Routine Foot Care CPT G0245, G0246, G0247


This LCD does not supercede national policy for Medicare coverage of routine foot-care services found in theMedicare 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.
From the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 290:
Excluded Foot-Care Services
The following foot-care services are excluded from Medicare coverage:
  • Treatment of Subluxation of Foot
National – Reference attached article.
  • Supportive Devices for Feet
National – Reference attached article.
  • Routine Foot Care
National – Reference attached article.
  • Treatment of Flat Foot
National – Reference attached article.
Exceptions to Routine Foot-Care Exclusions
Payment may be made as an exception to the routine foot-care exclusion if one of the following conditions is met. In addition, as for any other Medicare-covered service, the foot-care service must be reasonable and necessary for the treatment of an illness or injury or to improve the functioning of a malformed body member.
  • Necessary and Integral Part of Otherwise Covered Services
National – Reference attached article.
  • Treatment of Warts on Foot
National – Reference attached article.
  • Presence of Systemic Condition
National – Reference attached article.
  • Mycotic Nails
See “Mycotic Nail Debridement – 4P-13AB” LCD.
Routine foot-care services to patients whose condition is not codifiable with a Q modifier describing the class findings listed in the attached article, and which are not covered under the provisions of the following paragraph regarding foot-care services for patients with diabetic sensory neuropathy and Loss of Protective Sensation (LOPS), are excluded from Medicare coverage (see “LCD Individual Consideration” paragraph below).
Services that are not codifiable using a Q modifier are not payable by Medicare except in those cases for which the review of medical records demonstrates that the patient’s condition meets exception criteria to the exclusion from Medicare payment for routine foot care. Individual consideration of such claims should be requested during the claim redetermination process. The LCD Individual Consideration procedure is described in the attached article.
  • Foot-Care Services for Patients with Diabetic Sensory Neuropathy and LOPS
The Medicare National Coverage Determinations Manual, Pub. 100-03, Part 1, Section 70.2.1, describes national policy regarding Medicare guidelines for services provided for the diagnosis and treatment of diabetic sensory neuropathy with LOPS. The pertinent national policy can be referenced in the attached article.
HCPCS codes G0245, G0246 and G0247 have been developed for reporting these physician services under this coverage. Codes G0245 and G0246 have been revised to describe them more accurately as E/M services. The new codes are described as:
G0245 Initial physician evaluation of a diabetic patient with diabetic sensory neuropathy resulting in LOPS, which must include:
    • The diagnosis of LOPS.
    • A patient history.
    • A physical examination consisting of findings regarding at least the following elements:
      • Visual inspection of the forefoot, hindfoot and toe web spaces.
      • Evaluation of protective sensation.
      • Evaluation of foot structure and biomechanics.
      • Evaluation of vascular status and skin integrity.
      • Evaluation and recommendation of footwear.
      • Patient education.
G0246 Follow-up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in LOPS to include at least the following:
    • A patient history.
    • A physical examination consisting of findings that includes:
      • Visual inspection of the forefoot, hindfoot and toe web spaces.
      • Evaluation of protective sensation.
      • Evaluation of foot structure and biomechanics.
      • Evaluation of vascular status and skin integrity.
      • Evaluation and recommendation of footwear.
      • Patient education.
G0247 Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in LOPS to include if present, at least the following:
    • Local care of superficial wounds.
    • Debridement of corns and calluses.
    • Trimming and debridement of nails.
Medicare payment for routine foot-care services to patients with diabetic sensory neuropathy who do not meet the class findings described in the attached article will be limited to the provisions of the coverage in this section of the LCD.
Limitations:
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 is 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 CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue 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 Publication 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
Note:
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.
11055©
Trim skin lesion
11056©
Trim skin lesions, 2 to 4
11057©
Trim skin lesions, over 4
11719©
Trim nail(s)
G0127
Trimming dystrophic nails, any number
G0245
Initial foot exam PT LOPS
G0246
Followup eval of foot PT LOPS
G0247
Routine footcare PT W LOPS
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 codes 11055, 11056, 11057, 11719 andG0127:
Covered for:
030.1*
Leprosy, tuberculoid leprosy (type T)
042*
Human immunodeficiency virus [HIV] disease
090.1*
Early congenital syphilis, latent (neurosyphilis)
Note: Use codes 030.1*, 042*, 090.1* with 357.4 (polyneuropathy in other diseases classified elsewhere).
250.00**–250.03**
Diabetes mellitus without mention of complication
250.10**–250.13**
Diabetes with ketoacidosis
250.20**–250.23**
Diabetes with hyperosmolarity
250.30**–250.33**
Diabetes with other coma
250.40**–250.43**
Diabetes with renal manifestations
250.50**–250.53**
Diabetes with ophthalmic manifestations
250.60**–250.63**
Diabetes with neurological manifestations
250.70**–250.73**
Diabetes with peripheral circulatory disorders
250.80**–250.83**
Diabetes with other specified manifestations
250.90**–250.93**
Diabetes with unspecified complication
265.2**
Pellagra
272.7*
Lipidoses (Fabry’s disease)
277.30*
Amyloidosis, unspecified
277.39*
Other amyloidosis
281.0**
Pernicious anemia
Note: Use codes 265.2*, 272.7*, 277.30*, 277.39*, 281.0* with 357.4 (polyneuropathy in other diseases classified elsewhere).
340**
Multiple sclerosis
344.00–344.04
Quadriplegia
344.09
Other quadriplegia
344.1
Paraplegia
344.30–344.32
Monoplegia of lower limb
355.0–355.6
Mononeuritis of lower limb and unspecified site
355.71
Causalgia of lower limb
355.79
Other mononeuritis of lower limb
355.8–355.9
Unspecified inflammatory and toxic neuropathies
356.0–356.4
Hereditary peripheral neuropathy
356.8–356.9
Unspecified idiopathic peripheral neuropathy
357.0–357.1
Inflammatory and toxic neuropathy
357.2**–357.7**
Polyneuropathy in malignant disease
357.81–357.82
Other, inflammatory and toxic neuropathy
357.9
Unspecified inflammatory and toxic neuropathies
440.20–440.24
Atherosclerosis of native arteries of the extremities
440.29
Other atherosclerosis of native arteries of the extremities
440.30–440.32
Atherosclerosis of bypass graft of the extremities
440.4
Chronic total occlusion of artery of the extremities
443.1
Thromboangiitis obliterans (Buerger’s disease)
443.9
Peripheral vascular disease, unspecified
447.9
Unspecified disorders of arteries and arterioles
451.0**
Phlebitis and thrombophlebitis of superficial vessels of lower extremities
451.11**
Phlebitis and thrombophlebitis of femoral vein (deep) (superficial)
451.19**
Phlebitis and thrombophlebitis of other deep vessels of lower extremities
451.2**
Phlebitis and thrombophlebitis of lower extremities, unspecified
579.0**–579.1**
Intestinal malabsorption
585.4**–585.6**
Chronic kidney disease
Note: Use codes 579.0*–579.1* and 585.4*–585.6* with 357.4 (polyneuropathy in other diseases classified elsewhere).
For Medicare to cover routine foot care for patients with diagnoses marked by double asterisks in the list above:
  • The patient must be under the active care of an MD or DO to qualify for covered routine foot care.
  • 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 (MDs and DOs), NPs, PAs and CNSs.
Medicare is establishing the following limited coverage for CPT/HCPCS codes G0245, G0246 and G0247:
Covered for:
250.60–250.63
Diabetes with neurological manifestations
357.2
Polyneuropathy in diabetes
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

1 comment:

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