This LCD does not supersede national policy for Medicare coverage of routine foot-care services or mycotic nail debridement found in the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 290. Pertinent parts of that national policy are referenced in this LCD and the attached article. See Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 290 to access the entire national policy for routine foot care and mycotic nail debridement. See the TrailBlazer LCD and article, “Routine Foot Care – LCD 4P-11AB,” for local coverage requirements.
As with other Medicare-covered services, mycotic nail debridement must be reasonable and necessary for the treatment of an illness or injury or to improve the functioning of a malformed body member. Medicare payment generally may be made for mycotic nail debridement in the two following circumstances:
- As “routine foot care” under Medicare’s national “Exceptions to Routine Foot Care Exclusions” provision when there is clinical evidence of mycosis of the toenail and the services and patient conditions meet national requirements for that exception.
- When, whether or not services and patient conditions meet national requirements for routine foot care, there is clinical evidence of mycosis of the toenail, and the patient has marked limitation of ambulation due solely to pain due to the nails, (patients who are non-ambulatory for other reasons must have severe pain) or has secondary soft tissue infection resulting from the thickening and dystrophy of the infected nail plate. The treatment of symptomatic mycotic nails in the absence of a qualifying covered systemic condition will not be covered after the acute symptoms caused by mycosis have abated. In the absence of a qualifying systemic condition, debridement of six or more nails in a single encounter is not payable without medical review of records associated with the service (see Individual Consideration paragraph).
Onychomycosis may present as one or more nail findings, including hypertrophy/thickening, lysis, discoloration, brittleness or loosening of the nail plate. Confirmation of mycotic nail infections by laboratory tests such as fungal cultures and/or stains is not necessary for Medicare coverage of debridement when clinical findings are strongly supportive of the diagnosis and treatment without mycologic confirmation is not contraindicated. Mycologic confirmation by culture necessary to differentiate fungal disease from other nail pathology is required for Medicare payment of mycotic nail debridement in some circumstances such as previous unsatisfactory treatment results (recurrent nail disease, unsuccessful treatment with antifungal medications, long term (beyond six debridements per 24 months, etc.) and for patients whose debridement is prescribed absent of concomitant pharmacologic therapy, such as for patients deemed to be too high risk for oral antifungal medication use.
Definitive treatment of mycotic nails involves the appropriate use of effective antifungal pharmacologic agents with or without periodic debridement of dystrophic nail plates. Medicare will cover debridement of mycotic nails as an adjunct to pharmacologic treatment with a prescription antifungal agent indicated per its Food and Drug Administration (FDA) label for the treatment of fungal nail infections.
Debridement of nails, whether by electric grinder or manual method, is a temporary reduction in the length and thickness (short of avulsion) of an abnormal nail plate. This is usually performed without anesthesia. The debridement code should not be used if the only part of the nail removed is the distal nail border or other portion of nail not attached to the nailbed. Medicare expects debridement services reported for Medicare payment to include removal of maximum nail material possible (in consideration of the clinical condition of the nail and the patient’s degree of comfort during the procedure) and required for control of symptoms or infection.
LCD Individual Consideration
Individual consideration should be requested during the claim redetermination process. The LCD Individual Consideration procedure is described in the attached article.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
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.
11X, 12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
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.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all the Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub.100-04 Claims Processing Manual, for further guidance.
Revenue codes have not been identified for all procedures/services as they can be performed in a number of revenue centers within a hospital, such as emergency room (0450), operating room (0360) or clinic (0510).
CPT/HCPCS Codes
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Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
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11720©
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Debride nail, 1–5
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11721©
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Debride nail, 6 or more
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G0247
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Routine footcare PT W LOPS
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Note: Use G0427 to report debridement of nails when performed as routine foot care to patients who meet CMS coverage requirements for G0247.
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ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS code G0247 (when used to report mycotic nail debridement for patients who qualify for coverage under Loss of Protective Sensation (LOPS) rules:
Report covered mycotic nail debridement services with a primary diagnosis from the following list:
Covered for:
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250.60–250.63
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Diabetes with neurological manifestations
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357.2
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Polyneuropathy in diabetes
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Nail Debridement in the Presence of a Qualifying Systemic Disease:
Medicare is establishing the following limited coverage for CPT/HCPCS codes 11720 and 11721 for patients who qualify for coverage under the routine foot care exclusion exception (i.e., services appropriately coded with modifier Q7, Q8 or Q9).
