Billing and Coding: Routine Foot Care and Debridement of Nails (A57759) (2022)

Article ID
A57759

Article Title
Billing and Coding: Routine Foot Care and Debridement of Nails

Article Type
Billing and Coding


12/26/2019


10/01/2021


N/A


N/A


CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services.The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology &copy 2021 American Dental Association. All rights reserved.

Copyright &copy 2013 - 2022, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission.No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA.AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution orderivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816.Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in anyproduct or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association.To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act:

Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862 (a) (1) (A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1862 (a) (13)(C) defines the exclusion for payment of routine foot care services.

Code of Federal Regulations:

(CFR) Part 411.15., subpart A addresses general exclusions and exclusion of particular services.

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

290 Foot care services which are exceptions to the Medicare coverage exclusion.

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Part 1:

70.2.1 Services provided for diagnosis and treatment of diabetic peripheral neuropathy.

CMS Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5:

National Correct Coding Initiative.

Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Routine Foot Care and Debridement of Nails.

National Coverage Provisions:

The following services are considered to be components of routine foot care, regardless of the provider rendering the service:

  • The 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, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.

Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and 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 a peripheral neuropathy, must be present and grant the presumption of coverage. Payment may be made for the debridement of a mycotic nail (whether by manual method or by electrical grinder) when definitive antifungal treatment options have been reviewed and discussed with the patient at the initial visit and the physician attending the mycotic condition documents that the following criteria are met: In the absence of a systemic condition, the following criteria must be met:

  • In the case of ambulatory patients there exists:

Clinical evidence of mycosis of the toenail, and

Marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

  • In the case of non-ambulatory patients there exists:

Clinical evidence of mycosis of the toenail, and The patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

Class A findings

Non-traumatic amputation of foot or integral skeletal portion thereof.

Class B findings

Absent posterior tibial pulse;

Advanced trophic changes such as (three required):

  • hair growth (decrease or absence);
  • nail changes (thickening);
  • pigmentary changes (discoloration);
  • skin texture (thin, shiny);
  • skin color (rubor or redness); AND

Absent dorsalis pedis pulse.

Class C findings

Claudication;

Temperature changes (e.g., cold feet);

Edema;

Paresthesias (abnormal spontaneous sensations in the feet); and

Burning.

The presumption of coverage may be applied when the physician rendering the routine foot care has identified:

  1. A Class A finding;
  2. Two of the Class B findings; or
  3. One Class B and two Class C findings.

Loss of Protective Sensation (LOPS):

For coverage information on Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (LOPS), and its relation to coverage of Routine Foot Care Services, refer to Medicare National Coverage Determinations (NCD) Manual, Section 70.2.1.

According to this National Coverage Determination,

Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim. LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically. Heavily callused areas should be avoided. As suggested by the American Podiatric Medicine Association, an absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation.

The examination includes:

A patient history, and

A physical examination that must consist of at least the following elements:

Visual inspection of forefoot and hindfoot (including toe web spaces);

Evaluation of protective sensation;

Evaluation of foot structure and biomechanics;

Evaluation of vascular status and skin integrity;

Evaluation of the need for special footwear; and

Patient education.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Specific Coding Guidelines:

Global surgery rules will apply to routine foot care procedure codes 11055, 11056, 11057, 11719, 11720, 11721, and G0127. As a result, an E&M service billed on the same day as a routine foot care service is not eligible for reimbursement unless the E&M service is a significant separately identifiable service, indicated by the use of modifier 25, and documented by medical records.

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation supporting the medical necessity, such as physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement must be maintained in the patient record.

Physical findings and services must be precise and specific (e.g., left great toe, or right foot, 4th digit.) Documentation of co-existing systemic illness should be maintained.

There must be adequate medical documentation to demonstrate the need for routine foot care services as outlined in this determination. This documentation may be office records, physician notes or diagnoses characterizing the patient’s physical status as being of such severity to meet the criteria for exceptions to the Medicare routine foot care exclusion.

Routine identification of cultures of fungi in the toenail is medically indicated when necessary to differentiate fungal disease from psoriatic nail, or when definitive treatment for prolonged oral antifungal therapy has been planned. If cultures are performed and billed, documentation of cultures and the need for prolonged oral antifungal therapy must be in the patient record and available to Medicare upon request.

Utilization Guidelines:

Routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be considered not medically necessary. Services for debridement of more than five nails in a single day may be subject to special review.

FAQs

What is the CPT code for nail debridement? ›

When reporting debridement of mycotic nails (CPT codes 11720, 11721), the primary diagnosis representing the patient's dermatophytosis of the nail must be listed, as well as the secondary diagnosis representing the systemic condition.

Can CPT 11721 and 11055 be billed together? ›

Area of focus: Proper reporting of nail trimming, nail debridement, and lesion trimming and appropriate modifier usage. CPT® codes 11720 – 11721 and 11055 – 11057 should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe.

Can you bill 11720 and G0127 together? ›

CPT codes 11719, 11721 & G0127 should not be billed together to avoid inclusive denials If the insurance company denies the claim even when the modifier is billed correctly, CCI (Correct Coding Initiative) edits should be checked and appealed with appropriate medical records.

