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but you must check with your individual or company plan to verify actual coverage is available.

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If you’ve been searching for podiatric surgeons for your foot and ankle needs, take time to meet with the Podiatry Group of Georgia. Our doctor has the experience and knowledge you need to help your feet and ankles feel their best. Give us a call today and set up an appointment for your initial consultation. Call us today!

Call Our Marietta, Georgia Office Today at 404-806-3731 or Book your appointment online now!

 Serving Marietta and Atlanta Area!

BlueCHiP for Medicare and Commercial Products
Annual Exam for Diabetics
An annual evaluation of diabetics who are being treated with medication is covered for patients not otherwise receiving podiatric services. Frequency of greater than once per year for this foot care evaluation would  be considered not medically necessary.
Loss of Protective Sensation
This exam/evaluation may identify the diagnosis of diabetic sensory neuropathy with loss of protective
sensation (LOPS) or patients with known LOPS. Patients with this diagnosis may receive two foot
evaluations (examination and treatment) per year, specifically for diabetic peripheral neuropathy with LOPS diagnosis, provided they have not seen a foot care professional for some other reason.
Medical Coverage Policy |

Routine Foot Care and Nail Debridement

Nail Debridement
Nail debridement is medically necessary when the patient has one of the following conditions:
• Onychogryphosis
• Onychauxis
• Patient has mycotic nails causing pain, functional limitation, or secondary infections (see B
mycotic nails with severe symptoms below)
• A nail disorder with diagnosis and systemic condition (see A1 and A2 below)

A. Nail disorder (a minimum of 1 diagnoses listed below in section 1) AND a systemic
condition (listed below in section 2):
1. Diagnosis (required):
o Dermatophytosis of nail
o Onychomycosis (mycotic, fungal infection)
o Ingrowing nail
o Other specified disease of nail
o Onychogryphosis (enlarging of nails with abnormal curving)
o Onychauxis (club nail)
o Onychodystrophy (deformed nail)
o Specified anomalies of nail

2. Systemic conditions: A systemic condition is defined as a metabolic, neurological, or
peripheral vascular disease resulting in decreased sensation or severe circulatory
compromise in the patient’s legs or feet, such as, but not limited to, the following:
o Diabetes mellitus
o Peripheral neuropathies involving the foot
o Associated with malnutrition and/or vitamin deficiency:
o Malnutrition (general, pellagra)
o Alcoholism
o Malabsorption (celiac disease, tropical sprue, pernicious anemia) associated
with:
• Carcinoma
• Diabetes Mellitus
• Drugs and toxins
• Multiple sclerosis
• Uremia (chronic renal disease)
• Traumatic injury
• Leprosy or neurosyphilis
• Hereditary disorders (Hereditary sensory radicular neuropathy,
Angiokeratoma corporis diffusum (Fabry’s), Amyloid neuropathy)
o Arteriosclerosis obliterans
o Burger’s disease

