procedure code and description
10060- INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE – average fee payment- $120 – $130
10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION
11056 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS
Coding and Billing Guideliens
1. Report the appropriate procedure code and modifiers for the service(s) performed.
a. When reporting foot/nail care report the applicable “Q” modifier.
b. These services should be reported with quantity of one in the quantity/units field.
2. Report the ICD-9 code for which the service(s) is performed in the first position in the diagnosis field of the CMS 1500 claim form or electronic equivalent; report the systemic condition(s) in the remaining positions. Where the systemic condition is marked with an (*) (see below) and the services were rendered by a podiatrist, include the 8-digit (MM/DD/CCYY) date the patient was last seen and the NPI of his/her attending (MD/DO) physician who diagnosed the complicating condition in item 19 of the CMS 1500 claim form or electronic equivalent field, diabetes mellitus*
Chronic Thrombophlebitis*
Peripheral neuropathies involving the feet – Associated with malnutrition and vitamin deficiency*
Malnutrition (general, pellagra)
Alcoholism
Malabsorption (celiac disease, tropical sprue)
Pernicious anemia
Associated with carcinoma*
Associated with diabetes mellitus*
Associated with drugs and toxins*
Associated with multiple sclerosis*
Associated with uremia (chronic renal disease)* Hereditary sensory radicular neuropathy
Angiokeratoma corporis diffusum (fabry’s)
Amyloid neuropathy
Long term oral anticoagulant therapy (e.g. Coumadin, Dicoumaral, etc.)* Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections.
3. When billing for services, requested by the beneficiary for denial, that are statutorily excluded by Medicare (i.e. Routine foot care), report an ICD-9 code that best describes the patients condition and the GY modifier (items or services statutorily excluded or does not meet the definition of any Medicare benefit)
4. When billing for services, requested by the beneficiary for denial, that would be considered not reasonable and necessary, report an ICD-9 code that best describes the patients condition and the GA modifier if an ABN signed by the beneficiary is on file or the GZ modifier (items or services expected to be denied as not reasonable) when there is no ABN for the service on file.
5. For patients on long term oral anticoagulant therapy, report the ICD-9 related to the performed service in the first position, the drug ICD-9 (V58.61) in the second position and the condition being treated with the anticoagulant in the third position of item 21 of the CMS 1500 claim form or electronic equivalent.
6. It is inappropriate and incorrect to report an E&M code when routine foot care or a nail trimming/debridement service is the service actually performed.
7. The following class finding modifiers should usually be used with G0127, 11055, 11056, 11057, 11719, and when appropriate, CPT codes 11720, 11721.
A Class A finding (Modifier Q7) Two of the Class B findings (Modifier Q8); or One Class B and two Class C findings (Modifier Q9).
8. 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-9 CM codes in list three of “ICD-9 Codes that Support
Medical Necessity” listed in the LCD.
9. A diagnosis of onychomycosis can allow 11720 or 11721 if it has either a Q modifier (but does not need a MD or DO last seen) or if it has one of the 6 ICD-9 codes listed in the special section for onychomycosis, i.e. difficulty with walking (681.10, 681.11, 703.0, 719.7, 729.5, 781.2).
Routine Foot Care
Except as provided above, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following:
The cutting or removal of corns and calluses;
The trimming, cutting, clipping, or debriding of nails; and Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.
Exceptions To Routine Foot Care Exclusion
1 – Necessary And Integral Part Of Otherwise Covered Services
In certain circumstances, services ordinarily considered to be 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.
2 – Presence Of Systemic Condition
The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from coverage). Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet.
In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions.
Coding Information
Date Last Seen by Attending Physician (for those ICD-9 CM codes which fall under the active care requirement): CPT codes 11055, 11056, 11057, 11719, and G0127 or 11720, 11721. The approximate date when the beneficiary was last seen by the M.D., D.O., 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 or if the patient sees their primary care physician no later than 30 days after the services were furnished.
For claims submitted to the fiscal intermediary:
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-9-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.
Hospital Outpatient Claims:
• The hospital should report the full ICD-9-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-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
• The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. RHC/FQHC encounters billed on TOBs 071x or 073x do not require HCPCS coding. Home health claims billed on 12X or 22X TOBs do not require HCPCS coding.
