INDIANA HEALTH COVERAGE PROGRAMS

Transcription

1 INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding updates, inclusion of a code on the code tables does not necessarily indicate current coverage. See IHCP Banner Pages and Bulletins and the IHCP Fee Schedules for updates to coding, coverage, and benefit information. For information about using these code tables, see the Podiatry Services provider reference module. Table 1 Covered s for Podiatrists (Specialty 140) Table 2 s for Routine Foot Care Table 3 ICD-10 Diagnosis Codes for Routine Foot Care Coverage Table 4 s for Therapeutic Shoes for Severe Diabetic Foot Disease Table 1 Covered s for Podiatrists (Specialty 140) Drainage of abscess Drainage of multiple abscess Drainage of blood or fluid accumulation Aspiration of abscess, blood accumulation, blister, or cyst Removal of inflamed or infected skin, up to 10% of body surface Removal of inflamed or infected skin Removal of skin and tissue first 20 sq cm or less Removal of skin and/or muscle first 20 sq cm or less Removal of skin and bone first 20 sq cm or less Removal of skin and tissue Removal of skin and/or muscle Removal of skin and bone Removal of single thickened skin growth Removal of 2 to 4 thickened skin growths Removal of more than 4 thickened skin growths Biopsy of single growth of skin and/or tissue Published: October 16,

2 Table 1 Covered s for Podiatrists (Specialty 140) Biopsy of each additional growth of skin and/or tissue Shaving of 0.5 centimeters or less skin growth of scalp, neck, hands, feet, or genitals Shaving of 0.6 centimeters to 1.0 centimeters skin growth of scalp, neck, hands, feet, or genitals Shaving of 1.1 to 2.0 centimeters skin growth of scalp, neck, hands, feet, or genitals Shaving of over 2.0 centimeters skin growth of scalp, neck, hands, feet, or genitals Removal of growth (0.5 centimeters or less) of the scalp, neck, hands, feet, or genitals Removal of growth (0.6 to 1.0 centimeters) of the scalp, neck, hands, feet, or genitals Removal of growth (1.1 to 2.0 centimeters) of the scalp, neck, hands, feet, or genitals Removal of growth (2.1 to 3.0 centimeters) of the scalp, neck, hands, feet, or genitals Removal of growth (3.1 to 4.0 centimeters) of the scalp, neck, hands, feet, or genitals Removal of growth (over 4.0 centimeters) of the scalp, neck, hands, feet, or genitals Trimming of fingernails or toenails Removal of tissue from 1 to 5 finger or toe nails Removal of tissue from 6 or more finger or toe nails Separation of nail plate from nail bed Separation of nail plate from nail bed Removal of blood accumulation between nail and nail bed Removal of nail Biopsy of finger or toe nail Repair of finger or toe nail bed Removal of skin of finger or toe nail Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms and/or legs Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/or legs Repair of separation of wound closure Repair of wound (2.5 centimeters or less) of neck, hands, feet, and/or genitals Second repair of surgical wound Tissue transfer repair of wound (10 sq centimeters or less) of the forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, and/or feet Tissue transfer repair of wound (10.1 to 30.0 sq centimeters) of the forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, and/or feet Repair of tissue loss of finger or toe Preparation of graft site at trunk, arms, or legs (first 100 sq cm or 1% body area infants and children) Preparation of graft site of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or 1% body area of infants and children) Relocation of skin (100 sq cm or less) for tissue cultured graft Published: October 16,

