579.0-579.4 Intestinal malabsorption 585.1-585.9 Chronic kidney disease -4-

681.10 Unspecified cellulitis and abscess of toe 681.11 Onychia and paronychis of toe 700 Corns and callosities 703.0 Ingrowing nail 703.8 Other specified diseases of nail 714.0 Rheumatoid arthritis 719.7 Difficulty in walking 729.5 Pain in limb 781.2 Abnormality of gait 956.0-956.9 Injury to peripheral nerve (s) of pelvic girdle and lower limb V58.61 Long-term (current) use of anticoagulants ICD-10-CM CODES; EFFECTIVE 10/01/2015 A30.0-A30.9 Leprosy A50.40-A50.43 Congenital syphilis A50.45 Juvenile general paresis A52.10-A52.3 Late syphilis B35.1 Tinea unguium D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency D81.818-D81.819 Combined immunodeficiencies E08.00-E08.9 Diabetes mellitus due to underlying condition E09.00-E09.9 Drug or chemical induced diabetes mellitus E10.10-E10.9 Type 1 diabetes mellitus E11.00-E11.9 Type 2 diabetes mellitus E13.00-E13.9 Other specified diabetes mellitus E46 Unspecified protein-calorie malnutrition E51.11 Dry beriberi E51.12 Wet beriberi E52 Niacin deficiency [pellagra] E53.1 Pyridoxine deficiency E53.8 Deficiency of other specified B group vitamins E64.0 Sequelae of protein-calorie malnutrition E75.21 Fabry (-Anderson) disease E75.22 Gaucher disease E75.240-E75.249 Niemann-Pick disease E75.3 Sphingolipidosis, unspecified E77.0-E77.9 Other disorders of glycoprotein metabolism E85.1-E85.9 Amyloidosis G04.1 Tropical spastic paraplegia G10 Huntington's disease G11.0-G11.2 Hereditary ataxia G11.4 Hereditary spastic paraplegia G12.21 Amyotrophic lateral sclerosis G12.9 Spinal muscular atrophy, unspecified G13.0-G13.1 Systemic atrophies primarily affecting central nervous system in diseases classified elsewhere G20 Parkinson's disease G21.4 Vascular parkinsonism G25.3 Myoclonus G35 Multiple sclerosis G36.1 Acute and subacute hemorrhagic leukoencephalitis [Hurst] G36.8 Other specified acute disseminated demyelination G37.1 Central demyelination of corpus callosum G37.2 Central pontine myelinolysis G37.4 Subacute necrotizing myelitis of central nervous system G37.8 Other specified demyelinating diseases of central nervous system G54.4 Lumbosacral root disorders, not elsewhere classified G54.8 Other nerve root and plexus disorders G55 Nerve root and plexus compressions in diseases classified elsewhere G57.00-G57.52 Mononeuropathies of lower limb G60.0-G65.2 Polyneuropathies and other disorders of the peripheral nervous system -5-

G70.1 Toxic myoneural disorders G73.3 Myasthenic syndromes in other diseases classified elsewhere G80.0-G83.14 Cerebral palsy and other paralytic syndromes G90.09 Other idiopathic peripheral autonomic neuropathy G99.0 Autonomic neuropathy in diseases classified elsewhere I67.89 Other cerebrovascular disease I69.041-I69.049 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage I69.051-I69.059 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage I69.061-I69.069 Other paralytic syndrome following nontraumatic subarachnoid hemorrhage I69.141-I69.149 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage I69.151-I69.159 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage I69.161-I69.169 Other paralytic syndrome following nontraumatic intracerebral hemorrhage I69.241-I69.249 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage I69.251-I69.259 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage I69.261-I69.269 Other paralytic syndrome following other nontraumatic intracranial hemorrhage I69.341-I69.349 Monoplegia of lower limb following cerebral infarction I69.351-I69.359 Hemiplegia and hemiparesis following cerebral infarction I69.361-I69.369 Other paralytic syndrome following cerebral infarction I69.841-I69.849 Monoplegia of lower limb following other cerebrovascular disease I69.851-I69.859 Hemiplegia and hemiparesis following other cerebrovascular disease I69.861-I69.869 Other paralytic syndrome following other cerebrovascular disease I69.941-I69.949 Monoplegia of lower limb following unspecified cerebrovascular disease I69.951-I69.959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease I69.961-I69.969 Other paralytic syndrome following unspecified cerebrovascular disease I70.0-I70.92 Atherosclerosis I72.4 Aneurysm of artery of lower extremity I73.00-I73.9 Other peripheral vascular diseases I74.01 Saddle embolus of abdominal aorta I74.09 Other arterial embolism and thrombosis of abdominal aorta I74.10 Embolism and thrombosis of unspecified parts of aorta I74.19 Embolism and thrombosis of other parts of aorta I74.3 Embolism and thrombosis of arteries of the lower extremities I74.4 Embolism and thrombosis of arteries of extremities, unspecified I74.5 Embolism and thrombosis of iliac artery I74.8 Embolism and thrombosis of other arteries I77.1 Stricture of artery I77.3 Arterial fibromuscular dysplasia I77.6 Arteritis, unspecified I77.89 Other specified disorders of arteries and arterioles I77.9 Disorder of arteries and arterioles, unspecified I79.1 Aortitis in diseases classified elsewhere I79.8 Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere I80.00-I80.9 Phlebitis and thrombophlebitis I82.541-I82.549 Chronic embolism and thrombosis of tibial vein I82.5Z1-I82.5Z9 Chronic embolism and thrombosis of unspecified deep veins of distal lower extremity I82.811-I82.819 Embolism and thrombosis of superficial veins of lower extremities I82.891 Chronic embolism and thrombosis of other specified veins I82.91 Chronic embolism and thrombosis of unspecified vein I83.001- I83.93 Varicose veins of lower extremities I87.009- I87.099 Postthrombotic syndrome of lower extremities I87.1 Compression of vein I87.2 Venous insufficiency (chronic) (peripheral) I87.311- I87.9 Other disorders of veins of lower extremities I89.0 Lymphedema, not elsewhere classified I99.8 Other disorder of circulatory system I99.9 Unspecified disorder of circulatory system K90.0-K90.3 Intestinal malabsorption L02.611- L02.619 Cutaneous abscess of foot L03.031- L03.039 Cellulitis of toe L03.041- L03.049 Acute lymphangitis of toe -6-