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number Care is considered routine unless the patient has a secondary diagnosis of a systemic disease and is under the active care of a doctor.
NATIONAL FOOT CARE MODIFIERS:
Q7 — One (1) Class A finding
Q8 –Two (2) Class B findings
Q9 –One (1) Class B and Two (2) Class C findings
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
Coverage Indications, Limitations, and/or Medical Necessity
An abscess is a cavity containing pus surrounded by inflamed tissue. It is generally associated with pain, swelling and erythema. An abscess often requires incision and drainage to remove the purulent material in order for healing to occur.
Procedure codes 10060 and 10061 represent incision and drainage of an abscess involving the skin, subcutaneous and/or accessory structures. This includes the following types of abscess: furuncle, carbuncle, suppurative hidradenitis, an abscessed cyst, an abscessed paronychia, and/or other abscess involving the cutaneous and/or subcutaneous structures.
The use of incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures will be considered to be medically reasonable and necessary for the treatment of a symptomatic abscess (e.g. inflamed, painful, tender) involving these structures. This includes the incision and drainage of the following types of abscess:
furuncle;
carbuncle;
suppurative hidradenitis;
an abscessed cyst;
an abscessed paronychia; and/or
other abscess of cutaneous and/or subcutaneous structures.
It would not generally be expected to see incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures to be repeated frequently and/or multiple times. If frequent repeated incision and drainage is required, the medical record must reflect the reason for persistent/recurrent abscess formation, as well as any measures taken to prevent reoccurrence.
CPT/HCPCS Codes
10060 Drainage of skin abscess
10061 Drainage of skin abscess
Limitations
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.
The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.
Coding for Mycotic Nails
Although CPT coding does not exclusively apply CPT codes 11720 and 11721 to mycotic nails or to the feet, Medicare assumes these are the CPT codes usually used to code for services related to debriding mycotic nails.
Assuming services are being provided based on this indication, and the above requirements are documented, the claim should be coded with ICD-10 diagnosis code B35.1 as a primary code AND L02.611- L02.612, L03.031-L03.032, L03.041-L03.042, M79.671- M79.672, M79.674-M79.675 or R26.2 as a secondary code. Systemic condition modifiers are not necessary for services performed for this indication with these diagnosis codes.
The nail debridement procedure codes (11720-11721) are considered noncovered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care they must meet the same criteria as all other routine foot care services to be considered for payment.
Coding for Systemic Conditions
Foot care services are covered in the presence of a systemic condition based on the list of illnesses described in Chapter 15, Section 290 of the Benefit Policy Manual and coded by the following ICD-10 codes:
Diabetes mellitus*
E08.00-E13.9
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
I70.201-I70.92
I73.00-I73.01
I73.9
Buerger’s disease (thromboangiitis obliterans)
I73.1
Chronic thrombophlebitis*
I80.00-I80.3
Peripheral neuropathies involving the feet:
Associated with malnutrition and vitamin deficiency*
E56.9 and G63
Malnutrition (general, pellagra)*
E46, E52, or E64.0 and G63
Alcoholism*
G62.1
Malabsorption (celiac disease, tropical sprue)*
K90.0 or K90.1 and G63
Pernicious Anemia*
D51.0 and G63
Associated with carcinoma*
G13.0
Associated with diabetes mellitus*
E08.40
E08.42
E09.40
E09.42
E10.40
E10.42
E11.40
E11.42
E13.40
E13.42
Associated with drugs and toxins*
G62.0
G62.2
G62.82
Associated with multiple sclerosis*
G35 and G63
Associated with uremia (chronic renal disease)*
N18.1-N18.9 and G63
Associated with traumatic injury
S86.001A-S86.009S
S86.091A-S86.109S
S86.191A-S86.201S
S86.209A-S86.209S
S86.291A-S86.309S
S86.391A-S86.809S
S86.891A-S86.909S
S86.991A-S86.999S
S89.80XA-S89.92XS
S96.001A-S96.009S
S96.091A-S96.109S
S96.191A-S96.209S
S96.291A-S96.809S
S96.891A-S96.909S
S96.991A-S96.999S
S99.811A-S99.929S
and G63
Associated with leprosy or neurosyphilis
A30.0-A30.9 and G63
A52.10-A52.3 and G63
Associated with hereditary disorders
G60.0-G60.9
Heredity sensory radicular neuropathy
G60.0
Angiokeratoma corporis diffusum (Fabry’s)
E75.21 and G63
Amyloid neuropathy
E85.0-E85.9 and G63
When the patient’s condition is one of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition. This must be indicated by the name and NPI of the attending physician in block 17 and 17B of the CMS-1500 or the equivalent electronic claim format. The date the patient was last seen by the attending physician should be billed in block 19. Claims for such routine services should show the complicating systemic disease in block 21 of the CMS-1500.
