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August 4, 2014

Routine Foot Care and Debridement of Nails: Coverage and Claim Submission

It has been brought to our attention that there is some confusion regarding the use of a primary and secondary ICD-9 diagnosis when submitting claims for the treatment of mycotic nails (CPT codes 11720 and 11721). Coverage for debridement of mycotic nails is based on guidelines from the Centers for Medicare & Medicaid Services (CMS) and in CGS’s Local Coverage Determination (LCD) 31896. In general, “routine foot care” is excluded from coverage under Medicare, with several exceptions.  Treatment of mycotic nails may be covered as an exception to the routine foot care exclusion if one of the following criteria is met:

  • The patient  has  a metabolic, neurologic or peripheral vascular disease resulting in severe circulatory reduction or desensitization in the patient’s legs or feet or
  • In the absence of a systemic condition, meets the following criteria:
    -   For ambulatory patients, there exist:   

    1. Clinical evidence of mycosis of the toenail (110.1) or/and onychogryphosis  (703.8) or onychauxis (703.8)
    2. Marked limitation of ambulation (719.7, 718.2), pain (729.5, 703.0)
    3. And/or secondary infection (681.10, 681.11) resulting from the thickening and dystrophy of an infected toenail plate
  • In the case of non-ambulatory patients, there exists:
    1. Clinical evidence of mycosis of the toenail (110.1), and
    2. The patient suffers from pain (729.5, 703.0)
    3. And/or secondary infection (681.10, 681.11) resulting from the thickening and dystrophy of the infected toenail plate.

In addition to the LCD, there are additional instructions in CGS’s related coverage article (A50877), which explains:

  • A primary ICD-9 diagnosis of 110.1 or 703.8 must be reported and
  • A secondary diagnosis must be reported, representing either:
    1. The patient’s systemic condition or;
    2. In the absence of a systemic condition the diagnosis code representing the patient’s
      symptom must be reported

In order for the service to be covered, both an appropriate primary and secondary diagnosis must be submitted, or the service will be denied.  In all cases, the patient’s medical record must support the diagnoses and procedures submitted as well as the medical necessity for the services.

Reference:

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