B. Mycotic nails with severe symptoms ambulatory and non-ambulatory patients:
o In the absence of a systemic condition (yet patient has mycotic nails causing
pain, functional limitation, or secondary infections), mycotic nail
debridement may be covered in ambulatory and non-ambulatory patients if
the following conditions are met:
• Treatment of mycotic nails is covered only in the presence
documentation providing:
• Clinical evidence of fungal infection (mycosis) of the toenail
evidenced by:
O A positive fungal culture (by microscopic
confirmation of fungus or positive PAS
pathology); OR
o Three (3) out of the five (5) following signs:
• nail hypertrophy/thickening
• lysis or loosening of the nail plate
• discoloration
• subungual debris, and/or
• brittleness
o AND one of the below:
• Ambulatory patient: must present
significant limitation of
ambulation, either pain (other than
just”painful nails”), or secondary
infection resulting from the
thickening and degenerative
changes of the infected toenail
plate; OR
• Non-ambulatory patient: pain or
secondary infection resulting from
the thickening and degenerative
changes of the infected toenail
plate.
Routine Foot Care
Routine foot care is considered medically necessary only when the physical and clinical findings meet the
guidelines(qualifying and class findings) below and is documented and maintained in the patient record.
The criteria below outlines the specific conditions for coverage of routine foot care when the following
findings are documented in the medical record:
Qualifying Systemic disease and one of the following:
1. One Class A finding
2. Two of the Class B findings or
3. One Class B and two Class C findings
Qualifying Systemic Diseases
The following is a list of qualifying systemic diseases that may pose a risk for injury to the foot and lower
extremity. The list is not all-inclusive, but represents the most commonly billed diagnoses that qualify for coverage for routine foot care.
Note: For a complete list of qualifying systemic diseases, see the complete list of diagnosis codes in
the attachment(s)below.
o Diabetes mellitus
o Arteriosclerosis obliterans
o Burger’s disease
o Chronic thrombophlebitis
o Dermatophytosis of nail
o Peripheral neuropathies involving the feet associated with malnutrition and/or
vitamin deficiency including:
• Malnutrition (general, pellagra)
• Alcoholism
• Malabsorption (celiac disease, tropical sprue)
o Pernicious anemia associated with:
• carcinoma
• diabetes mellitus
• drugs and toxins
• multiple sclerosis
• uremia (chronic renal disease)
• traumatic injury
• leprosy
• neurosyphilis
• hereditary disorders
o Hereditary sensory radicular neuropathy
o Angiokeratoma corporis diffusum (Fabry’s)
o Amyloid neuropathy
o Amyotrophic lateral sclerosis
o Multiple sclerosis
o Quadriplegia
o Paraplegia
o Peripheral Vascular Disease
Class Findings:
Class A, B, C criteria requirements (reported using Modifiers Q7, Q8 or Q9) for medically necessary
coverage:
o One Class A finding; (Q7) or
o Two Class B findings; (Q8) or
o One Class B and Two Class C findings, (Q9).
Class A finding (one required):
o Non-traumatic amputation of foot or integral skeletal portion
Class B findings (two required):
o Absent posterior tibial pulse
o Absent dorsalis pedis pulse
o Advanced trophic changes by any three of the following;
• Hair growth (decrease or absence);
• Nail changes (thickening);
• Pigmentary changes (discoloration);
• Skin texture changes (thin, shiny);
• Skin color changes (rubor or redness)
Class C findings (one Class B and two Class C findings required):
o Claudication
o Temperature changes
o Paresthesias
o Burning
o Edema
In the absence of a systemic condition, the following criteria must be met:
o In the case of ambulatory patients there exists:
• Clinical evidence of mycosis of the toenail and;
• The patient suffers from marked limitation of ambulation, pain and/or
secondary infection resulting from the
thickening and dystrophy of the infected toenail plate.
o In the case of non-ambulatory patients there exists:
• Clinical evidence of mycosis of the toenail, and
• The patient suffers from pain and/or secondary infection resulting from
the thickening and dystrophy of the infected toenail plate.
Routine Foot Care with other indications
Services normally considered routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.
COVERAGE
Benefits vary between groups/contracts. Please refer to the appropriate Evidence of Coverage or
Subscriber Agreement for applicable surgery services and services not medically necessary coverage and the related exclusions in the podiatrist services section.
BACKGROUND
Routine foot care is typically rendered when the patient has a systemic disease, such as metabolic,
neruologic, or peripheral vascular disease, of sufficient severity that performance of such services by a
nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted
in severe circulatory embarrassment or areas of desensitization in the patient’s legs or feet).
Routine foot care includes 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 include shaving or paring of plantar warts that do not require thermal or chemical cautery and curettage, other hygienic and preventive maintenance care in the realm of self care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients. Also included are any services performed in the absence of localized illness, injury, or symptoms involving the foot.
Podiatric physicians may establish diagnoses (care plan by an allopathic/osteopathic physician is not a
coverage or medical necessity requirement) but may be part of appropriate medical care.
Definitions
Routine foot care: cutting or removal of corns or calluses; trimming of toenails; other hygienic, preventive
maintenance care included in self-care (such as cleaning and soaking the feet, the use of skin creams to
maintain skin tone of both ambulatory and non-ambulatory patients); and any services performed in the
absence of localized disease, injury, or symptoms involving the foot.
Nail debridement: the significant reduction in the thickness and length of the toenail 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.
Reduction in the length of normal or thickened elongated toenails (whether done with an electric burr or by hand) is not debridement. Similarly, buffing the surface or the edges of manually trimmed mycotic toenails (mycotic=fungal infection) is not debridement.
Loss of protective sensation (LOPS): A diagnosis of diabetic sensory neuropathy with loss of protective
sensation(LOPS) requires early intervention to prevent serious complications that typically afflict diabetics with sensory neuropathy. Patients with this diagnosis may receive two foot evaluations, no more often than  every six months (examination and treatment) per year, specifically for diabetic peripheral neuropathy with LOPS, as long as they have not seen a foot care professional for another reason. It is not necessary that an osteopathic (DO) or allopathic (MD) physician have established a diagnosis of LOPS and comprehensive diabetic care plan. However, the podiatric professional (i.e., Doctor of Podiatric Medicine) should take appropriate steps for care coordination and promotion of appropriate diabetic care with the physician who is managing the patient’s diabetes.
Peripheral neuropathy: peripheral neuropathy involving the feet, but without the vascular impairment
outlined in Class B findings. The neuropathy would be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary.
Onychogryphosis: a long-standing thickening, in which typically a curved hooked nail (ram’s horn nail)
occurs, and there is marked limitation of ambulation pain and/or secondary infection where the nail plate iscausing symptomatic indentation of or minor laceration of the affected distal toe.
Onychauxis: a thickening (hypertrophy) of the base of the nail/nail bed and there is marked limitation of
ambulation pain and/or secondary infection that causes symptoms.