A presumption of coverage will be applied when the physician rendering the routine foot care has identified:
one (1) Class A finding using modifier Q7;
two (2) Class B findings using modifier Q8; or
one (1) Class B and two (2) Class C findings using modifier Q9.
In addition to a valid billing indicator, these services must include a systemic condition diagnosis listed above. All claims for routine foot care based on the presence of a systemic condition should have a billing indicator of Q7, Q8 or Q9 to be considered for payment.
Claims without a systemic diagnosis listed will be denied as noncovered routine-type foot care services.
Services not meeting the instructions and criteria in this statement of national coverage will be denied as statutory noncovered services. For ICD-10 codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the doctor of medicine or osteopathy.
Loss of protective sensation (LOPS) is not the subject of this LCD.
The following class finding modifiers should usually be used with G0127, 11055, 11056, 11057, 11719, and when appropriate, CPT codes 11720, 11721.
A Class A finding (Modifier Q7) Two of the Class B findings (Modifier Q8); or One Class B and two Class C findings (Modifier Q9).
Routine foot care CPT codes
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number Care is considered routine unless the patient has a secondary diagnosis of a systemic disease and is under the active care of a doctor.
NATIONAL FOOT CARE MODIFIERS:
Q7 — One (1) Class A finding
Q8 –Two (2) Class B findings
Q9 –One (1) Class B and Two (2) Class C findings
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
ICD-10 Codes that Support Medical Necessity
K13.0 Diseases of lips
L02.01 Cutaneous abscess of face
L02.02 Furuncle of face
L02.03 Carbuncle of face
L02.11 Cutaneous abscess of neck
L02.12 Furuncle of neck
L02.13 Carbuncle of neck
L02.211 Cutaneous abscess of abdominal wall
L02.212 Cutaneous abscess of back [any part, except buttock]
L02.213 Cutaneous abscess of chest wall
L02.214 Cutaneous abscess of groin
L02.215 Cutaneous abscess of perineum
L02.216 Cutaneous abscess of umbilicus
L02.221 Furuncle of abdominal wall
L02.222 Furuncle of back [any part, except buttock]
L02.223 Furuncle of chest wall
L02.224 Furuncle of groin
L02.225 Furuncle of perineum
L02.226 Furuncle of umbilicus
L02.231 Carbuncle of abdominal wall
L02.232 Carbuncle of back [any part, except buttock]
L02.233 Carbuncle of chest wall
L02.234 Carbuncle of groin
L02.235 Carbuncle of perineum
L02.236 Carbuncle of umbilicus
L02.31 Cutaneous abscess of buttock
L02.32 Furuncle of buttock
L02.33 Carbuncle of buttock
L02.411 Cutaneous abscess of right axilla
L02.412 Cutaneous abscess of left axilla
L02.413 Cutaneous abscess of right upper limb
L02.414 Cutaneous abscess of left upper limb
L02.415 Cutaneous abscess of right lower limb
L02.416 Cutaneous abscess of left lower limb
L02.421 Furuncle of right axilla
L02.422 Furuncle of left axilla
L02.423 Furuncle of right upper limb
L02.424 Furuncle of left upper limb
L02.425 Furuncle of right lower limb
L02.426 Furuncle of left lower limb
L02.431 Carbuncle of right axilla
L02.432 Carbuncle of left axilla
L02.433 Carbuncle of right upper limb
L02.434 Carbuncle of left upper limb
L02.435 Carbuncle of right lower limb
L02.436 Carbuncle of left lower limb
L02.511 Cutaneous abscess of right hand
L02.512 Cutaneous abscess of left hand
L02.521 Furuncle right hand
L02.522 Furuncle left hand
L02.531 Carbuncle of right hand
L02.532 Carbuncle of left hand
L02.611 Cutaneous abscess of right foot
L02.612 Cutaneous abscess of left foot
L02.619 Cutaneous abscess of unspecified foot
L02.621 Furuncle of right foot
L02.622 Furuncle of left foot
L02.631 Carbuncle of right foot
L02.632 Carbuncle of left foot
L02.811 Cutaneous abscess of head [any part, except face]
L02.818 Cutaneous abscess of other sites
L02.821 Furuncle of head [any part, except face]
L02.828 Furuncle of other sites
L02.831 Carbuncle of head [any part, except face]
L02.838 Carbuncle of other sites
L02.91 Cutaneous abscess, unspecified
