This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34246-Routine Foot Care and Debridement of Nails.
General Guidelines for Claims submitted to Part A or Part B MAC:
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.
Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.
The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
Codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127 should be billed with a UNIT of “1” regardless of the number of lesions or nails treated.
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.
In the absence of a systemic condition, claims for debridement of mycotic nails must report the primary diagnosis of dermatophytosis, and also report one of the diagnosis codes listed in the “ICD-10-CM Codes that Support Medical Necessity” section of the LCD which indicates secondary infection or pain. A diagnosis of mycotic nails alone is insufficient for payment.
When reporting procedures for treatment of Onychogryphosis or Onychauxis, the primary diagnosis representing one of these conditions must be reported, as well as one of the diagnosis codes listed in the “ICD-10-CM Codes that Support Medical Necessity” section of the LCD which indicates secondary infection or pain. A diagnosis of Onychogryphosis or Onychauxis alone is insufficient for payment.
Modifiers:
One of the modifiers listed below must be reported with codes 11055, 11056, 11057, 11719, G0127, and with codes 11720 and 11721 when the coverage is based on the presence of a qualifying systemic condition, to indicate the class findings and site:
Modifier Q7: One (1) Class A finding
Modifier Q8: Two (2) Class B findings
Modifier Q9: One (1) Class B finding and two (2) Class C findings.
NOTE: If the patient has evidence of neuropathy, but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the ICD-10-CM codes listed in the table below under “ICD-10-CM Codes that are Covered”.
For claims submitted to the Part B MAC:
All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
Modifiers:
For four or fewer modifiers, providers should enter the information in Item 24D of the CMS-1500 claim form or the electronic equivalent. If five or more modifiers are used, the provider should report modifier 99 in Item 24D, and list the modifiers in Item 19 of the CMS-1500 claim form, or electronic equivalent.
Date Last Seen by Attending Physician (for those ICD-10-CM codes which fall under the active care requirement):
The approximate date when the beneficiary was last seen by the M.D., D.O., or qualified non-physician practitioner who diagnosed the complicating condition (attending physician) must be reported in an 8-digit (MM/DD/YYYY) format in Item 19 of the CMS-1500 claim form or the electronic equivalent.
Name and NPI (attending physician):
The NPI of the attending physician must be reported in Item 19 of the CMS-1500 claim form or electronic equivalent.
Claims for routine foot care and debridement of nails services are payable under Medicare Part B in the following places of service: office (11), home (12), assisted living facility (13), group home (14), off campus-outpatient hospital (19), urgent care (for CPT codes 11720 and 11721 only) (20), inpatient hospital (21), on campus-outpatient hospital (22), ambulatory surgical center (24), skilled nursing facility for patients in a Part A stay (31), nursing facility for patients not in a Part A stay (32), custodial care facility (33), independent clinic (49), inpatient psychiatric facility (51), psychiatric facility partial hospitalization (52), community mental health center (53), intermediate care facility (54), residential substance abuse treatment facility (55), psychiatric residential treatment center (56) comprehensive inpatient rehabilitation facility (61), comprehensive outpatient rehabilitation facility (62), end stage renal disease treatment facility (65), state or local public health clinic (71), and adult daycare facility (99).
For claims submitted to the Part A MAC:
Hospital Inpatient Claims:
- The hospital should report the patient’s principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
- The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
- For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Hospital Outpatient Claims:
- The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).
- The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
Home health claims billed on 12X or 22X TOBs do not require HCPCS coding.
Modifiers:
Level two modifiers (indicating digit or limb) are entered in Field Locator 44 UB-04 claim form or the electronic equivalent.
Modifiers identifying indication for treatment (Q7, Q8, or Q9) are entered in Field Locator 44 UB-04 claim form or the electronic equivalent when applicable to validate medical necessity.
Documentation Requirements
The patient’s medical record should include but is not limited to:
- The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
- Relevant medical history
- Results of pertinent tests/procedures
- Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
For debridement of mycotic nails, each service encounter, the medical record should contain a description of each nail which requires debridement. This should include, but is not limited to, the size (including thickness) and color of each affected nail. In addition, the local symptomatology caused by each affected nail resulting in the need for debridement must be documented. For CPT code 11720 documentation of at least one nail will be accepted. For CPT code 11721 complete documentation must be provided for at least 6 nails.
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.
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.
Other Comments:
For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LL to process their claims.
Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.
Medicare does not routinely cover fungus cultures and KOH preparations performed on toenail clippings in the doctor’s office. Identification of cultures of fungi in the toenail clippings is medically necessary only:
- When it is required to differentiate fungal disease from psoriatic nails.
- When a definitive treatment for a prolonged period of time is being planned involving the use of a prescription medication.
Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
For outpatient settings other than CORFs, references to “physicians” throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for foot care services as authorized by State law. (See Sections 1861[s][2] and 1862[a][140 of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)