Medical Policy Routine Foot Care and Debridement of Toenails

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Medical Policy Routine Foot Care and Debridement of Toenails Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description Endnotes Authorization Information Policy History Policy Number: 385 BCBSA Reference Number: None Related Policies None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity 1 Routine foot care may be considered MEDICALLY NECESSARY when all of the following conditions are met: I. The patient has a complicating systemic disease indicated by the diagnosis on the claim: a. Diabeted mellitus with complications, including * : i. Diabetes with kidney manifestations ii. Diabetes with eye manifestations iii. Diabetes with neurological manifestations iv. Diabetes with peripheral vascular manifestations** b. Arteriosclerosis obliterans (ASO) of lower extremities with manifestation c. Buerger s disease d. Chronic thrombophlebitis * e. Peripheral neuropathies involving feet associated with malnutrition and vitamin deficiency such as * : i. malnutrition (general, pellagra) ii. alcoholism, iii. malabsorption (celiac disease, tropical sprue) iv. pernicious anemia (281.0) f. Carcinoma * g. Diabetes mellitus * h. Drugs and toxins * i. Multiple sclerosis * j. Uremia (chronic renal disease) * k. Traumatic injury l. Leprosy or neurosyphilis 1

m. Hereditary disorders, including: i. hereditary sensory radicular neuropathy, ii. angiokeratoma corporis diffusum (Fabry s disease), iii. amyloid neuropathy II. Physical and/or Clinical Findings consistent with the diagnosis and indicative of severe peripheral involvement; severe peripheral involvement should be documented with the appropriate modifier. To fulfill coverage requirements for routine foot care the following physical/clinical class findings must be met: a. One class A finding; OR b. Two class B findings; OR c. One class B and two class C findings. Class A findings non-traumatic amputation of foot or integral skeletal portion Class B findings absent posterior tibial pulse; absent dorsalis pedis pulse; advance trophic changes such as: decrease or absence of hair growth; thickening of nail; pigmentary changes; skin texture; skin color (three trophic changes are required to meet one class finding). Class C findings claudication; temperature changes (e.g., cold feet); edema; paresthesia; burning * Routine foot care is covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition. ** Diabetes with neurological manifestations does not require class findings. Nail debridement may be considered MEDICALLY NECESSARY for the treatment of onychogryposis, onychauxis or mycotic toenails only when the provider attending the patient s condition documents the following: I. For ambulatory patients that there is: a. Clinical evidence of mycosis of the toenail, AND b. The patient has marked limitation of ambulation, pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate. II. For non-ambulatory patients that there is: a. Clinical evidence of mycosis of the toenail, AND b. The patient suffers from pain or secondary infection resulting from thickening and dystrophy of the infected toenail plate. The following foot care services are considered NOT MEDICALLY NECESSARY: Treatment, care or correction of flat foot Surgical or non-surgical treatments for the sole purpose of correcting a subluxed structure in the foot. This exclusion does not apply to medical or surgical treatment of subluxation of the ankle joint. In addition, reasonable and necessary medical or surgical services, diagnosis or treatment for medical conditions resulting from, or associated with partial displacement of structures is covered Supportive devices for feet. Nail debridement for any other condition other than those listed above including the simple trimming of the ends of the nail by cutting or grinding are considered NOT MEDICALLY NECESSARY. Medicare HMO Blue SM and Medicare PPO Blue SM Members Local Coverage Determination (LCD) for Routine Foot Care and Debridement of Nails (L26426): http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?lcdid=26426&contrid=304&ver=63&contrver=1&cntrctrselected=286*1&cntrctr=286&na me=national+government+services%2c+inc.+(14211%2c+mac+- +Part+A)&s=24&DocType=Active%7cRetired%7cFuture&bc=AggAAAIACAAAAA%3d%3d& 2