L02.92 Furuncle, unspecified
L02.93 Carbuncle, unspecified
L03.011 Cellulitis of right finger
L03.012 Cellulitis of left finger
L03.019 Cellulitis of unspecified finger
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.039 Cellulitis of unspecified toe
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.211 Cellulitis of face
L03.221 Cellulitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.811 Cellulitis of head [any part, except face]
L03.818 Cellulitis of other sites
L03.90 Cellulitis, unspecified
L73.2 Hidradenitis suppurativa
N48.21 Abscess of corpus cavernosum and penis
N48.22 Cellulitis of corpus cavernosum and penis
N48.29 Other inflammatory disorders of penis
N61 Inflammatory disorders of breast
Comment: A commenter stated if paronychia is considered a nail margin inflammation, then removing a portion of the nail plate and relieve the pressure with packing is appropriate. However, if there is an infection, then an incision and drainage is needed. CPT code 10060 or 10061 is appropriate in this case
Response: We agree if an infection is present and incision and drainage is necessary, then it is appropriate to report CPT code 10060. If no infection is present, and the nail plate is removed to relieve pressure, then it is inappropriate to use the incision and drainage CPT codes.
Comment: A commenter stated there are times when the nail (plate total or partial) needs to be avulsed in order to perform the incision and drainage for the abscess. Therefore, CPT codes10060 or 10061 is the appropriate and CPT code 11730 is incidental. This is consistent with the National Correct Coding Initiative (NCCI) which bundles CPT code 11730 into CPT codes 10060 and10061. We believe the LCD should be consistent with NCCI.
Response: If the avulsion of the nail plate alone is sufficient to drain the abscess, this is the service which should be billed, (i.e. 11730). If, however, it is necessary to remove part of the nail plate in order to complete the drainage of the abscess, then the incision and drainage codes are appropriate. We believe this is appropriately explained in the LCD and no change is necessary.
CPT CODE FOR Treatment of Ulcers and Symptomatic hyperkeratoses CPT 11042, 11043, 11044, 97597
For Medicare purposes, an “ulcer” does not exist until there is a partial thickness skin loss involving epidermis with or without dermis. Some authors will define a “pre-ulcer” condition and others even a “Stage 1 Ulcer” (e.g. “Wagner 0”) where the skin is still intact. Such changes do not constitute an “ulcer” for Medicare payment purposes under this policy.
Ulcers may develop because of a combination of ischemia, infection, abscess, trauma, prolonged pressure, repetitive stress, edema, and loss of sensation.
The management of skin ulcers includes:
1. Overall medical and surgical treatment of the cause and
2. Meticulous care of the ulcerated skin and other associated soft tissue with application of medications and dressings, and
3. When reasonable and necessary, debridement of the necrotic and devitalized tissue and
4. Offloading of the external pressure source(s).
The management of a symptomatic hyperkeratosis may involve medical treatment, paring or cutting, shaving, excision, or destruction. This policy addresses only the paring or cutting approach.
This policy does not address treatment of burns or debridement of nails. For treatment of burns, including debridement, refer to the CPT 16000 series. For debridement of nails, refer to CPT codes 11720 and 11721.
When the only service provided is the non-surgical cleansing of the ulcer site with or without the application of a surgical dressing, the provider should bill this service with the appropriate evaluation and management (E/M) code and not bill a debridement code(s).
CPT codes 11042-11043, 97597 and 97598 describe debridement of relatively localized areas with or without their contiguous underlying structures. These codes are appropriate for treatment of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and debridement of ground-in dirt such as from road abrasions.
