CMS Routine Foot Care and Debridement of Nails Form

Summary Of Evidence

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Analysis of Evidence

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Abstract:

The Medicare program generally does not cover routine foot care. However, this determination and the related Billing and Coding article outline the specific conditions for which coverage may be allowed.

Indications:

While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits.

Medicare payment may be made for routine foot care when the patient has a systemic disease, such as metabolic, neurologic, 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). 

Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. Please refer to the related Billing and Coding article for coverage criteria.

In addition, procedures for treating toenails are covered for the following:

Onychogryphosis (defined as 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 is causing symptomatic indentation of or minor laceration of the affected distal toe; and/or

Onychauxis (defined as 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.

The physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the patient record, in order for routine foot care services to be reimbursable. Refer to the related Billing and Coding article for Class Findings.

Note: Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should 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. This condition would be represented by the ICD-10-CM codes in Group 4 of the “ICD-10-CM Codes that Support Medical Necessity” section in the related Billing and Coding article. 

Limitations:

When the patient's condition is designated by an ICD-10-CM code with an asterisk (*) (see ICD-10-CM Codes That Support Medical Necessity in the related article), routine foot care procedures are reimbursable only if the patient is under the active care of a doctor of medicine or osteopathy (MD or DO) for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service. 

Other Comments:

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.