-7- L60.0 Ingrowing nail L60.1 Onycholysis L60.2 Onychogryphosis L60.3 Nail dystrophy L60.5 Yellow nail syndrome L60.8 Other nail disorders L62 Nail disorders in diseases classified elsewhere L84 Corns and callosities M05.40 Rheumatoid myopathy with rheumatoid arthritis of unspecified site M05.471 Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot M05.472 Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot M05.479 Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites M05.50 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot M05.579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites M05.70 Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement M05.771 Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement M05.772 Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement M05.779 Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement M05.80 Other rheumatoid arthritis with rheumatoid factor of unspecified site M05.871 Other rheumatoid arthritis with rheumatoid factor of right ankle and foot M05.872 Other rheumatoid arthritis with rheumatoid factor of left ankle and foot M05.879 Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site M06.071 Rheumatoid arthritis without rheumatoid factor, right ankle and foot M06.072 Rheumatoid arthritis without rheumatoid factor, left ankle and foot M06.079 Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites M06.20 Rheumatoid bursitis, unspecified site M06.271 Rheumatoid bursitis, right ankle and foot M06.272 Rheumatoid bursitis, left ankle and foot M06.279 Rheumatoid bursitis, unspecified ankle and foot M06.29 Rheumatoid bursitis, multiple sites M06.30 Rheumatoid nodule, unspecified site M06.371 Rheumatoid nodule, right ankle and foot M06.372 Rheumatoid nodule, left ankle and foot M06.379 Rheumatoid nodule, unspecified ankle and foot M06.39 Rheumatoid nodule, multiple sites M06.80 Other specified rheumatoid arthritis, unspecified site M06.871 Other specified rheumatoid arthritis, right ankle and foot M06.872 Other specified rheumatoid arthritis, left ankle and foot M06.879 Other specified rheumatoid arthritis, unspecified ankle and foot M06.89 Other specified rheumatoid arthritis, multiple sites M06.9 Rheumatoid arthritis, unspecified M30.0 Polyarteritis nodosa M30.2 Juvenile polyarteritis M30.8 Other conditions related to polyarteritis nodosa M31.4 Aortic arch syndrome [Takayasu] M31.7 Microscopic polyangiitis M34.83 Systemic sclerosis with polyneuropathy M79.671 Pain in right foot M79.672 Pain in left foot M79.673 Pain in unspecified foot

M79.674 Pain in right toe(s) M79.675 Pain in left toe(s) M79.676 Pain in unspecified toe(s) N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 (mild) N18.3 Chronic kidney disease, stage 3 (moderate) N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease N18.9 Chronic kidney disease, unspecified R26.0 Ataxic gait R26.1 Paralytic gait R26.2 Difficulty in walking, not elsewhere classified R26.89 Other abnormalities of gait and mobility R26.9 Unspecified abnormalities of gait and mobility S94.30xA Injury of cutaneous sensory nerve at ankle and foot level, unspecified leg, initial encounter S94.8x9A Injury of other nerves at ankle and foot level, unspecified leg, initial encounter S94.90xA Injury of unspecified nerve at ankle and foot level, unspecified leg, initial encounter S94.90xD Injury of unspecified nerve at ankle and foot level, unspecified leg, subsequent encounter S94.90xS Injury of unspecified nerve at ankle and foot level, unspecified leg, sequela S94.91xA Injury of unspecified nerve at ankle and foot level, right leg, initial encounter S94.91xD Injury of unspecified nerve at ankle and foot level, right leg, subsequent encounter S94.91xS Injury of unspecified nerve at ankle and foot level, right leg, sequela S94.92xA Injury of unspecified nerve at ankle and foot level, left leg, initial encounter S94.92xD Injury of unspecified nerve at ankle and foot level, left leg, subsequent encounter S94.92xS Injury of unspecified nerve at ankle and foot level, left leg, sequela Z79.01 Long term (current) use of anticoagulants -8- REVISION HISTORY EXPLANATION 01/01/13: Updated 07/23/13: Added code G0247. Updated Advantage coverage determination 03/11/14: Added & deleted ICD-9 Codes per LCD Routine FOOT CARE and Debridement of Nails (L31896). ICD- 10 codes added from ICD-9 conversion. Added HCPCS Codes G0245 & G0246. Policy reviewed and updated to reflect most current clinical evidence. Approved by Medical Policy Steering Committee as revised. REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid http://jfs.ohio.gov/ American Medical Association, Current Procedural Terminology (CPT ) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review