What is the CPT code for routine foot care? ›

Article - Billing and Coding: Routine Foot Care (A57188)

How do you bill for nail debridement? ›

When reporting debridement of mycotic nails (CPT codes 11720, 11721), the primary diagnosis representing the patient's dermatophytosis of the nail must be listed, as well as the secondary diagnosis representing the systemic condition.

Do you Bill 11720 and 11721 together? ›

Codes 11719, 11720-21

11719 applies when the nails are void of defects from nutritional or metabolic abnormalities. (in other words - healthy). 11720-11721 includes trimming and shaping of the nails as well as debridement. You would not bill 11719 and 11720-21 together.

Does 11721 need a modifier? ›

CPT code 11721 (Covered Nail Debridement 6 or more) requires Q8 modifier (for routine check-up) with systemic conditions which is medically necessary to be reimbursed by Medicare but only six times in a year.

Does 11055 require a modifier? ›

“Q” Modifiers (Q7, Q8, and Q9) are utilized to denote Class A (Q7), Class B (Q8) and Class C (Q9) findings. These modifiers may be used with procedure codes 11055, 11056, 11057, 11719, 11720, 11721 or G0127.

Does Medicare cover debridement of nails? ›

Medicare will cover debridement of nail(s) by any method(s); 1 to 5 and/or debridement of nail(s) by any method(s); 6 or more no more often than every 60 days.

Does 11720 need a modifier? ›

A diagnosis of onychomycosis can allow 11720 or 11721 if it has either a Q modifier (but does not need a MD or DO last seen) or if it has one of the 6 ICD-9 codes listed in the special section for onychomycosis, i.e. difficulty with walking (681.10, 681.11, 703.0, 719.7, 729.5, 781.2).

Can you bill an office visit with nail care? ›

A visit for nail trimming for patient convenience is not a medically necessary service and should not be billed with 99211 in order to get payment. You're going to get nothing on these.

What are the Q modifiers for podiatry? ›

Modifiers Q7, Q8, and Q9 are to be used to bill podiatric services.

What is the difference between nail debridement and nail trimming? ›

Debridement of Toenails: Nail debridement involves the significant reduction in the thickness and length of the nail to the tolerance of the patient with the aim of allowing the patient to ambulate without pain. Simple trimming of the end of the toenails by cutting or grinding is not considered debridement.

What is debridement toenails? ›

Nail debridement involves the removal of a diseased toenail bed or viable nail plate. This may be performed manually with an instrument, or with an electric grinder.

When do you use modifier 59 podiatry? ›

Modifier -59 may be reported if the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date to indicate they are different proce- dures on that date of service.

How often can 11721 be billed? ›

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.

How do I bill Medicare for routine foot care? ›

Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare can be found in Publication Number 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services, Section 290.2 Routine Foot Care.

What is the ICD 10 code for routine nail trimming? ›

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.

What does Q8 modifier mean? ›

HCPCS Modifier Q8 is used to report two class B findings as they pertain to routine foot care. Guidelines and Instructions. Routine foot care is not a covered Medicare benefit. Medicare assumes that the beneficiary or caregiver will perform these services by themselves, and they are therefore excluded from coverage.

How do you code podiatry? ›

Based on the 2021 E/M guidelines, podiatrists now have the ability to bill E/M 99204/99214 as well as E/M 99205/99215. To bill under these codes a medically appropriate history and/or an examination is needed and there's also a medical decision making or time element.

How do you bill for wound debridement? ›

Debridements should be coded with either selective or non-selective CPT codes (97597, 97598, or 97602) unless the medical record supports a surgical debridement has been performed. Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not be billed separately.

How often can you bill 11055? ›

According to the Centers for Medicare & Medicaid Services (CMS), routine foot care is allowed one time within a two-month period. Therefore, the following CPT codes should only be billed once within a two-month time frame: 11055-11057 (Paring or cutting of benign hyperkeratotic lesion).

Does Medicare cover routine nail care? ›

You pay 100% for routine foot care, in most cases. Routine foot care includes: Cutting or removing corns and calluses. Trimming, cutting, or clipping nails.

Does Medicare pay for podiatrist to cut toenails? ›

NonCovered Foot Care

The cutting of toenails in a healthy person or when they are not painful is not a payable service by Medicare. The cutting of corns and calluses in a healthy person is not a payable service by Medicare. Legally, your podiatrist cannot try to obtain Medicare payment for noncovered foot care.

Can 11720 and 11055 be billed together? ›

Notably, CMS says you can bill CPT code 11055 (Paring or cutting of benign hyperkeratotic lesion) with code 11720 (Debridement of nail[s] by any method; 1 to 5) as long as the two procedures are performed on different toes. The two codes are bundled, but you can use modifier 59 as evidence of the distinct procedure.

What does CPT code 11720 mean? ›

CPT® 11720, Under Surgical Procedures on the Nails

The Current Procedural Terminology (CPT®) code 11720 as maintained by American Medical Association, is a medical procedural code under the range - Surgical Procedures on the Nails.