Prior Authorization Information Pre-service approval is required for all inpatient services for all products. See below for situations where prior authorization may be required or may not be required for outpatient services. Yes indicates that prior authorization is required. No indicates that prior authorization is not required. Outpatient Commercial Managed Care (HMO and POS) No Commercial PPO and Indemnity No Medicare HMO Blue SM No Medicare PPO Blue SM No CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes CPT codes: Code Description 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 11719 Trimming of nondystrophic 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 HCPCS Codes HCPCS codes: Code Description G0127 Trimming of dystrophic nails, any number G0247 Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include the local care of superficial wounds (i.e., superficial to muscle and fascia) and at least the following, if present: (1) local care of superficial wounds, (2) debridement of corns and calluses, and (3) trimming and debridement of nails ICD-9 Diagnosis Codes ICD-9-CM diagnosis codes: Code Description 030.0 Lepromatous leprosy (type L) 030.1 Tuberculoid leprosy [type T] 030.2 Indeterminate leprosy (group I) 030.3 Borderline leprosy (group B) 030.8 Other specified leprosy 030.9 Unspecified leprosy 090.40 Unspecified juvenile neurosyphilis 3

090.42 Congenital syphilitic meningitis 094.0 Tabes dorsalis 094.1 General paresis 094.2 Syphilitic meningitis 094.3 Asymptomatic neurosyphilis 094.81 Syphilitic encephalitis 094.82 Syphilitic Parkinsonism 094.83 Syphilitic disseminated retinochoroiditis 094.84 Syphilitic optic atrophy 094.85 Syphilitic retrobulbar neuritis 094.86 Syphilitic acoustic neuritis 094.87 Syphilitic ruptured cerebral aneurysm 094.89 Other specified neurosyphilis 094.9 Neurosyphilis, unspecified 195.5 Malignant neoplasm of lower limb 198.89 Secondary malignant neoplasm of other specified sites Diabetes mellitus without mention of complication, type II or unspecified type, not stated 250.00 as uncontrolled Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled 250.01 250.02 Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled 250.03 Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled 250.40 Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled 250.41 Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled 250.42 Diabetes with renal manifestations, type II or unspecified type, uncontrolled 250.43 Diabetes with renal manifestations, type I [juvenile type], uncontrolled Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled 250.50 250.51 Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled 250.52 Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled 250.53 Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled 250.60 250.61 Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled 250.62 Diabetes with neurological manifestations, type II or unspecified type, uncontrolled 250.63 Diabetes with neurological manifestations, type I [juvenile type], uncontrolled 250.70 250.71 Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled 250.72 Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled 250.73 Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled Diabetes with other specified manifestations, type II or unspecified type, not stated as 250.80 uncontrolled Diabetes with other specified manifestations, type I [juvenile type], not stated as 250.81 uncontrolled 250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled 250.83 Diabetes with other specified manifestations, type I [juvenile type], uncontrolled Diabetes with unspecified complication, type II or unspecified type, not stated as 250.90 uncontrolled 250.91 Diabetes with unspecified complication, type I [juvenile type], not stated as uncontrolled 250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled 250.93 Diabetes with unspecified complication, type I [juvenile type], uncontrolled 4