3 Table 1 Covered s for Podiatrists (Specialty 140) Skin graft (2 centimeters) to tip of finger or toe Skin graft at trunk, arms, or legs (first 100 sq cm or less, or 1% body are of infants and children) Skin graft at trunk, arms, or legs (first 100 sq cm or less, or 1% body area of infants and children) Skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children) Skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children) Skin graft at trunk, arms, or legs (first 100 sq cm or less, or 1% body area of infants and children) Skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or less, or 1% body area of infants and children) Skin graft at trunk, arms, or legs (first 25 sq centimeters or less) Skin graft of face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 25 sq centimeters or less) Relocation of patient skin (20 sq centimeters or less) to scalp, arms, and/or legs Relocation of patient skin to forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, and/or feet (20 sq centimeters or less) Application of skin substitute (wound surface up to 100 sq cm) to trunk, arms, or legs (first 25 sq cm or less) Application of skin substitute (wound surface up to 100 sq cm) to trunk, arms, or legs Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs (first 100 sq cm or 1% body area of infants and children) Application of skin substitute (wound surface greater or equal to 100 sq cm) to trunk, arms, or legs Application of skin substitute (wound surface up to 100 sq cm) to face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 25 sq cm or less) Application of skin substitute (wound surface up to 100 sq cm) to face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes Application of skin substitute (wound surface great than or equal to 100 sq cm) to face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes (first 100 sq cm or 1% body area of infants and children) Application of skin substitute (wound surface great than or equal to 100 sq cm) to face, scalp, eyelids, mouth, neck, ears, eye region, genitals, hands, feet, and/or multiple fingers or toes Destruction of skin growth Destruction of 2-14 skin growths Destruction of 15 or more skin growths Destruction of up to 14 skin growths Destruction of 15 or more skin growths Application of chemical agent to excessive wound tissue Published: October 16,

4 Table 1 Covered s for Podiatrists (Specialty 140) Exploration of penetrating wound of arm or leg Biopsy of bone using needle or trocar Deep biopsy of bone using needle or trocar Biopsy of bone, open procedure Injections of tendon sheath, ligament, or muscle membrane Injections of tendon attachment to bone Injections of trigger points in 1 or 2 muscles Aspiration and/or injection of small joint or joint capsule Aspiration and/or injection of medium joint or joint capsule Aspiration and/or injection of large joint or joint capsule Aspiration and/or injection of cysts Removal of bone implant Removal of deep bone implant Application of uniplane external bone fixation on one arm or leg Application of multiplane external bone fixation system on one arm or leg Removal of external bone fixation under anesthesia Application of multiplane external bone fixation system on one arm or leg Application of multiplane external bone fixation system Small bone graft harvest Incision of tissue of front and/or lateral muscle compartments of lower leg Incision of tissue of rear muscle compartments of lower leg Incision of tissue of front and/or lateral and rear muscle compartments of lower leg Drainage of abscess or blood collection at lower leg or ankle Drainage of infected fluid-filled sac (bursa) of leg or ankle Incision of Achilles tendon, accessed through the skin using local anesthetic Incision of Achilles tendon, accessed through the skin requiring general anesthesia Incision of bone of leg or ankle Exploration, drainage, or removal of foreign body of ankle Release of ankle joint capsule Exploration of ankle joint Removal of membrane covering of ankle joint Removal of membrane covering ankle joint and tendon Removal of growth of leg and/or ankle tendon lining or capsule Removal or scraping of cyst or growth of either bone of lower leg Removal or scraping of cyst or growth of either bone of lower leg with patient-derived bone graft Removal or scraping of cyst or growth of either bone of lower leg with donor bone graft Published: October 16,

5 Table 1 Covered s for Podiatrists (Specialty 140) Partial removal of shin bone Partial removal of leg bone Repair of ruptured Achilles tendon, open or through skin procedure Repair of ruptured Achilles tendon with graft, open or through skin procedure Repair of ruptured Achilles tendon Repair of leg tendon Repair of leg tendon Repair of leg tendon Repair of leg tendon Repair of dislocating lower leg tendons Repair of dislocating lower leg tendons Release of leg and/or ankle tendon Release of multiple tendons of leg and/or ankle Lengthening or shortening of tendon of leg or ankle Lengthening or shortening of multiple tendons of leg or ankle Lengthening of calf muscle Transplant of tendon and muscle rerouting at lower leg or ankle Transplant of deep tendon with muscle rerouting at lower leg or ankle Transplant of tendon and muscle rerouting at lower leg or ankle Repair of disrupted collateral ligament of ankle Repair of disruption of both collateral ligaments of ankle Repair of disrupted collateral ligament of ankle Repair of ankle joint Repair of ankle joint with prosthesis Repair of ankle joint with revision of prosthesis Removal of ankle implant Incision of shin bone Incision of leg bone Incision of shin and outer lower leg bones Closed treatment of broken ankle Closed treatment of broken ankle with manipulation Open treatment of broken ankle Closed treatment of broken ankle Closed treatment of broken ankle with manipulation Open treatment of broken ankle Closed treatment of broken ankle Closed treatment of broken ankle with manipulation Published: October 16,