CPT codes 11042-11047 do not refer solely to ulcer size, but also to levels of actual tissue debridement levels (based on tissue type; e.g., partial skin, full thickness skin, subcutaneous tissue, etc.) of independent (non contiguous) skin and other deeper tissue structures.
When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of wounds that are the same depth, but do not combine wounds from different depths. This A/B MAC allows payment for an aggregate total of one independent tissue debridement on a given day of service. Any number greater than the aggregate total of four for one or both feet per date of service will result in a denial which may be appealed with documentation justifying the additional services. Once debridement is properly done repeat debridement is not expected for several days afterward.
CPT 97597 and 97598 may be used for the medically reasonable and necessary debridement with utilization consistent with this LCD and within scope of practice of the performing provider.
As is the case in all unusual and complicated procedures, the use of Modifier 22 may be appropriate to report and describe inordinately complex services performed. When used, the procedure note should contain a separate section that describes the “unusual” nature of the procedure.
When addressing a specific toe(s) or finger(s) use the respective CPT® HCPCS Level II modifier to identify them on the claim.
Other modifiers may include (but are not to be used alone when the more specific above modifiers are needed to clarify the procedure):
LT Left
RT Right
59 Independent Anatomical Site
XE Separate encounter
XS Separate Structure
XP Separate Practitioner
XU Unusual Non-Overlapping Service
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
CPT codes 11055, 11056, and 11057 will also be covered when billed with one of the diabetes, neurological or vascular disease diagnosis codes listed below any one of the following routine foot care diagnosis codes: B35.3, L60.1-L60.5, L60.8, L62, L84, M21.6X1, M21.6X2 or M21.6X9.
CPT/HCPCS Codes
Group 1 Codes:
10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE
10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS
11043 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS
11044 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS
11045 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
11046 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
11047 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION
11056 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS
11057 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS
97597 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS
97598 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
E10.620* Type 1 diabetes mellitus with diabetic dermatitis
E10.621* Type 1 diabetes mellitus with foot ulcer
E10.622* Type 1 diabetes mellitus with other skin ulcer
E10.628* Type 1 diabetes mellitus with other skin complications
E10.65* Type 1 diabetes mellitus with hyperglycemia
E10.69* Type 1 diabetes mellitus with other specified complication
E11.620* Type 2 diabetes mellitus with diabetic dermatitis
E11.621* Type 2 diabetes mellitus with foot ulcer
E11.622* Type 2 diabetes mellitus with other skin ulcer
E11.628* Type 2 diabetes mellitus with other skin complications
E11.65* Type 2 diabetes mellitus with hyperglycemia
E11.69* Type 2 diabetes mellitus with other specified complication
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle
I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg
I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle
I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
I70.25 Atherosclerosis of native arteries of other extremities with ulceration
I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg
I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I87.011 Postthrombotic syndrome with ulcer of right lower extremity
I87.012 Postthrombotic syndrome with ulcer of left lower extremity
I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity
I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity
I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity
I96* Gangrene, not elsewhere classified
K12.2 Cellulitis and abscess of mouth
K62.6 Ulcer of anus and rectum
L03.011 Cellulitis of right finger
L03.012 Cellulitis of left finger
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.211 Cellulitis of face
L03.221 Cellulitis of neck
L03.222 Acute lymphangitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.811 Cellulitis of head [any part, except face]
L05.01 Pilonidal cyst with abscess
L08.0 Pyoderma
L08.89 Other specified local infections of the skin and subcutaneous tissue
L12.0 Bullous pemphigoid
L59.8 Other specified disorders of the skin and subcutaneous tissue related to radiation
L73.8 Other specified follicular disorders
L89.012 Pressure ulcer of right elbow, stage 2
L89.013 Pressure ulcer of right elbow, stage 3
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *For ICD-10-CM codes E10.65, E10.620, E10.621, E10.622, E10.628, E10.69, E11.620, E11.621, E11.622, E11.628, E11.65, E11.69, the “specified manifestation” is skin ulcer. For clarity one should consider adding a 2nd ICD-10 code (L97.111, L97.112,
L97.113, L97.114, L97.121, L97.122, L697.123, L97.124, L97.211, L97.212, L97.213, L97.214, L97.221, L97.222, L97.223, L97.224, L97.311, L97.312, L97.13, L97.314, L97.321, L97.322, L97.323, L97.324, L97.411, L97.412, L97.413, L97.414, L97.421
L97.422, L97.423, L97.424, L97.511
L97.512, L97.513, L97.514, L97.521
L97.522, L97.523, L97.524, L97.811
L97.812, L97.813, L97.814, L97.821
L97.822, L97.823, L97.824, L98.411
L98.412, L98.413, L98.414, L98.421
L98.422, L98.423, L98.424, L98.491
L98.492, L98.493, L98.494) to define the ulcer.
