Primary Care Coding Alert

Although CPT 11055-CPT 11057 (Paring or cutting of benign hyperkeratotic lesion [e.g., corn or callus] ...) describe the treatment of non-deep-seated keratotic lesions (e.g., a corn or callus), Medicare and some private payers will not reimburse for them. However, if the patient has specific risk factors, Medicare will cover this treatment. To be considered at risk, the patient must meet a systemic condition or have certain symptoms.

The following list of systemic diseases is not all-inclusive but represents commonly billed diagnoses that qualify for routine foot care:

1. arteriosclerosis obliterans (440.9) (arteriosclerosis of the extremities [440.20] occlusive peripheral arteriosclerosis [440.9])

2. Buerger's disease (443.1) (thromboangiitis obliterans)

1. alcoholism (357.5)

2. associated with malnutrition and vitamin deficiency (269.9)

3. malabsorption (celiac disease [579.0], tropical sprue [579.1])

4. malnutrition (general, pellagra [265.2])

1. carcinoma

2. diabetes mellitus (250.xx)

3. drugs and toxins (284.8)

4. leprosy (030.x) or neurosyphilis (094.9)

5. multiple sclerosis (340)

6. traumatic injury

7. uremia (chronic renal disease) (585)

1. amyloid neuropathy (277.3)

2. angiokeratoma corporis diffusum (Fabry's) (272.7)

3. hereditary sensory radicular neuropathy (356.2).

Systemic disease qualifications vary among carriers. Ask your local carrier for its complete list.

To fulfill the coverage requirements for routine foot care, patients must also exhibit specific symptoms. Medicare divides the symptoms into three classes:

1. nontraumatic amputation of foot or integral skeletal portion thereof

1. advanced trophic changes such as hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny) or skin color (rubor or redness)


2. absent posterior tibial pulse

3. absent dorsalis pedis pulse

1. claudication (e.g., leg or calf pain with walking, pain in calf causing limping, cessation of walking secondary to calf pain)

2. temperature changes (cold feet)

3. paresthesias (abnormal spontaneous sensations in the feet)

4. burning.

Coders indicate class finding by appending modifiers -Q7 (One Class A finding), -Q8 (Two Class B findings) and -Q9 (One Class B and two Class C findings).

If a patient meets the symptoms requirements, use 11055-11057 appended with the appropriate Q modifier to indicate the class finding. For example, a diabetic patient presents with two calluses on her right foot. She complains of cold feet and pain in her calf. The physician determines that the patient lacks a posterior tibial pulse. The FP pares both lesions. Because the patient met the systemic disease criteria for diabetes mellitus, as well as one Class B finding (absent posterior tibial pulse) and two Class C findings (claudication and temperature change), Medicare and most private payers will reimburse for this routine foot care. Code this visit as 11056 (... two to four lesions) with modifier -Q9 attached to indicate the class findings. In addition, report 700 (Corns and callosities) and 250.00 (Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled). "List 700 first because it is the chief reason for the visit," says Jean Stoner, CPC, RCC, manager of coding operations for CodeRyte, a coding software company in Bethesda, Md.

Medicare does not reimburse for trimming, paring, cutting or shaving in addition to debridement of the same keratotic lesion on the same day. But if the FP trims, cuts, pares and shaves in addition to debridement of separate lesions with unrelated conditions, each procedure can be paid for.

If the FP debrides a deep-seated keratotic lesion (such as an intractable plantar keratotic lesion or non-diffuse keratomas) when the soft tissue surrounding it is painful or inflamed, some Medicare carriers (e.g., National Heritage Insurance Company, the California carrier) provide coverage because they do not consider it routine foot care. "The difference between non-deep-seated and deep-seated keratotic lesions is that non-deep-seated can usually be completely treated by paring and require no anesthesia," says Phillip Rodgers, MD, clinical instructor in the department of family medicine at the University of Michigan Medical School in Ann Arbor, "whereas deep-seated keratoses would take more effort and invasion to remove completely."

Medicare provides routine foot care coverage for toenail treatment when the patient fulfills the same "at risk" criteria as those with foot lesions.

For example, a patient presents with hyperkeratosis. The patient has peripheral neuropathy of the feet related to his alcoholism. He also has thickening of the toenail with red, shiny skin surrounding it, and the FP notes the absence of a posterior tibial pulse. The physician trims the patient's nails. Because the patient meets the systemic disease requirement as well as two Class B findings, the procedure is covered. This would be coded with either 11719 (Trimming of nondystrophic nails, any number) with modifier -Q8 appended or G0127-Q8 (Trimming of dystrophic nails, any number), depending on whether the nails were nondystrophic or dystrophic, respectively.

Corresponding ICD-9 codes would be:

"Correct coding would require the nail thickening (703.8) to be listed first rather than the neuropathy," Stoner says. "But different LMRPs may want them listed in a different order."

Coverage is also provided for certain toenail procedures when the nail is severely deformed or diseased. For example, a patient presents with subungual hematoma, and the FP performs an evacuation of the nail. Report 11740 (Evacuation of subungual hematoma) with 924.3 (Contusion of lower limb and of other and unspecified sites; toe), which includes the toenail.

When the toenail affects ambulation, Medicare also covers treatment. A patient presents with an ingrown toenail that is making it difficult for her to walk. The FP performs a nail avulsion. Use 11730* (Avulsion of nail plate, partial or complete, simple; single) with the proper T modifier to indicate which toe, and 703.0 (Ingrowing nail).

The Correct Coding Initiative bundles the nail debridement codes (11720-11721) with the drainage and incision of abscess codes (10060-10061), the nail avulsion codes (11730-11732) and 11750 (Excision of nail and nail matrix, partial or complete, [e.g., ingrown or deformed nail] for permanent removal). It also bundles 11730-11732 with 11750.

Note: To view national coverage on foot care, see the Medicare Carriers Manual, sections 2323 and 4120. Both are online at ww.hcfa.gov/pubforms/14_car/3btoc.htm