263.9 Unspecified protein-calorie malnutrition 265.2 Pellagra 272.7 Lipidoses 277.30 Amyloidosis, unspecified 277.31 Familial Mediterranean fever 277.39 Other amyloidosis 281.0 Pernicious anemia 340 Multiple sclerosis 356.0 Hereditary peripheral neuropathy 356.2 Hereditary sensory neuropathy 356.3 Refsum's disease 356.4 Idiopathic progressive polyneuropathy 356.8 Other specified idiopathic peripheral neuropathy 356.9 Unspecified hereditary and idiopathic peripheral neuropathy 357.0 Acute infective polyneuritis 357.1 Polyneuropathy in collagen vascular disease 357.2 Polyneuropathy in diabetes 357.3 Polyneuropathy in malignant disease 357.4 Polyneuropathy in other diseases classified elsewhere 357.5 Alcoholic polyneuropathy 357.6 Polyneuropathy due to drugs 357.7 Polyneuropathy due to other toxic agents 357.81 Chronic inflammatory demyelinating polyneuritis 357.82 Critical illness polyneuropathy 357.89 Other inflammatory and toxic neuropathy 440.20 Atherosclerosis of native arteries of the extremities, unspecified 440.21 Atherosclerosis of native arteries of the extremities with intermittent claudication 440.22 Atherosclerosis of native arteries of the extremities with rest pain 440.23 Atherosclerosis of native arteries of the extremities with ulceration 440.24 Atherosclerosis of native arteries of the extremities with gangrene 440.29 Other atherosclerosis of native arteries of the extremities 443.1 Thromboangiitis obliterans (Buerger's disease) 443.81 Peripheral angiopathy in diseases classified elsewhere 443.82 Erythromelalgia 443.89 Other peripheral vascular disease 443.9 Unspecified peripheral vascular disease 451.11 Phlebitis and thrombophlebitis of femoral vein (deep) (superficial) 451.19 Phlebitis and thrombophlebitis of other deep vessels of lower extremities 451.2 Phlebitis and thrombophlebitis of lower extremities, unspecified 579.0 Celiac disease 579.1 Tropical sprue 585.1 Chronic kidney disease, Stage I 585.2 Chronic kidney disease, Stage II (mild) 585.3 Chronic kidney disease, Stage III (moderate) 585.4 Chronic kidney disease, Stage IV (severe) 585.5 Chronic kidney disease, Stage V 585.6 End stage renal disease 585.9 Chronic kidney disease, unspecified 586 Unspecified renal failure 956.0 Injury to sciatic nerve 956.1 Injury to femoral nerve 956.2 Injury to posterior tibial nerve 956.3 Injury to peroneal nerve 5

956.4 Injury to cutaneous sensory nerve, lower limb 956.5 Injury to other specified nerve(s) of pelvic girdle and lower limb 956.8 Injury to multiple nerves of pelvic girdle and lower limb 956.9 Injury to unspecified nerve of pelvic girdle and lower limb 959.7 Injury, other and unspecified, knee, leg, ankle, and foot ICD-10-CM Diagnosis Codes ICD-10-CM diagnosis codes: Code Description A30.0 Indeterminate leprosy A30.1 Tuberculoid leprosy A30.2 Borderline tuberculoid leprosy A30.3 Borderline leprosy A30.4 Borderline lepromatous leprosy A30.5 Lepromatous leprosy A30.8 Other forms of leprosy A50.40 Late congenital neurosyphilis, unspecified A50.41 Late congenital syphilitic meningitis A50.43 Late congenital syphilitic polyneuropathy A50.45 Juvenile general paresis A52.10 Symptomatic neurosyphilis, unspecified A52.11 Tabes dorsalis A52.12 Other cerebrospinal syphilis A52.13 Late syphilitic meningitis A52.14 Late syphilitic encephalitis A52.15 Late syphilitic neuropathy A52.16 Charcà t's arthropathy (tabetic) A52.17 General paresis A52.19 Other symptomatic neurosyphilis A52.2 Asymptomatic neurosyphilis A52.3 Neurosyphilis, unspecified B35.1 Tinea unguium C76.50 Malignant Neoplasm Of Unspecified Lower Limb C79.89 Secondary Malignant Neoplasm Of Other Specified Sites D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency E08.42 Diabetes Mellitus Due To Underlying Condition With Diabetic Polyneuropathy Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without E08.51 gangrene Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with E08.52 gangrene Drug Or Chemical Induced Diabetes Mellitus With Neurological Complications With E09.42 Diabetic Polyneuropathy Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without E09.51 gangrene Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with E09.52 gangrene E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema 6

E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E10.321 edema Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E10.329 edema Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E10.331 edema Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without E10.339 macular edema Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular E10.341 edema Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E10.349 edema E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 Diabetes Mellitus With Other Diabetic Arthropathy 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 E10.630 Type 1 Diabetes Mellitus With Periodontal Disease E10.638 Type 1 Diabetes Mellitus With Other Oral Complications E10.649 Type 1 Diabetes Mellitus With Hypoglycemia Without Coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 Diabetes Mellitus With Other Specified Complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 Diabetes Mellitus Without Complications E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular E11.321 edema Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular E11.329 edema Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular E11.331 edema Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without E11.339 macular edema 7

Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular E11.341 edema Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular E11.349 edema E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy E11.618 Type 2 Diabetes Mellitus With Other Diabetic Arthropathy 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 E11.630 Type 2 Diabetes Mellitus With Periodontal Disease E11.638 Type 2 Diabetes Mellitus With Other Oral Complications E11.649 Type 2 Diabetes Mellitus With Hypoglycemia Without Coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 Diabetes Mellitus With Other Specified Complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 Diabetes Mellitus Without Complications E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication Other specified diabetes mellitus with unspecified diabetic retinopathy with macular E13.311 edema Other specified diabetes mellitus with unspecified diabetic retinopathy without macular E13.319 edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with E13.321 macular edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without E13.329 macular edema Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with E13.331 macular edema Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy E13.339 without macular edema Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with E13.341 macular edema Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without E13.349 macular edema Other specified diabetes mellitus with proliferative diabetic retinopathy with macular E13.351 edema Other specified diabetes mellitus with proliferative diabetic retinopathy without macular E13.359 edema 8

E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy E13.8 Other specified diabetes mellitus with unspecified complications E46 Unspecified Protein-Calorie Malnutrition E52 Niacin deficiency [pellagra] E75.21 Fabry (-Anderson) disease E85.0 Non-neuropathic heredofamilial amyloidosis E85.1 Neuropathic heredofamilial amyloidosis E85.2 Heredofamilial amyloidosis, unspecified E85.3 Secondary systemic amyloidosis E85.4 Organ-limited amyloidosis E85.8 Other amyloidosis E85.9 Amyloidosis, unspecified G13.0 Paraneoplastic neuromyopathy and neuropathy G13.1 Other systemic atrophy primarily affecting central nervous system in neoplastic disease G35 Multiple sclerosis G60.0 Hereditary motor and sensory neuropathy G60.1 Refsum'S Disease G60.3 Idiopathic Progressive Neuropathy G60.8 Other Hereditary And Idiopathic Neuropathies G60.9 Hereditary And Idiopathic Neuropathy, Unspecified G61.1 Serum neuropathy G61.81 Chronic Inflammatory Demyelinating Polyneuritis G61.89 Other Inflammatory Polyneuropathies G62.0 Drug-induced polyneuropathy G62.1 Alcoholic polyneuropathy G62.2 Polyneuropathy due to other toxic agents G62.81 Critical Illness Polyneuropathy G62.82 Radiation-induced polyneuropathy G63 Polyneuropathy in diseases classified elsewhere G65.0 Sequelae of Guillain-Barrà syndrome G65.1 Sequelae of other inflammatory polyneuropathy G65.2 Sequelae of toxic polyneuropathy I70.201 Unspecified atherosclerosis of native arteries of extremities, right leg I70.202 Unspecified atherosclerosis of native arteries of extremities, left leg I70.203 Unspecified atherosclerosis of native arteries of extremities, bilateral legs I70.208 Unspecified atherosclerosis of native arteries of extremities, other extremity I70.209 Unspecified atherosclerosis of native arteries of extremities, unspecified extremity I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs 9

Atherosclerosis of native arteries of extremities with intermittent claudication, other I70.218 extremity Atherosclerosis of native arteries of extremities with intermittent claudication, unspecified I70.219 extremity I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg I70.222 Atherosclerosis of native arteries of extremities with rest pain, left leg I70.223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs I70.228 Atherosclerosis of native arteries of extremities with rest pain, other extremity I70.229 Atherosclerosis of native arteries of extremities with rest pain, unspecified extremity 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 I70.242 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 I70.299 Other Atherosclerosis Of Native Arteries Of Extremities, Unspecified Extremity I73.1 Thromboangiitis obliterans [Buerger's disease] I73.81 Erythromelalgia I73.89 Other specified peripheral vascular diseases I73.9 Peripheral vascular disease, unspecified I79.1 Aortitis in diseases classified elsewhere I79.8 Other disorders of arteries, arterioles and capillaries in diseases classified elsewhere I80.10 Phlebitis and thrombophlebitis of unspecified femoral vein I80.11 Phlebitis and thrombophlebitis of right femoral vein I80.12 Phlebitis and thrombophlebitis of left femoral vein I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral I80.201 Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity I80.202 Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity I80.203 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral I80.209 Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity I80.221 Phlebitis and thrombophlebitis of right popliteal vein I80.222 Phlebitis and thrombophlebitis of left popliteal vein I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral I80.229 Phlebitis and thrombophlebitis of unspecified popliteal vein I80.231 Phlebitis and thrombophlebitis of right tibial vein I80.232 Phlebitis and thrombophlebitis of left tibial vein I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral I80.239 Phlebitis and thrombophlebitis of unspecified tibial vein I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity 10