6 Table 1 Covered s for Podiatrists (Specialty 140) Open treatment of broken ankle Closed treatment of broken ankle Closed treatment of broken ankle with manipulation Open treatment of broken ankle Closed treatment of broken ankle Closed treatment of broken ankle with manipulation Open treatment of broken ankle Open treatment of broken ankle Closed treatment of fracture of lower weight bearing joint of shin bone Closed treatment of fracture of lower weight bearing joint of shin bone with traction and/or manipulation Open treatment of ligament tear at ankle joint Closed treatment of knee joint dislocation Closed treatment of knee joint dislocation under anesthesia Closed treatment of ankle dislocation Closed treatment of ankle dislocation under anesthesia Open treatment of ankle dislocation Open treatment of ankle dislocation with repair or internal or external hardware Manipulation of ankle under general anesthesia Fusion of ankle joint, open procedure Drainage of fluid-filled sac (bursa) of foot Drainage of fluid-filled sac (bursa) of foot Drainage of multiple fluid-filled sacs (bursa) of foot Incision of foot bone Incision of tissues of muscle compartment of foot and/or toe Repair of toe tendon, accessed through the skin Repair of multiple toe tendons, accessed through the skin Incision of foot bone at ankle joint with exploration, drainage, or removal of foreign body Exploration, drainage, or removal of foreign body of foot Exploration, drainage, or removal of foreign body of toe joint Release of nerve between tissue and bone of foot Removal (1.5 centimeters or greater) tissue growth beneath the skin of foot or toe Removal (1.5 centimeters or greater) muscle growth of foot or toe Removal (less than 1.5 centimeters) tissue growth beneath the skin of foot or toe Removal (less than 1.5 centimeters) muscle growth of foot or toe Removal (less than 3 centimeters) tissue growth of foot or toe Removal (3 centimeters or greater) tissue growth of foot or toe Published: October 16,

7 Table 1 Covered s for Podiatrists (Specialty 140) Partial removal of tissue at sole of foot Removal of tissue at sole of foot Removal of joint lining of foot bone at ankle joint Removal of joint lining at first joint of toe Removal of fibrous nerve growth from between toes Removal of foot tendon Removal of foot tendon Removal of growth of tendon covering or joint capsule of foot Removal of growth of tendon covering or joint capsule of toes Removal or scraping of bone cyst or growth of heel bone Removal or scraping of bone cyst or growth of heel bone with graft from hip or other bone Removal or scraping of bone cyst or growth of heel bone with donor bone graft Removal or scraping of bone cyst or growth of ankle bone Removal or scraping of bone cyst or growth of ankle bone with graft from hip or other bone Removal or scraping of bone cyst or growth of foot bone with donor bone graft Removal or scraping of bone cyst or growth of toes Removal of bunion at fifth toe joint Removal of bone at fifth toe joint Removal of bones at second, third, or fourth toe joints Removal of foot bone at fifth toe joint Removal of multiple foot bones Removal of abnormal bones at ankle joint Removal of heel bone Removal of heel bone spur Partial removal of foot or heel bone Partial removal of foot or heel bone Partial removal of toe bone Removal of bone at base of toe Removal of ankle joint bone Removal of foot bone Removal of toe Partial removal of toe bone joints Partial removal of toe joint Extensive removal of bone growth, middle portion of foot Removal of bone growth of foot Removal of bone growth of toe Removal of foreign body of foot tissue, accessed beneath the skin Published: October 16,

