Medicare Advisory Liaison

Routine Foot Care 101

The most common codes billed and most commonly misunderstood codes are those dealing with routine foot care. Below are the guidelines from NGS for coverage with examples of coding scenarios.  Please note for Group 1 and 4 codes you only need one diagnosis code. I never use the callus diagnosis or nail diagnosis with routine foot care except if I am using Group 2, and this is only with the three nail codes listed.  Callus codes and nail codes with Group 1 and Group 4 is not required and just confuses the carrier. For your reference, I have included the link to the entire policy at the end of this article.

Group 1 ICD-10 Codes: 205

CPT Codes: CPT codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127

Medical Necessity ICD-10 Codes Asterisk Explanation: ** For these diagnoses, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) or qualified non-physician practitioner for the treatment and/or evaluation of the complicating disease process during the six month period prior to the rendition of the routine-type service or no more than 30 days after the date of service

Example 1: A 74 year old diabetic presents with thick nails 1-5 both feet.  Absent DP pulses, loss of hair growth, thin skin.

›ICD-10 :E11.59*  Type 2 diabetes mellitus with other circulatory complications

›Date of last MD visit was within six months

›CPT 11721-Q8

›No other ICD-10 code needed

Example 2:   An 80 year old male presents with thick hallux nails and dystrophic 2-5

DP 0/4 Right       DP1/4 Left PT 0/4 Bilateral

›ICD-10: I70.91   Generalized atherosclerosis

›CPT 11720-59 & G0127 Q8

›No date of last doctors visit needed

Group 2 ICD-10: 3 codes- must be the first code listed!

CPT codes: 11719, 11720, 11721, and G0127

›Primary diagnosis :

  • B35.1 Tinea unguium
  • L60.2 Onychogryphosis
  • L60.3 Nail dystrophy

Refer to Group 3 for the secondary ICD-10-CM codes required for coverage for Group 2 CPT/HCPCS codes

*Pain, infection, or mobility problems 

Example 3: This 69 year old female relates painful and thickened nails both feet. Nails 1-5 both feet are yellow with subungual debris

›ICD-10:L60.2 Onychogryphosis

›M79.671 Pain in right foot

›M79.672 Pain in left foot

›CPT 11721

Group 3 ICD-10: 16 codes-must be second code listed

›Secondary Diagnosis required to go with Group 2 codes

›Refer to the “Indications and Limitation of Coverage and/or Medical Necessity” section of the Routine Foot Care and Debridement of Nails (LCD L33636)

Group 4 ICD-10: 95 codes

CPT codes: 11055, 11056, 11057, 11719, 11720, 11721 and G0127

Group 4 The ICD-10-CM codes in the paragraph, represent those diagnoses where the patient has evidence of neuropathy, but no vascular impairment, for which class findings modifiers are not required.

Example 4: A 66 year old female with diabetes and thick nails present with loss of protective sensation on both feet

›ICD-10: E11.49*  Type 2 diabetes mellitus with other diabetic neurological complication

›CPT 11721

›MD/DO date of last visit required

Link to the full policy below:

Routine Foot Care Policy

Dr. Jeffrey Crowhurst

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s