BlueCross and BlueShield of Montana Medical Policy/Codes
Foot Care Services
Chapter: Surgery: Procedures
Current Effective Date: February 01, 2014
Original Effective Date: November 26, 2013
Publish Date: January 15, 2014
Revised Dates: January 15, 2014
Description

Foot care services include the examination, diagnosis, and medical or surgical treatment of conditions and dysfunctions of the foot.

Routine Foot Care may include the following:

  • The cutting or removal of corns, calluses or plantar keratosis,
  • The trimming of nails, (including mycotic nails),
  • Other hygienic and preventive/maintenance care in the realm of self-care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedfast patients, AND/OR
  • Any services performed in the absence of localized illness, injury or symptoms involving the foot.

The following are increased risk factors for ulcers or amputations:

  • Diabetes mellitus,
  • Vision impairment,
  • Diabetic nephropathy, (especially patients on dialysis)
  • Poor glycemic control,
  • Cigarette smoking,
  • Peripheral neuropathy with loss of protective sensation,
  • Altered biomechanics (in the presence of neuropathy),
  • Evidence of increased pressure (erythema, hemorrhage under a callus),
  • Foot or bony deformity,
  • Peripheral vascular disease (decreased or absent pulses),
  • History of ulcers or amputation,
  • Severe nail pathology,
  • Arteriosclerosis obliterans, AND/OR
  • Buerger’s disease.

Symptoms associated with comorbidities may include:

  • Ischemic ulcer,
  • Intermittent claudication or other ischemic-type pain,
  • Non-palpable pedal pulses,
  • Decreased hair growth in the leg,
  • Nail overgrowth,
  • Abnormal skin texture (thinning),
  • Abnormal skin color,
  • Abnormal skin temperature (i.e., cold feet), AND/OR
  • Pigmentation changes.

In most situations, a family member or nursing staff may perform these services. However, in patients with conditions associated with inadequate circulation to the extremities, routine foot services may require the services of a professional (for example, a podiatrist or physician) in order to limit the potential complications of impaired wound healing and infection.

Preventive foot-care practice, such as annual foot examination by multidisciplinary health care providers, can substantially reduce the risk in patients with foot problems caused by underlying disease, foot deformities, and alteration in the normal perfusion to the lower leg and foot. 

If an infection, such as onychomycosis, occurs to the nails, conventional medical treatment requires pharmacological therapy, mechanical intervention or surgical treatment. 

Foot ulcers and amputations are a major cause of morbidity, disability, as well as emotional and physical costs for patients with high-risk foot related conditions. Early recognition and management of independent risk factors can prevent or delay the onset of adverse outcomes.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Routine foot care for patients with comorbidities (e.g., arteriosclerosis obliterans, peripheral artery or vascular disease, Buerger’s disease, diabetes mellitus) which can impede healing and can jeopardize life or limb may be considered medically necessary when the following criteria are met:

  • Services are delivered by a qualified provider of foot care services (a qualified provider is one who is licensed and is performing within the scope of licensure), AND
  • Services are considered specific, effective, and reasonable for the patient’s diagnosis and condition.

Routine foot care, (hygiene and preventive maintenance such as trimming of corns, calluses, or nails), does not usually require the skills of a qualified provider of foot care services, and is considered not medically necessary.

Manual debridement and electric grinding procedures of the toenails may be considered medically necessary, when performed by a qualified provider, for the following conditions:

  • Onychomycosis (mycotic nails), when confirmed by positive culture or by documented signs and symptoms, which substantiate difficulty in wearing shoes or in ambulation.
  • Onychauxis (club nail), onychodystrophy (deformed nail), and onychogryposis (thickened nail), when such conditions result in paronychia or pain from gross distortions of the nail, as well as difficulty in wearing shoes or in ambulation.

Laser treatment of onychomycosis is considered experimental, investigational and/or unproven; lasers used include, but are not limited to, NoveonTM by Nomir Medical Technologies, Inc. and PinPointe™FootLaser™ by PinPointe USA, Inc.

NOTE: Treatment of medical conditions and symptomatic diseases of the feet is not routine foot care. These conditions may include but are not limited to the following examples: bunion, hammer toe, plantar fasciitis, neuroma and plantar warts.