Report covered symptomatic mycotic nail debridement services in the presence of a qualifying systemic disease with a primary diagnosis from the following list:
Covered primary diagnoses:
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110.1
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Onychomycosis
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112.3
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Candidiasis of the nail
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703.8
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Other specified diseases of nail
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703.9
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Unspecified disease of nail
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Report covered symptomatic mycotic nail debridement services in the presence of a qualifying systemic disease with a secondary diagnosis from the following list:
Covered secondary diagnoses:
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030.1*
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Leprosy, tuberculoid leprosy (type T)
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042*
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Human immunodeficiency virus [HIV] disease
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090.1*
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Early congenital syphilis, latent (neurosyphilis)
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Note: Use codes 030.1*, 042* and 090.1* with 357.4 (polyneuropathy in other diseases classified elsewhere)
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250.00**–250.03**
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Diabetes mellitus without mention of complication
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250.10**–250.13**
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Diabetes with ketoacidosis
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250.20**–250.23**
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Diabetes with hyperosmolarity
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250.30**–250.33**
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Diabetes with other coma
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250.40**–250.43**
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Diabetes with renal manifestations
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250.50**–250.53**
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Diabetes with ophthalmic manifestations
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250.60**–250.63**
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Diabetes with neurological manifestations
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250.70**–250.73**
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Diabetes with peripheral circulatory disorders
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250.80**–250.83**
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Diabetes with other specified manifestations
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250.90**–250.93**
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Diabetes with unspecified complication
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265.2**
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Pellagra
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272.7*
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Lipidoses (Fabry’s disease)
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277.30*
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Amyloidosis, unspecified
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277.39*
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Other amyloidosis
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281.0**
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Pernicious anemia
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Note: Use codes 265.2*, 272.7*, 277.30*, 277.39*, 281.0* with 357.4 (polyneuropathy in other diseases classified elsewhere).
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340**
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Multiple sclerosis
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344.00–344.04
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Quadriplegia
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344.09
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Other quadriplegia
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344.1
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Paraplegia
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344.30–344.32
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Monoplegia of lower limb
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355.0–355.6
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Mononeuritis of lower limb and unspecified site
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355.71
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Causalgia of lower limb
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355.79
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Other mononeuritis of lower limb
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355.8–355.9
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Mononeuritis of lower limb and unspecified site
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356.0–356.4
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Hereditary peripheral neuropathy
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356.8–356.9
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Unspecified idiopathic peripheral neuropathy
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357.0–357.1
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Inflammatory and toxic neuropathy
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357.2**–357.7**
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Polyneuropathy in malignant disease
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357.81–357.82
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Other inflammatory and toxic neuropathy
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357.9
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Unspecified inflammatory and toxic neuropathies
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440.20–440.24
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Atherosclerosis of native arteries of the extremities
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440.29
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Other atherosclerosis of native arteries of the extremities
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440.30–440.32
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Atherosclerosis of bypass graft of the extremities
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440.4
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Chronic total occlusion of artery of the extremities
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443.1
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Thromboangiitis obliterans (Buerger’s disease)
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443.9
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Peripheral vascular disease, unspecified
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447.9
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Unspecified disorders of arteries and arterioles
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451.0**
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Phlebitis and thrombophlebitis of superficial vessels of lower extremities
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451.11**
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Phlebitis and thrombophlebitis of femoral vein (deep) (superficial)
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451.19**
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Phlebitis and thrombophlebitis of other deep vessels of lower extremities
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451.2**
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Phlebitis and thrombophlebitis of lower extremities, unspecified
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579.0**–579.1**
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Intestinal malabsorption
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585.4**–585.6**
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Chronic kidney disease
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Note: Use codes 579.0*–579.1* and 585.4*–585.6* with 357.4 (polyneuropathy in other diseases classified elsewhere).
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For Medicare to cover routine foot care for patients with diagnoses marked by double asterisks (**) in the two lists above:
- The patient must be under the active care of an MD or DO to qualify for covered routine foot care.
And,
- The patient must have been seen by that physician for the specified condition within six months prior to or six weeks following the foot-care services.
- For the purposes of this LCD, the coverage condition of “active care by a physician” clause above may be satisfied when appropriate care has been rendered by a Nurse Practitioner (NP), Physician Assistant (PA) or Clinical Nurse Specialist (CNS) who is licensed by the state to provide such services. References to “MD or DO” or “physician” in regard to the active care clause will include physicians (MD and DO), NPs, PAs and CNSs.