8 Table 1 Covered s for Podiatrists (Specialty 140) Removal of foreign body of foot tissue Removal of foreign body of foot tissue Repair of foot tendon Repair of foot tendon Repair of foot tendon Repair of foot tendon Release of foot tendon Release of multiple foot tendons Release of foot tendon Release of multiple tendons in foot Incision to lengthen foot tendons, open procedure Incision to lengthen toe tendon, open procedure Incision to release foot tendon, open procedure Advancement of ankle tendon with removal of ankle joint bone Incision to release foot muscle tendon Incision to release tissue and muscle of sole of foot Incision of ankle joint capsule to correct foot deformity Correction of foot deformity with incision of ankle joint capsule and tendon lengthening Correction of foot deformity with incision of ankle joint capsule and lengthening of tendons Release of capsule of ankle joint Incision of joint capsule of foot and toe Incision of toe joint capsule Creation of web space between toes Correction of toe joint deformity Correction of fifth toe joint deformity Removal of foot bone spur Correction of rigid deformity of first joint of big toe Correction of rigid deformity of first joint of big toe using implant Correction of bunion Correction of bunion Correction of bunion Correction of bunion Correction of bunion Correction of bunion Incision to repair heel bone Incision to repair ankle joint bone Incision to correct foot or ankle bones Published: October 16,

9 Table 1 Covered s for Podiatrists (Specialty 140) Incision to correct foot or ankle bones with patient-derived bone graft Incision to straighten big toe bone Incision to straighten big toe bone with patient-derived bone graft Incision to straighten toe bone Incision to straighten toe bones Incision to straighten big toe bone Incision to straighten toe bone Reconstruction of soft tissue angular deformity of toe Removal of small bone underlying long bone of foot at toe joint Repair of non-healed foot bone Repair of non-healed foot bone Reconstruction of abnormal toe Reconstruction of abnormal toe Reconstruction of extra toes Removal of congenital web space deformity of toes Reconstruction of congenitally deformed foot Closed treatment of broken heel bone Closed treatment of broken heel bone with manipulation Insertion of hardware to broken heel bone with manipulation, accessed through the skin Open treatment of broken heel bone Open treatment of broken heel bone with graft Closed treatment of broken ankle joint bone Closed treatment of broken ankle joint bone with manipulation Insertion of hardware to broken ankle joint with manipulation, accessed through the skin Open treatment of broken heel bone Implantation of donor cartilage cells into foot joint with grafts, open procedure Treatment of broken foot bone Treatment of broken foot bone Insertion of hardware to broken foot joint with manipulation, accessed through the skin Open treatment of broken foot bone Closed treatment of broken foot bone Closed treatment of fracture of foot with manipulation Insertion of hardware to broken foot bone with manipulation, accessed through the skin Open treatment of broken foot bone Closed treatment of broken great toe Closed treatment of broken great toe with manipulation Insertion of hardware to broken great toe with manipulation, accessed through the skin Published: October 16,

10 Table 1 Covered s for Podiatrists (Specialty 140) Open treatment of broken great toe Closed treatment of broken toe Closed treatment of broken toe with manipulation Open treatment of broken toe Closed treatment of broken foot bone Open treatment of broken foot bone Closed treatment of ankle joint bone dislocation Closed treatment of ankle joint bone dislocation under anesthesia Insertion of hardware to foot joint dislocation with manipulation, accessed through the skin Open treatment of dislocated foot joint Closed treatment of dislocated foot joint Closed treatment of dislocated foot joint under anesthesia Insertion of hardware to foot joint dislocation with manipulation, accessed through the skin Open treatment of dislocated foot joint Closed treatment of dislocated foot joint Closed treatment of dislocated foot joint under anesthesia Insertion of hardware to foot joint dislocation with manipulation, accessed through the skin Open treatment of dislocated foot joint Closed treatment of dislocated foot bone Closed treatment of dislocated foot bone under anesthesia Insertion of hardware to foot bone dislocation with manipulation, accessed through the skin Open treatment of dislocated foot bone Closed treatment of dislocation of toe joint Closed treatment of dislocation of toe joint under anesthesia Insertion of hardware to toe joint dislocation with manipulation, accessed through the skin Open treatment of toe joint dislocation Fusion of ankle joint Fusion of ankle joint Fusion of foot joint Fusion of multiple foot joints Fusion of multiple foot joints Fusion of foot joint Fusion of foot joint Fusion of great toe Fusion of great toe Fusion of great toe Amputation of foot Published: October 16,

