Routine Foot Care/Mycotic Nail Debridement …

1 Routine foot Care/Mycotic nail Debridement (DRAFT. POLICY). Search LCDs/LMRPs Effective: 3/1/2008. Status: Draft Final Revision Date: 12/3/2007. LCD Title Routine foot Care/Mycotic nail Debridement - 4P-7AB. Contractor's Determination Number 4P-7AB (L26617). Contractor Name TrailBlazer Health Enterprises, LLC. Contractor Number 04001. 04002. Contractor Type MAC Part A. MAC Part B. AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2007. American Medical Association (or such other date of publication of CPT). All rights reserved.

2 Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2002, 2004. American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CMS National Coverage Policy Medicare Benefit Policy Manual Pub. 100-02, Chapter 15, Section 290. Medicare National Coverage Determinations Manual Pub. 100- 03, Part 1, Section Correct Coding Initiative Medicare Contractor Beneficiary and Provider Communications Manual Pub.

3 100-09, Chapter 5. Social Security Act (Title XVIII) Standard References, Sections: o 1862 (a)(1)(A) Medically Reasonable & Necessary. o 1862 (a)(1)(D) Investigational or Experimental. o 1862 (a)(7) Screening ( Routine Physical Checkups). o 1862 (a)(13)(A) Treatment of Flat foot . o 1862 (a)(13)(B) Treatment of Subluxation of the foot . o 1862 (a)(13)(C) Routine foot care . o 1833 (e) Incomplete Claim. Primary Geographic Jurisdiction CO 04101. NM 04201. OK 04301. TX 04401: o Indian Health Service. o End State Renal Disease (ESRD) facilities. o Skilled Nursing Facilities (SNFs).

4 O Rural Health Clinics (RHCs). CO 04102. NM 04202. OK 04302. TX 04402: o Indian Health Service. Secondary Geographic Jurisdiction N/A. Oversight Region Region VI. Original Determination Effective Date 03/01/2008. 03/21/2008. 06/13/2008. Original Determination Ending Date N/A. Revision Effective Date N/A. Revision Ending Date N/A. Indications and Limitations of Coverage and/or Medical Necessity The Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 290, describes national policy regarding Medicare guidelines for Routine foot - care services.

5 The pertinent national policy can be referenced in the attached article. 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.

6 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 Definitive treatment of mycotic nails involves the appropriate use of systemic or topical anti-fungal pharmacologic agents with or without periodic Debridement of dystrophic nail plates.

7 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 usually not indicated. Medicare does not routinely cover fungus cultures and KOH. preparations performed on toenail clippings in the doctor's office. Culture identification of fungi in toenail clippings is medically necessary only when culture is required to differentiate fungal disease from psoriatic nails or when treatment involving potentially hazardous medications is planned.

8 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. Treatment of asymptomatic mycotic nails may be covered as Routine foot care in the presence of a systemic condition that meets the requirements as previously defined in this LCD ( , a qualifying systemic condition).

9 Treatment of mycotic nails may be covered in the absence of a qualifying covered systemic condition if there is clinical evidence of mycosis of the toenail, and the patient has marked limitation of ambulation, pain, or secondary soft tissue infection resulting from the thickening and dystrophy of the infected nail plate. The treatment of mycotic nails in the absence of a qualifying covered systemic condition will not be covered after the acute symptoms caused by mycosis have abated. National coverage can be referenced in the attached article. Routine foot - care services to patients who have a coverable condition, the severity of which does not meet the class findings listed in the attached article, are excluded services with the exception of patients who have diabetic ulcers, wounds, infections and sensory neuropathy that is covered only according to the provisions of the following paragraph regarding foot - care services for patients with diabetic sensory neuropathy and LOPS.

10 foot - care Services for Patients with Diabetic Sensory Neuropathy and LOPS. The Medicare National Coverage Determinations Manual Pub. 100- 03, Part 1, Section , 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.