I80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity I80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral I80.299 Phlebitis and thrombophlebitis of other deep vessels of unspecified lower extremity I80.3 Phlebitis And Thrombophlebitis Of Lower Extremities, Unspecified K90.0 Celiac disease K90.1 Tropical sprue L60.1 Onycholysis L60.2 Onychogryphosis L60.3 Nail dystrophy L60.4 Beau's lines L60.5 Yellow nail syndrome L60.8 Other nail disorders L62 Nail disorders in diseases classified elsewhere M34.83 Systemic sclerosis with polyneuropathy N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 (mild) N18.3 Chronic kidney disease, stage 3 (moderate) N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease N18.9 Chronic kidney disease, unspecified N19 Unspecified Kidney Failure S84.00xA Injury of tibial nerve at lower leg level, unspecified leg, initial encounter S84.00xD Injury of tibial nerve at lower leg level, unspecified leg, subsequent encounter S84.00xS Injury of tibial nerve at lower leg level, unspecified leg, sequela S84.01xA Injury of tibial nerve at lower leg level, right leg, initial encounter S84.01xD Injury of tibial nerve at lower leg level, right leg, subsequent encounter S84.01xS Injury of tibial nerve at lower leg level, right leg, sequela S84.02xA Injury of tibial nerve at lower leg level, left leg, initial encounter S84.02xD Injury of tibial nerve at lower leg level, left leg, subsequent encounter S84.02xS Injury of tibial nerve at lower leg level, left leg, sequela S84.10xA Injury of peroneal nerve at lower leg level, unspecified leg, initial encounter S84.10xD Injury of peroneal nerve at lower leg level, unspecified leg, subsequent encounter S84.10xS Injury of peroneal nerve at lower leg level, unspecified leg, sequela S84.11xA Injury of peroneal nerve at lower leg level, right leg, initial encounter S84.11xD Injury of peroneal nerve at lower leg level, right leg, subsequent encounter S84.11xS Injury of peroneal nerve at lower leg level, right leg, sequela S84.12xA Injury of peroneal nerve at lower leg level, left leg, initial encounter S84.12xD Injury of peroneal nerve at lower leg level, left leg, subsequent encounter S84.12xS Injury of peroneal nerve at lower leg level, left leg, sequela S84.20xA Injury of cutaneous sensory nerve at lower leg level, unspecified leg, initial encounter Injury of cutaneous sensory nerve at lower leg level, unspecified leg, subsequent S84.20xD encounter S84.20xS Injury of cutaneous sensory nerve at lower leg level, unspecified leg, sequela S84.21xA Injury of cutaneous sensory nerve at lower leg level, right leg, initial encounter S84.21xD Injury of cutaneous sensory nerve at lower leg level, right leg, subsequent encounter S84.21xS Injury of cutaneous sensory nerve at lower leg level, right leg, sequela S84.22xA Injury of cutaneous sensory nerve at lower leg level, left leg, initial encounter S84.22xD Injury of cutaneous sensory nerve at lower leg level, left leg, subsequent encounter S84.22xS Injury of cutaneous sensory nerve at lower leg level, left leg, sequela S84.801A Injury of other nerves at lower leg level, right leg, initial encounter 11