11 Table 1 Covered s for Podiatrists (Specialty 140) Amputation of foot Amputation of foot Amputation of foot Amputation of foot Application of short leg cast (below knee to toes) Application of short leg cast (below knee to toes); walking or ambulatory type Application of knee cap tendon bearing cast Adding walker to previously applied cast Application of rigid total contact leg cast Application of long or short leg clubfoot cast Application of short leg splint (calf to foot) Strapping of ankle and/or foot Strapping of toes Strapping; Unna boot Application of vein wound compression system lower leg below knee including ankle and foot Removal or bivalving of gauntlet, boot, or body cast Casting or strapping procedure Removal of bone defect of shin and/or ankle using an endoscope Removal and repair of large bone defect of shin or ankle using an endoscope Repair of fibrous tissue of foot using an endoscope Removal of loose or foreign body of ankle using an endoscope Partial removal of ankle joint lining using an endoscope Partial removal of ankle joint lining using an endoscope Removal of dead or infected ankle joint tissue using an endoscope Fusion of ankle joint using an endoscope Removal of loose or foreign body of ankle joint at heel bones using an endoscope Removal of lining of foot joint using an endoscope Removal of dead or infected foot joint tissue using an endoscope Fusion of foot joint using an endoscope Injection of anesthetic agent, other peripheral nerve or branch Injections of anesthetic and/or steroid drug into nerve of foot Destruction of nerve of foot Destruction of peripheral nerve or branch Release of nerve of finger Release of nerve of hand or foot Release of nerve of arm or leg, open procedure Published: October 16,

12 Table 1 Covered s for Podiatrists (Specialty 140) Release of nerve at sole of foot Removal of growth of skin nerve Removal of growth of finger or toe nerve Removal of growth of finger or toe nerve Removal of growth of hand or foot nerve Removal of growth of hand or foot nerve Implantation of nerve end into bone or muscle X-ray of lower leg, 2 views X-ray of ankle, 2 views X-ray of ankle, minimum of 3 views Radiological supervision and interpretation x-ray of ankle joint X-ray of foot, 2 views X-ray of foot, minimum of 3 views X-ray of heel, minimum of 2 views X-ray of toes, minimum of 2 views MRI scan of leg MRI scan of leg with contrast MRI scan of leg joint MRI scan of leg joint with contrast Ultrasound of leg or arm Ultrasound of arm or leg Ultrasonic guidance imaging supervision and interpretation for insertion of needle Ultrasound study of arteries of both arms and legs Ultrasound study of arteries of both arms and legs, three or more levels Removal of tissue from wounds per session, 20 cm or less Removal of tissue from wounds per session, each additional 20 cm or less Removal of tissue from wounds per session Negative pressure wound therapy, surface area less than or equal to 50 square centimeters, per session Self-management education & training, face-to-face, 1 patient Self-management education & training, face-to-face, 2-4 patients Self-management education & training, face-to-face, 5-8 patients Handling and/or conveyance of specimen for transfer from physician office to laboratory New patient office or other outpatient visit, typically 10 minutes New patient office or other outpatient visit, typically 20 minutes New patient office or other outpatient visit, typically 30 minutes Established patient office or other outpatient visit, typically 5 minutes Published: October 16,

13 Table 1 Covered s for Podiatrists (Specialty 140) Established patient office or other outpatient visit, typically 10 minutes Established patient office or other outpatient visit, typically 15 minutes Initial hospital inpatient care, typically 30 minutes per day Subsequent hospital inpatient care, typically 15 minutes per day Subsequent hospital inpatient care, typically 25 minutes per day Initial nursing facility visit, typically 25 minutes per day Subsequent nursing facility visit, typically 10 minutes per day Subsequent nursing facility visit, typically 15 minutes per day New patient assisted living visit, typically 20 minutes New patient assisted living visit, typically 30 minutes Established patient assisted living visit, typically 15 minutes New patient home visit, typically 20 minutes Established patient home visit, typically 15 minutes Laboratory procedures are reimbursable for podiatrist as allowed by provider CLIA certification on file A5500 A5501 A5503 A5504 A5505 A5506 A5507 A5508 A5510 A5512 A5513 G0108 U6 For diabetics only, fitting (including follow-up) custom preparation and supply of off-theshelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient s foot (custom molded shoe), per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe For diabetics only, direct formed, compression molded to patient s foot without external heat source, multiple-density insert(s) prefabricated, per shoe For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each Diabetes outpatient self-management training services, individual, per 30 minutes Published: October 16,

