THIS INFORMATION HAS BE TAKEN FROM THE MEDICARE INTERNET ONLY MANUAL FOR YOUR USE.  THIS REPLACES THE PREVIOUS LCDs.

290 – Foot Care

(Rev. 1, 10 – 01 – 03)
A3-3158, B3-2323, HO-260.9, B3-4120.1

A. Treatment of Subluxation of Foot

Subluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons ligaments, or muscles of the foot. Surgical or nonsurgical treatments undertaken for the sole purpose of correcting a subluxated structure in the foot as an isolated entity are not covered.

However, medical or surgical treatment of subluxation of the ankle joint (talo-crural joint) is covered. In addition, reasonable and necessary medical or surgical services, diagnosis, or treatment for medical conditions that have resulted from or are associated with partial displacement of structures is covered. For example, if a patient has
osteoarthritis that has resulted in a partial displacement of joints in the foot, and the primary treatment is for the osteoarthritis, coverage is provided.

B. Exclusions from Coverage

The following foot care services are generally excluded from coverage under both Part A and Part B. (See §290.F and §290.G for instructions on applying foot care exclusions.)

1. Treatment of Flat Foot

The term “flat foot” is defined as a condition in which one or more arches of the foot have flattened out. Services or devices directed toward the care or correction of such conditions, including the prescription of supportive devices, are not covered.

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.

3. Supportive Devices for Feet

Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics.

C. 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. Treatment of Warts on Foot

The treatment of warts (including plantar warts) on the foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.

3. 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. (See subsection A.)

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. (See §290.G for procedural instructions.)

4. Mycotic Nails

In the absence of a systemic condition, treatment of mycotic nails may be covered.

The treatment of mycotic nails for an ambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

The treatment of mycotic nails for a nonambulatory patient is covered only when the physician attending the patient’s mycotic condition documents that (1) there is clinical evidence of mycosis of the toenail, and (2) the patient suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.

For the purpose of these requirements, documentation means any written information that is required by the carrier in order for services to be covered. Thus, the information submitted with claims must be substantiated by information found in the patient’s medical record. Any information, including that contained in a form letter, used for documentation purposes is subject to carrier verification in order to ensure that the information adequately justifies coverage of the treatment of mycotic nails.

D. Systemic Conditions That Might Justify Coverage

Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might justify coverage for routine foot care.

• Diabetes mellitus *
• Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
• Buerger’s disease (thromboangiitis obliterans)
• 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) *
  • Associated with traumatic injury
  • Associated with leprosy or neurosyphilis
  • Associated with hereditary disorders
    • Hereditary sensory radicular neuropathy
    • Angiokeratoma corporis diffusum (Fabry’s)
    • Amyloid neuropathy

When the patient’s condition is one of those designated by an asterisk (*), routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

E. Supportive Devices for Feet

Orthopedic shoes and other supportive devices for the feet generally are not covered. However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to diabetics.

F. Presumption of Coverage

In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement.
For purposes of applying this presumption the following findings are pertinent:

Class A Findings

Nontraumatic amputation of foot or integral skeletal portion thereof.

Class B Findings

Absent posterior tibial pulse;
Advanced trophic changes as: hair growth (decrease or absence) nail changes
(thickening) pigmentary changes (discoloration) skin texture (thin, shiny) skin
color (rubor or redness) (Three required); and
Absent dorsalis pedis pulse.

Class C Findings

Claudication;
Temperature changes (e.g., cold feet);
Edema;
Paresthesias (abnormal spontaneous sensations in the feet); and
Burning.

The presumption of coverage may be applied when the physician rendering the routinefoot care has identified:

1. A Class A finding;
2. Two of the Class B findings; or
3. One Class B and two Class C findings.

Cases evidencing findings falling short of these alternatives may involve podiatric treatment that may constitute covered care and should be reviewed by the intermediary’s medical staff and developed as necessary.

For purposes of applying the coverage presumption where the routine services have been rendered by a podiatrist, the contractor may deem the active care requirement met if the claim or other evidence available discloses that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the rendition of the routine-type services. The intermediary may also accept the podiatrist’s statement that the diagnosing and treating M.D. or D.O. also concurs with the podiatrist’s findings as to the severity of the peripheral involvement indicated.

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.

G. Application of Foot Care Exclusions to Physician’s Services

The exclusion of foot care is determined by the nature of the service. Thus, payment for an excluded service should be denied whether performed by a podiatrist, osteopath, or a doctor of medicine, and without regard to the difficulty or complexity of the procedure.

When an itemized bill shows both covered services and noncovered services not integrally related to the covered service, the portion of charges attributable to the noncovered services should be denied. (For example, if an itemized bill shows surgery for an ingrown toenail and also removal of calluses not necessary for the performance of
toe surgery, any additional charge attributable to removal of the calluses should be denied.)

In reviewing claims involving foot care, the carrier should be alert to the following exceptional situations:

1. Payment may be made for incidental noncovered services performed as a necessary and integral part of, and secondary to, a covered procedure. For example, if trimming of toenails is required for application of a cast to a fractured foot, the carrier need not allocate and deny a portion of the charge for the trimming of the nails. However, a separately itemized charge for such excluded service should be disallowed. When the primary procedure is covered the administration of anesthesia necessary for the performance of such procedure is also covered.
2. Payment may be made for initial diagnostic services performed in connection with a specific symptom or complaint if it seems likely that its treatment would be covered even though the resulting diagnosis may be one requiring only noncovered care.

The name of the M.D. or D.O. who diagnosed the complicating condition must be submitted with the claim. In those cases, where active care is required, the approximate date the beneficiary was last seen by such physician must also be indicated.
NOTE: Section 939 of P.L. 96-499 removed “warts” from the routine foot care exclusion effective July 1, 1981.

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 careshould 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 in §D above does not of itself indicate the severity of the condition. Where development is indicated to verify diagnosis and/or severity the carrier should follow existing claims processing practices, which may include review of carrier’s history and medical
consultation as well as physician contacts.

The rules in §290.F concerning presumption of coverage also apply.

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. Carriers must instruct physicians to use the most appropriate code available when billing for
routine foot care.