E75.21* Fabry (-Anderson) disease
G60.0* Hereditary motor and sensory neuropathy
G60.1* Refsum’s disease
G60.2* Neuropathy in association with hereditary ataxia
G60.3* Idiopathic progressive neuropathy
G60.8* Other hereditary and idiopathic neuropathies
L11.0* Acquired keratosis follicularis
L84* Corns and callosities
L85.0* Acquired ichthyosis
L85.1* Acquired keratosis [keratoderma] palmaris et plantaris
L85.2* Keratosis punctata (palmaris et plantaris)
L85.8* Other specified epidermal thickening
L86* Keratoderma in diseases classified elsewhere
L87.0* Keratosis follicularis et parafollicularis in cutem penetrans
L87.2* Elastosis perforans serpiginosa
Q81.9* Epidermolysis bullosa, unspecified
Q82.8* Other specified congenital malformations of skin
Guidelines for Foot care
UnitedHealthcare has assigned Service Code 8101 to represent the codes for Medicare Covered Foot Care. Service Code 8100 has been assigned for Non-Medicare covered foot care. Only certain individual and/or group plans provide benefits for Non-Medicare covered foot care. The line item coding criteria directs a foot care service line to the proper service code using a complex set of criteria including CPT/HCPCS codes, ICD-10 diagnosis codes and modifiers when applicable. Codes and policies for routine foot care and supportive devices for the feet are not exclusively for the use of Podiatrists. These codes must be used to report foot care services regardless of the specialty of the physician who furnishes the services. Physicians should use the most appropriate code available when billing for routine foot care. Relatively few claims for routine-type care are anticipated considering the severity of conditions contemplated as the basis for this exception. Claims for this type of foot care should not be paid in the absence of convincing evidence that nonprofessional performance of the service would have been hazardous for the beneficiary because of an underlying systemic disease. The mere statement of a diagnosis such as those mentioned above does not of itself indicate severity of the condition. Where development is indicated to verify diagnosis and/or severity, records may be requested to review the history and medical conditions of the patient as well as any physician contacts for management of those conditions.
“Q” Modifiers (Q7, Q8, and Q9) are utilized to denote Class A (Q7), Class B (Q8) and Class C (Q9) findings. These modifiers may be used with procedure codes 11055, 11056, 11057, 11719, 11720, 11721 or G0127. Submitting claims using Q7, Q8, or Q9 modifiers indicates the findings related to the patient’s condition. However, the provider is still responsible for documenting the findings in the patient’s record. Failure to provide documentation supporting the use of the Q modifiers on any claim may result in denial of that claim.
Hyperkeratotic Lesions Coding Criteria Procedure Code 11055, 11056, or 11057 will be included in the Medicare covered foot care service code (8101) when billed with a diagnosis from the Diagnosis List 1. Refer to the ICD-10 Diagnosis Codes attachment.
APPLICABLE CODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.
CPT Code Description
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 benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); 1 to 5
11721 Debridement of nail(s) by any method(s); 6 or more
G0127, 11055, 11056, 11057, 11719, 11720, 11721 While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits. These include:
1. 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).
2. Treatment of warts on foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.
3. 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.
4. Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. (Treatment of mycotic nails for patients without systemic illnesses may also be covered and are defined in a separate local coverage determination (LCD) for Debridement of Mycotic Nails) The following 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. The presumption of coverage is applied when the physician rendering the routine foot care has identified either (1) the Class A finding (Q7); (2) two of the Class B findings (Q8); or (3) one Class B and two Class C findings, in addition to a primary condition (Q9).