S84.801D S84.801S S84.802A S84.802D S84.802S S84.809A S84.809D S84.809S S84.90xA S84.90xD S84.90xS S84.91xA S84.91xD S84.91xS S84.92xA S84.92xD S84.92xS S89.80XA S89.80XD S89.80XS S89.90XA S89.90XD S89.90XS S94.00xA S94.00xD S94.00xS S94.01xA S94.01xD S94.01xS S94.02xA S94.02xD S94.02xS S94.10xA S94.10xD S94.10xS S94.11xA S94.11xD S94.11xS S94.12xA S94.12xD S94.12xS S94.20xA S94.20xD S94.20xS S94.21xA S94.21xD S94.21xS S94.22xA S94.22xD S94.22xS Injury of other nerves at lower leg level, right leg, subsequent encounter Injury of other nerves at lower leg level, right leg, sequela Injury of other nerves at lower leg level, left leg, initial encounter Injury of other nerves at lower leg level, left leg, subsequent encounter Injury of other nerves at lower leg level, left leg, sequela Injury of other nerves at lower leg level, unspecified leg, initial encounter Injury of other nerves at lower leg level, unspecified leg, subsequent encounter Injury of other nerves at lower leg level, unspecified leg, sequela Injury of unspecified nerve at lower leg level, unspecified leg, initial encounter Injury of unspecified nerve at lower leg level, unspecified leg, subsequent encounter Injury of unspecified nerve at lower leg level, unspecified leg, sequela Injury of unspecified nerve at lower leg level, right leg, initial encounter Injury of unspecified nerve at lower leg level, right leg, subsequent encounter Injury of unspecified nerve at lower leg level, right leg, sequela Injury of unspecified nerve at lower leg level, left leg, initial encounter Injury of unspecified nerve at lower leg level, left leg, subsequent encounter Injury of unspecified nerve at lower leg level, left leg, sequela Other specified injuries of unspecified lower leg, initial encounter Other specified injuries of unspecified lower leg, subsequent encounter Other specified injuries of unspecified lower leg, sequela Unspecified injury of unspecified lower leg, initial encounter Unspecified injury of unspecified lower leg, subsequent encounter Unspecified injury of unspecified lower leg, sequela Injury of lateral plantar nerve, unspecified leg, initial encounter Injury of lateral plantar nerve, unspecified leg, subsequent encounter Injury of lateral plantar nerve, unspecified leg, sequela Injury of lateral plantar nerve, right leg, initial encounter Injury of lateral plantar nerve, right leg, subsequent encounter Injury of lateral plantar nerve, right leg, sequela Injury of lateral plantar nerve, left leg, initial encounter Injury of lateral plantar nerve, left leg, subsequent encounter Injury of lateral plantar nerve, left leg, sequela Injury of medial plantar nerve, unspecified leg, initial encounter Injury of medial plantar nerve, unspecified leg, subsequent encounter Injury of medial plantar nerve, unspecified leg, sequela Injury of medial plantar nerve, right leg, initial encounter Injury of medial plantar nerve, right leg, subsequent encounter Injury of medial plantar nerve, right leg, sequela Injury of medial plantar nerve, left leg, initial encounter Injury of medial plantar nerve, left leg, subsequent encounter Injury of medial plantar nerve, left leg, sequela Injury of deep peroneal nerve at ankle and foot level, unspecified leg, initial encounter Injury of deep peroneal nerve at ankle and foot level, unspecified leg, subsequent encounter Injury of deep peroneal nerve at ankle and foot level, unspecified leg, sequela Injury of deep peroneal nerve at ankle and foot level, right leg, initial encounter Injury of deep peroneal nerve at ankle and foot level, right leg, subsequent encounter Injury of deep peroneal nerve at ankle and foot level, right leg, sequela Injury of deep peroneal nerve at ankle and foot level, left leg, initial encounter Injury of deep peroneal nerve at ankle and foot level, left leg, subsequent encounter Injury of deep peroneal nerve at ankle and foot level, left leg, sequela 12

