Medicare Coverage for Routine Foot Care

While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits. In order for routine foot care to be a covered service, the patient must have one or more of the diagnoses listed under the ‘ICD-10 Codes that Support Medical Necessity’ section. These exceptions include:

• 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).
• Treatment of warts on foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.
• 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.
• 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 peripheral neuropathy, must be present. (Treatment of mycotic nails for patients without systemic illnesses may also be covered and are defined in a separate local coverage determination (LCD) for Debridement of Mycotic Nails)

Please note that the 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.

Medicare Covered Foot Care CPT Codes

CPT 11055:

Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion

CPT 11056:

Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions

CPT 11057:

Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions

CPT 11719:

Trimming of non-dystrophic nails, any number

CPT 11720:

Debridement of nail(s) by any method(s); 1 to 5

CPT 11721:

Debridement of nail(s) by any method(s); 6 or more

Applicable Modifiers

Modifier Q7:

One Class A finding

Modifier Q8:

Two Class B findings

Modifier Q9:

One class B and 2 class C findings

Where, class A findings: nontraumatic amputation of the foot or integral skeletal portion thereof; class B findings: absent posterior tibial pulse, advanced trophic changes, and absent dorsalis pedis pulse; and class C findings: Claudication, temperature changes, edema, paresthesias, and burning. LOPS: Loss of Sensory Protection from Diabetic Neuropathy.

The above-mentioned list of procedure codes and modifiers is provided for reference purposes only and may not be all-inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member-specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Policies and billing guidelines may vary as per the insurance carrier.

Medisys Data Solutions Inc. is a leading medical billing company that is well versed with billing policies and guidelines for Medicare. To educate providers, we constantly share the latest billing guidelines and industry news in form of articles. We hope this article might have given you a good understanding of Medicare coverage for routine foot care and applicable procedure codes. If you need any assistance in podiatry medical billing, contact us at info@medisysdata.com/ 888-720-8884

Ref: Specific Coding Guidelines