Nail Debridement in the Absence of a Qualifying Systemic Disease:
Medicare is establishing the following limited coverage for CPT/HCPCS codes 11720 and 11721 for patients who do not qualify for coverage under the routine foot care exclusion exception (i.e., services not appropriately coded with modifier Q7, Q8 or Q9).
Report covered mycotic nail debridement services in the absence of a qualifying systemic disease with a primary diagnosis from the following list:
Covered primary diagnoses:
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110.1
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Onychomycosis
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112.3
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Candidiasis of the nail
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Report covered symptomatic mycotic nail debridement services in the absence of a qualifying systemic disease with a secondary diagnosis from the following list:
Covered secondary diagnoses:
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681.00-681.02
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Cellulitis and abscess of finger
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681.10–681.11
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Cellulitis and abscess of toe
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719.7
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Difficulty walking
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729.5*
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Pain in limb
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Note: Use code 729.5* to report the condition of pain resulting from mycotic nails.
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Note: If a covered secondary diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
- Documentation supporting medical necessity must be legible and available to Medicare upon request.
- For mycotic nail debridement covered under the routine foot care exception. Medicare expects the clinical record to contain a sufficiently detailed clinical description of the feet to provide convincing evidence that non-professional performance of the service is hazardous to the patient. For this purpose, documentation limited to a simple listing of class findings is insufficient. Medicare does not require the detailed clinical description to be repeated at each instance of mycotic nail debridement when an earlier record continues to accurately describe the patient’s condition at the time of the foot care. In such cases, the record should reference the location in the record of the previously recorded detailed information. Further, detailed information so referenced should be made available to Medicare upon request.
- For coverage of mycotic nail debridement by reason of the presence of specified conditions (i.e., in the absence of a qualifying covered systemic condition), the record should contain a description of the specified condition beyond a mere mention that the particular condition is present (i.e., painful nails, limited ambulation, infection).
- The patient’s record must include identification (by number or name) and description of all nails treated.
- To distinguish debridement from trimming or clipping, Medicare expects records to contain some description of the debridement procedure beyond simple statements such as “nail(s) debrided.”
- For routine foot care and debridement of multiple symptomatic nails to people who have a qualifying systemic condition, the record should demonstrate the necessity of each service considering the patient’s usual activities.
- The record must demonstrate the necessity of debridement of each debrided nail considering the patient’s usual activities.
- Clinical rationale for treatment of mycotic nails with less than definitive care (i.e., debridement without pharmacologic intervention) must be explained in the record.
- Documentation of mycotic nail debridement services to residents of nursing homes must include a current nursing facility order (dated and signed with date of signature) for mycotic nail debridement service issued by the patient’s supervising physician. Such orders must meet the following requirements:
- The order must be dated and must have been issued by the supervising physician prior to mycotic nail debridement services being rendered.
- Telephone or verbal orders not written personally by the supervising physician must be authenticated by the dated physician’s signature within a reasonable period of time following issuance of the order.
- The order must be consistent with the attending physician’s overall plan of care.
- The order must be for medically necessary services to address a specific patient complaint or physical finding.
- Routinely issued or “standing” facility orders for mycotic nail debridement services that do not meet the above requirements are insufficient.
- Documentation of mycotic nail debridement services to residents of nursing homes performed at the request of the patient or patient’s family/conservator should name the person who requested the services and should identify the requesting person’s relationship to the patient.
- The following documentation requirements for HCPCS codes G0245, G0246 and G0247 are provided by CMS:
- For code G0247, the patient history should include, but is not limited to, how, when and by whom the diagnosis of LOPS was made, as well as any pertinent present and/or past history regarding the feet).
- For code G0247, the patient history should include, at the least, an interval history regarding the feet since the previous evaluation.
- For code G0247, the description of mycotic nail debridement procedures contains similar information as other covered mycotic nail debridement procedures as listed above.
Appendices
N/A
Utilization Guidelines
- Medicare will cover 11720 and/or 11721 mycotic nail debridement no more often than every 60 days.
- Medicare will cover no more than six 11720 and/or 11721 sessions per patient per 24 months absent medical review of patient records demonstrating medical necessity for the procedure.
- Medicare will not cover 11721 in the absence of a routine foot care exception qualifying condition absent medical review of patient records demonstrating medical necessity for the procedure.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