BlueCHiP for Medicare and Commercial Products
The following CPT codes are medically necessary when submitted with 1 of the diagnosis codes in the
attachment below. All other indications are considered not medically necessary.
11055: Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056: Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions
11057: Paring or cutting of benignhyperkeratotic lesion (e.g., corn or callus); more than 4 lesions
ICD10_other_Indications.pdf
The following CPT codes are covered only when submitted with 1 primary and 1 secondary diagnosis code OR a code noted in the ICD attachment below. All other indications are considered not medically necessary.
11719: Trimming of nondystrophic nails, any number
11720: Debridement of nail(s) by any mothod(s); 1 to 5
11721: Debridement of nail(s) by any method(s); 6 or more
G0127: Trimming of dystrophic nails, any number
Primary Diagnosis codes: ICD10: E10.610, E11.610
Secondary Diagnosis codes: ICD10: B35.1, L60.2, L60.3, L02.611, L02.612, L03.031, L03.032, L03.041.
L03.042, L60.0, M79.671, M79.672, M79.674, M79.675, R26.0, R26.1, R26.2, R26.81, R26.89,
OR
ICD10_other_Indicat
ions.pdf
RELATED POLICIES
None
PUBLISHED
Provider Update, February 2017
Provider Update, September 2016
Provider Update, July 2015
Provider Update, September 2014
Provider Update, August 2012
Provider Update, August 2011
Provider Update, December 2010
REFERENCES
CMSMedicareBenefitPolicyManual
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/do

Call Our Marietta, Georgia Office Today at 404-806-3731 or Book your appointment online now!

 Serving Marietta and Atlanta Area!

 

 

Contact Us

Phone: 404.806.3731
Fax: 770.321.0001
3901 Roswell Road
Suite 340
Marietta GA 30062

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