14 Table 1 Covered s for Podiatrists (Specialty 140) G0109 U6 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes G0127 J0670 J0702 J1020 J1030 J1040 J1100 J2920 J3301 K0903 L1902 L1906 L1910 L1930 L1932 L1940 L1960 L1970 L1971 L2210 L2232 L2270 L2275 L2280 L2330 L2340 L2350 L2370 Trimming of dystrophic nails, any number Injection, mepivacaine hydrochloride, per 10 ml Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg Injection, methylprednisolone acetate, 20 mg Injection, methylprednisolone acetate, 40 mg Injection, methylprednisolone acetate, 80 mg Injection, dexamethasone sodium phosphate 1 mg Injection, methylprednisolone sodium succinate, up to 40 mg Injection, triamcinolone acetonide, not otherwise specified, 10 mg For diabetics only, multiple density insert, made by direct carving with CAM technology from a rectified CAD model created from a digitized scan of the patient, total contact with patient s foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment Ankle foot orthosis, plastic or other material, custom fabricated Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated Ankle foot orthosis, plastic with ankle joint, custom fabricated Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only Addition to lower extremity, varus/valgus correction ( T ) strap, padded/lined or malleolus pad Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined Addition to lower extremity, molded inner boot Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only Addition to lower extremity, pre-tibial shell, molded to patient model Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB AFO orthoses) Addition to lower extremity, Patten bottom Published: October 16,

15 Table 1 Covered s for Podiatrists (Specialty 140) L2397 L2755 L2820 L3000 L3001 L3002 L3010 L3020 L3030 L3040 L3060 L3170 L3219 L3224 L3310 L3350 L4205 L4350 L4360 L4361 L4386 L4396 L4397 L4631 L5000 Q4100 Q4101 Q4102 Addition to lower extremity orthosis, suspension sleeve Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only Addition to lower extremity orthosis, soft interface for molded plastic, below knee section Foot, insert, removable, molded to patient model, UCB type, Berkeley shell, each Foot insert, removable, molded to patient model, Spenco, each Foot insert, removable, molded to patient model, Plastazote or equal, each Foot, insert, removable, molded to patient model, longitudinal arch support, each Foot, insert, removable, molded to patient model, longitudinal/metatarsal support, each Foot, insert, removable, formed to patient foot, each Foot, arch support, removable, premolded, longitudinal, each Foot, arch support, removable, premolded, longitudinal/metatarsal, each Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each Orthopedic footwear, men s shoes, oxford, each Orthopedic footwear, woman s shoe, oxford, used as an integral part of a brace (orthosis) Lift, elevation, heel and sole, neoprene, per inch Heel wedge Repair of orthotic device, labor component, per 15 minutes Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated Partial foot, shoe insert with longitudinal arch, toe filler Skin substitute, not otherwise specified Apligraf, per square centimeter Oasis wound matrix, per square centimeter Published: October 16,

16 Table 1 Covered s for Podiatrists (Specialty 140) Q4103 Q4104 Q4105 Q4106 Q4107 Q4108 Q4110 Q4111 Q4112 Q4113 Q4114 Q4115 Q4116 Q4117 Q4118 Q4121 Q4122 Q4123 Q4124 Q4125 Q4126 Q4127 Q4128 Q4130 Q4131 Q4132 Q4133 Q4134 Q4135 Q4136 Q4137 Q4138 Q4139 Q4140 Q4141 Q4142 Oasis burn matrix, per square centimeter Integra bilayer matrix wound dressing (BMWD), per square centimeter Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per square centimeter Dermagraft, per square centimeter Graftjacket, per square centimeter Integra matrix, per square centimeter Primatrix, per square centimeter Gammagraft, per square centimeter Cymetra, injectable, 1 cc Graftjacket Xpress, injectable, 1 cc Integra flowable wound matrix, injectable, 1 cc Alloskin, per square centimeter Alloderm, per square centimeter Hyalomatrix, per square centimeter MatriStem MicroMatrix, 1 mg Theraskin, per square centimeter Dermacell, per square centimeter Alloskin RT, per square centimeter Oasis Ultra Tri-Layer Wound Matrix, per square centimeter Arthroflex, per square centimeter Memoderm, DermaSpan, TranZgraft or InteguPly, per square centimeter Talymed, per square centimeter FlexHD, AlloPatch HD, or Matrix HD, per square centimeter StratticeTM, per square centimeter EpiFix or EpiCord, per square centimeter Grafix Core and GrafixPL Core, per square centimeter Grafix Prime and GrafixPL Prime, per square centimeter hmatrix, per square centimeter Mediskin, per square centimeter E-Z Derm, per square centimeter AmnioExCel or BioDExCel, per square centimeter BioDfence DryFlex, per square centimeter AmnioMatrix or biodmatrix, injectable, 1 cc BioDfence, per square centimeter Alloskin AC, per square centimeter XCM Biologic tissue matrix, per square centimeter Published: October 16,