S94.30xA S94.30xD S94.30xS S94.31xA S94.31xD S94.31xS S94.32xA S94.32xD S94.32xS S94.8x1A S94.8x1D S94.8x1S S94.8x2A S94.8x2D S94.8x2S S94.8x9A S94.8x9D S94.8x9S S94.90xA S94.90xD S94.90xS S94.91xA S94.91xD S94.91xS S94.92xA S94.92xD S94.92xS S99.819A S99.819D S99.819S S99.919A S99.919D S99.919S Injury of cutaneous sensory nerve at ankle and foot level, unspecified leg, initial encounter Injury of cutaneous sensory nerve at ankle and foot level, unspecified leg, subsequent encounter Injury of cutaneous sensory nerve at ankle and foot level, unspecified leg, sequela Injury of cutaneous sensory nerve at ankle and foot level, right leg, initial encounter Injury of cutaneous sensory nerve at ankle and foot level, right leg, subsequent encounter Injury of cutaneous sensory nerve at ankle and foot level, right leg, sequela Injury of cutaneous sensory nerve at ankle and foot level, left leg, initial encounter Injury of cutaneous sensory nerve at ankle and foot level, left leg, subsequent encounter Injury of cutaneous sensory nerve at ankle and foot level, left leg, sequela Injury of other nerves at ankle and foot level, right leg, initial encounter Injury of other nerves at ankle and foot level, right leg, subsequent encounter Injury of other nerves at ankle and foot level, right leg, sequela Injury of other nerves at ankle and foot level, left leg, initial encounter Injury of other nerves at ankle and foot level, left leg, subsequent encounter Injury of other nerves at ankle and foot level, left leg, sequela Injury of other nerves at ankle and foot level, unspecified leg, initial encounter Injury of other nerves at ankle and foot level, unspecified leg, subsequent encounter Injury of other nerves at ankle and foot level, unspecified leg, sequela Injury of unspecified nerve at ankle and foot level, unspecified leg, initial encounter Injury of unspecified nerve at ankle and foot level, unspecified leg, subsequent encounter Injury of unspecified nerve at ankle and foot level, unspecified leg, sequela Injury of unspecified nerve at ankle and foot level, right leg, initial encounter Injury of unspecified nerve at ankle and foot level, right leg, subsequent encounter Injury of unspecified nerve at ankle and foot level, right leg, sequela Injury of unspecified nerve at ankle and foot level, left leg, initial encounter Injury of unspecified nerve at ankle and foot level, left leg, subsequent encounter Injury of unspecified nerve at ankle and foot level, left leg, sequela Other specified injuries of unspecified ankle, initial encounter Other specified injuries of unspecified ankle, subsequent encounter Other specified injuries of unspecified ankle, sequela Unspecified injury of unspecified ankle, initial encounter Unspecified injury of unspecified ankle, subsequent encounter Unspecified injury of unspecified ankle, sequela Description Routine foot care services include the examination, diagnosis, and medical treatment of conditions and dysfunctions of the foot. Services normally considered routine foot care include: cutting or removal of corns and calluses; trimming, cutting, and clipping; other hygienic and preventive maintenance care considered self-care (i.e., cleaning and soaking the feet, and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients); and any services performed in the absence of localized illness, injury or symptoms involving the foot. Nail debridement is the removal of all diseased nail to the nail bed or viable nail plate or to the point where bleeding is imminent. Simple trimming of the nail ends of the toenails by cutting or grinding is not considered debridement. Summary The research for this policy was compiled using a combination of medical society recommendations, Medicare recommendations, and expert opinion. 13

Policy History Date Action 8/2014 Medical policy remediation: Formatting, editing and coding updates. No changes to policy statements. 5/2011 Medical Policy Group - Pediatrics and Endocrinology, no changes in coverage. 7/2006 Medical Policy Group - Orthopedic/Rheumatology, no changes in coverage. 7/2003 Medical Policy Group - orthopedics/rheumatology, no changes in coverage. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines Endnotes 1 In accordance with CMS (Centers for Medicare and Medicaid Services) guidelines MCM 2323, 4120 published October/November 1995; the American College of Foot Surgeons Preferred Practice Guidelines; and input from podiatrists on the Carrier Advisory Committee. 14

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