How do you use the Q7 modifier? ›

As far as the Q7 modifier is concerned, Class A Finding: Use –Q7 on claim form if there is a Class A finding. There is only 1 Class A Finding: Non-traumatic amputation of a foot or an integral skeletal part of the foot.

What is the ICD 10 code for toenail care? ›

L60. 9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM L60.

What is the Q7 modifier? ›

HCPCS Modifier Q7 is used to report one class A finding as it pertains to routine foot care. Guidelines and Instructions. Routine foot care is not a covered Medicare benefit. Medicare assumes that the beneficiary or caregiver will perform these services by themselves and they are therefore excluded from coverage.

What is CPT code G0247? ›

HCPCS code G0247 for Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include, the local care of superficial wounds (i.e. superficial to muscle and fascia) and at least the following if present: (1) local care of superficial ...

When do you use modifier KX? ›

Use the KX modifier only in cases where the condition of the individual patient is such that services are APPROPRIATELY provided in an episode that exceeds the cap.

What is Q6 modifier used for? ›

Submit HCPCS modifier Q6 to indicate that services were provided under a Fee-For-Service Time Compensation arrangement. The regular physician generally pays the substitute physician a fixed per diem amount.

Does CPT 11730 require a modifier? ›

For services performed on different nails: If CPT procedure codes 11730, 11750, or 11765 are performed on different nails, report the procedure performed with one unit of service (UOS) and append with the appropriate identifying digit modifiers.

What is nail debridement? ›

Nail debridement involves the removal of a diseased toenail bed or viable nail plate. This may be performed manually with an instrument, or with an electric grinder.

Does Medicare cover debridement of nails? ›

Medicare will cover debridement of nail(s) by any method(s); 1 to 5 and/or debridement of nail(s) by any method(s); 6 or more no more often than every 60 days.

How Much Does Medicare pay for nail debridement? ›

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.

What is procedure code 11056? ›

CPT® Code 11056 in section: Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus)

What is the difference between nail debridement and nail trimming? ›

Nail debridement: the significant reduction in the thickness and length of the toe nail with the aim of allowing the patient to ambulate without pain. Nail debridement is a distinct service from "routine foot care" . Simple trimming of the end of the toenails by cutting or grinding is not debridement.

What is the ICD 10 code for routine nail trimming? ›

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.

Can you bill an office visit with nail care? ›

A visit for nail trimming for patient convenience is not a medically necessary service and should not be billed with 99211 in order to get payment. You're going to get nothing on these.

Does Medicare cover routine nail care? ›

You pay 100% for routine foot care, in most cases. Routine foot care includes: Cutting or removing corns and calluses. Trimming, cutting, or clipping nails.

How do I bill 11721 to Medicare? ›

Procedure Code 11720 or 11721 are included in Medicare's covered foot care when billed with a diagnosis pertaining to debridement of nail. Refer to the Diagnosis Code List. Procedure Code G0127 is included in Medicare's covered foot care when billed with a diagnosis pertaining to dystrophic nails.

Does 11721 need a modifier? ›

CPT code 11721 (Covered Nail Debridement 6 or more) requires Q8 modifier (for routine check-up) with systemic conditions which is medically necessary to be reimbursed by Medicare but only six times in a year.

Does 11720 need a modifier? ›

A diagnosis of onychomycosis can allow 11720 or 11721 if it has either a Q modifier (but does not need a MD or DO last seen) or if it has one of the 6 ICD-9 codes listed in the special section for onychomycosis, i.e. difficulty with walking (681.10, 681.11, 703.0, 719.7, 729.5, 781.2).

How do I bill Medicare for routine foot care? ›

Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare can be found in Publication Number 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services, Section 290.2 Routine Foot Care.

What is the Q7 modifier? ›

HCPCS Modifier Q7 is used to report one class A finding as it pertains to routine foot care. Guidelines and Instructions. Routine foot care is not a covered Medicare benefit. Medicare assumes that the beneficiary or caregiver will perform these services by themselves and they are therefore excluded from coverage.

How do you bill for wound debridement? ›

Debridements should be coded with either selective or non-selective CPT codes (97597, 97598, or 97602) unless the medical record supports a surgical debridement has been performed. Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not be billed separately.

What is modifier Q7 Q8 and Q9? ›

Modifiers Q7, Q8, and Q9 are to be used to bill podiatric services. Modifier.

What is procedure code 11043? ›

CPT® Code 11043 in section: Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed)

You might also like

Latest Posts

Article information

Author: Merrill Bechtelar CPA

Last Updated: 07/29/2022

Views: 5365

Rating: 5 / 5 (70 voted)

Reviews: 85% of readers found this page helpful

Author information

Name: Merrill Bechtelar CPA

Birthday: 1996-05-19

Address: Apt. 114 873 White Lodge, Libbyfurt, CA 93006

Phone: +5983010455207

Job: Legacy Representative

Hobby: Blacksmithing, Urban exploration, Sudoku, Slacklining, Creative writing, Community, Letterboxing

Introduction: My name is Merrill Bechtelar CPA, I am a clean, agreeable, glorious, magnificent, witty, enchanting, comfortable person who loves writing and wants to share my knowledge and understanding with you.