17 Table 1 Covered s for Podiatrists (Specialty 140) Q4143 Q4145 Q4146 Q4147 Q4148 Q4149 Q4150 Q4151 Q4152 Q4153 Q4154 Q4155 Q4156 Q4157 Q4158 Q4159 Q4160 Q4161 Q4162 Q4163 Q4164 Q4165 Q4166 Q4167 Q4168 Q4169 Q4170 Q4171 Q4172 Q4173 Q4174 Q4175 Q4176 Q4177 Q4178 Q4179 Q4180 Repriza, per square centimeter EpiFix, injectable, 1 mg Tensix, per square centimeter Architect, Architect PX, or Architect FX, extracellular matrix, per square centimeter Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per square centimeter Excellagen, 0.1 cc Allowrap DS or Dry, per square centimeter Amnioband or Guardian, per square centimeter Dermapure, per square centimeter Dermavest and Plurivest, per square centimeter Biovance, per square centimeter NeoxFlo or ClarixFlo, 1 mg Neox 100 or Clarix 100, per square centimeter Revitalon, per square centimeter Kerecis Omega3, per square centimeter Affinity, per square centimeter Nushield, per square centimeter bio-connekt wound matrix, per square centimeter WoundEx Flow, BioSkin Flow, 0.5 cc WoundEx, BioSkin, per square centimeter Helicoll, per square centimeter Keramatrix, per square centimeter Cytal, per square centimeter Truskin, per square centimeter Amnioband, 1 mg Artacent wound, per square centimeter Cygnus, per square centimeter Interfyl, 1 mg Puraply or PuraPly AM, per square centimeter PalinGen or PalinGen XPlus, per square centimeter PalinGen or ProMatrX, 0.36 mg per 0.25 cc Miroderm, per square centimeter NeoPatch, per square centimeter Floweramnioflo, 0.1 cc Floweramniopatch, per square centimeter Flowerderm, per square centimeter Revita, per square centimeter Published: October 16,

18 Q4181 Q4182 Table 1 Covered s for Podiatrists (Specialty 140) Amnio wound, per square centimeter TransCyte, per square centimeter October 10, 2018, update: Added (effective July 1, 2018): Table Revision History August 3, 2018, update: Added (effective August 3, 2018): 11100, 11101, 11760, 12001, 12002, 12020, 12041, 13160, 14040, 14041, 14350, 15002, 15004, 15040, 15050, 15100, 15110, 15115, 15120, 15130, 15135, 15150, 15155, 15220, 15240, , 17000, 17003, 17004, 17250, 20103, 20220, 20225, 20240, 20612, 20670, 20680, 20690, 20692, 20694, 20696, 20697, 20900, 27600, 27601, 27602, , 27610, 27612, 27620, 27625, 27626, 27630, 27635, 27637, 27638, 27640, 27641, 27650, 27652, 27654, 27658, 27659, 27664, 27665, 27675, 27676, 27680, 27681, , , 27695, 27696, 27698, 27700, , 27707, 27709, , , 27786, 27788, 27792, 27808, 27810, 27814, 27816, 27818, , , 27840, 27842, 27846, 27848, 27860, 27870, 28208, 28291, 28295, 29700, 29799, 64640, 64774, 64776, 64778, 64782, 64783, 64787, 73590, Q4100 Q4108, Q4110 Q4118, Q4121 Q4128, Q4130 Q4143, Q4145 Q4182 Removed (correction): 29900, April 1, 2018, updated: Added (effective April 1, 2018): K0903 January 1, 2018, update: Removed (correction): 11752, 28290, 28293, November 17, 2017, update: Added (effective August 11, 2017): G0108 U6, G0109 U6 August 11, 2017, update: Code set created (effective August 11, 2017) Table 2 s for Routine Foot Care Reviewed/Updated: October 1, Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions Trimming of nondystrophic nails, any number Debridement of nail(s) by any method(s); 1 to Debridement of nail(s) by any method(s); 6 or more G0127 Trimming of dystrophic nails, any number Published: October 16,