Rationale

Preventive foot-care practice, such as annual foot examination by multidisciplinary professionals, can substantially reduce the risk in patients with foot problems caused by underlying disease, foot deformities, and alteration in the normal perfusion to the lower leg and foot. 

2009 Update

A search of peer-reviewed literature through April 2009 identified no well-designed published randomized clinical trials that prove clinical efficacy of laser treatment of nail infection.  The United States Food and Drug Administration (FDA) granted 510-k approval for the NoveonTM laser “for use in surgical procedures of the skin, subcutaneous tissues and nasal passages in dermatology, plastic surgery, podiatry and otolaryngology…” with indications “requiring incision, excision, vaporization, hemostasis, or coagulation of soft tissue”.  It is currently in clinical trials for use in treating onychomycosis.

The American Diabetes Association Standards of Medical Care in Diabetes (2009) state the following:

  • All patients with diabetes should have an annual comprehensive foot examination including inspection, assessment of foot pulses, and testing for loss of protective sensation to identify risk factors predictive of ulcers and amputations.
  • General foot self-care education should be provided to all patients with diabetes.
  • A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation.
  • Patients who smoke, have loss of protective sensation and structural abnormalities, or have history of prior lower-extremity complications, should be referred to foot care specialists for ongoing preventative care and life-long surveillance.
  • Screening for peripheral arterial disease (PAD) should include a history for claudication, an assessment of the pedal pulses, and consider obtaining an ankle-brachial index (ABI), as many patients with PAD are asymptomatic.
  • Patients with significant claudication or a positive ABI should be referred for further vasculature assessment and consider exercise, medications, and surgical options.

2013 Update

A search of peer reviewed literature through November 2013 did not identify any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Refer to the ICD-9-CM manual.

ICD-10 Codes

Refer to the ICD-10-CM manual.

Procedural Codes: 11055, 11056, 11057, 11719, 11720, 11721, 11730, 11732, 11740, 17999, G0127, G0245, G0246, G0247, S0390
References
  1. Warner, I.  Nursing and long-term care concerns of foot care in the elderly. Clinics in Podiatric Medicine and Surgery (2003 July) 32:S13-61.
  2. Foot Care Services. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 October) Miscellaneous Policies 9.01.01.
  3. The American Diabetes Association, Inc. Position Statement. Preventive Foot Care in Diabetes. Diabetes Care (2004 January) 27 Supplement 1:S63-4.
  4. Pogach, L., Charns, M.P., et al. The impact of policies and performance measurement upon the development of organizational coordinating strategies for chronic care delivery. American Journal of Managed Care (2004) 10:171-80.
  5. Blume, P., Wilkinson, J., et al. Treating difficult nails in diabetic patients. Podiatry Today (2006 March 1) Volume 3.
  6. FDA - Application for Noveon TM (Model LS1100-O1-0968) Dual Wavelength Laser Instrument. Food and Drug Administration – Centers for Devices and Radiologic Health (2007, November 19).  Available at http://www.fda.gov (accessed 2009 May 12).
  7. American Diabetes Association.  Standards of medical care in diabetes. Diabetes Care (2009 January) 32 Supplement 1:S13-61.
  8. Malay, D. S., Yi, S., et al. Efficacy of debridement alone versus debridement combined with topical antifungal nail lacquer for the treatment of pedal onychomycosis: a randomized, controlled trial. The Journal of Foot & Ankle Surgery (2009 May) 48(3):294-308.
  9. Foot Care Services - Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 February) Miscellaneous Policies 9.01.01.
  10. Waibel, J., Wulkan, A.J., Rudnick, A. Prospective efficacy and Safety evaluation of laser treatments with real-time temperature feedback for fungal onychomycosis. J Drugs Dermatol. 2013 Nov 1;12(11):1237-42.
  11. Gupta, A.K., Simpson, F.C. Laser therapy for onychomycosis. J Cutan Med Surg. 2013 Oct 1;17(5):301-7.
  12. American Diabetes Association. Standards of Medical Care in Diabetes--2013. Diabetes Care (2013 January) vol 36, Supplement 1: S11-S66. Available at www.care.diabetesjournals.org (Accessed 2013 November 18)
History
August 2013  New 2013 BCBSMT medical policy.
February 2014 Document updated with literature review. Coverage unchanged.
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Foot Care Services