19 Table 3 ICD-10 Diagnosis Codes for Routine Foot Care Coverage Diagnosis Code Reviewed/Updated: October 1, 2017 B35.1 Tinea unguium E08.00, E08.01, E08.10, E08.11, E08.21, E08.22, E08.29, E08.311, E08.319, E08.36, E08.39 E08.44, E08.49, E08.51, E08.52, E08.59, E08.610, E08.618, E E08.622, E08.628, E08.630, E08.638, E08.641, E08.649, E08.65, E08.69, E08.8, E08.9, E09.00, E09.01, E09.10, E09.11, E09.21, E09.22, E09.29, E09.311, E09.319, E09.36, E09.39, E09.40 E09.44, E09.49, E09.51, E09.52, E09.59, E09.610, E09.618, E E09.622, E09.628, E09.630, E09.638, E09.641, E09.649, E09.65, E09.69, E09.8, E09.9, E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.36, E10.39 E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.36, E11.39 E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.42 Diabetes mellitus, other diabetes mellitus with diabetic polyneuropathy, diabetes with unspecified complications G57.53 Tarsal tunnel syndrome, bilateral lower limbs G60.0, G60.1, G60.3, G60.8, G61.0, G62.0 G62.2, G63 I I70.203, I70.208, I70.209, I I70.213, I70.218, I70.219, I I70.223, I70.228, I70.229, I I70.235, I70.238, I70.239, I I70.245, I70.248, I70.249, I70.25, I I70.263, I70.268, I70.269, I I70.293, I70.298, I Hereditary and idiopathic peripheral neuropathy, Guillain Barre, drug induced, alcoholic induced, and polyneuropathy due to other toxic agents Arteriosclerotic vascular disease of the lower extremities I73.1 Thromboangiitis obliterans (Buerger s disease) I79.8 Other disorders of arteries Published: October 16,

20 Table 3 ICD-10 Diagnosis Codes for Routine Foot Care Coverage Diagnosis Code I I87.003, I87.009, I I87.013, I87.019, I I87.023, I87.029, I I87.033, I87.039, I I87.093, I87.099, I87.1, I87.2, I I87.303, I87.309, I I87.313, I87.319, I I87.323, I87.329, I I87.333, I87.339, I I87.393, I L84 M21.611, M21.612, M21.619, M21.621, M21.622, M Reviewed/Updated: October 1, 2017 Post-phlebitis syndrome Corns and callosities Bunions and bunionettes Table Revision History October 1, 2017, update: Removed (effective October 1, 2016): E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.321, E11.329, E11.331, E11.341, E11.349, E11.351, E Removed (correction): E08.6, E09.64 October 1, 2016, update: Added (effective October 1, 2016): G57.53, M21.611, M21.612, M21.619, M21.621, M21.622, M Table 4 s for Therapeutic Shoes for Severe Diabetic Foot Disease Reviewed/Updated: October 1, 2017 A5500 A5501 A5503 A5504 A5505 A5506 A5507 A5508 For diabetics only, fitting (including follow-up) custom preparation and supply of off-theshelf depth-inlay shoe manufactured to accommodate multidensity insert(s) per shoe For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded from cast(s) of patient s foot (custom molded shoe), per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe Published: October 16,

21 Table 4 s for Therapeutic Shoes for Severe Diabetic Foot Disease Reviewed/Updated: October 1, 2017 A5510 A5512 A5513 For diabetics only, direct formed, compression molded to patient s foot without external heat source, multiple-density insert(s) prefabricated, per shoe For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient s foot, including arch, base layer minimum of 1/4 inch material of Shore A 35 durometer or 3/16 inch material of shore A 40 durometer (or higher), prefabricated, each For diabetics only, multiple density insert, custom mold from model of patient s foot, total contact with patient s foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer or higher), includes arch filler and other shaping material, custom fabricated, each Published: October 16,