CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Routine Foot Care and Nail Debridement

Policy governing coverage and medical necessity criteria for routine foot care, nail debridement, and related foot examinations for Blue Cross & Blue Shield of Rhode Island members, including BlueCHiP for Medicare and Commercial Products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRoutine Foot Care and Nail Debridement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2009

Next Review DateN/A

Key ActionDocument qualifying systemic disease or specified class findings in the medical record to support reimbursement for routine foot care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2foot evaluations per year allowed for diabetics with LOPS

7medically necessary codes listed

2009-09-01effective date

2019-05-21policy last updated

Coverage and Medical Necessity Criteria

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Routine Foot Care Medical Necessity Logic

Routine foot care is considered medically necessary when specific systemic disease or documented class findings are present and recorded in the medical record.

Primary medical necessity paths: Either Path A OR Path B must be present

Path A: Systemic disease: Patient has a systemic disease (metabolic, neurologic, or peripheral vascular disease) of sufficient severity that performance of routine foot care by a nonprofessional would put the patient at risk (for example, severe circulatory impairment or areas of desensitization)

Documented in medical record

Path B: Documented class findings or severe neuropathy

Class A: Non-traumatic amputation of foot or integral skeletal portion thereof
(one required)
Class B (two required): Examples include absent posterior tibial pulse; absent dorsalis pedis pulse; and advanced trophic changes (three of: decreased/absent hair growth; nail thickening; pigmentary changes/discoloration; thin, shiny skin texture; rubor)2 of the listed B findings
Two Class B findings required
Class C (used with Class B): Examples include claudication; temperature changes (cold feet); edema; paresthesias; burning2 for the combination option
One Class B + two Class C findings qualifies
Peripheral neuropathy without vascular impairment: Peripheral neuropathy involving the feet of such severity that care by a nonprofessional would put the patient at risk (LOPS); in this situation class-finding modifiers are not necessary
Document neuropathy severity in record

Mycotic Toenail Coverage Criteria

Treatment of mycotic toenails may be covered in the absence of a systemic condition when specific clinical criteria are met.

Mycotic nail — ambulatory patients: Clinical evidence of toenail mycosis AND marked limitation of ambulation, pain, or secondary infection resulting from thickening and dystrophy of the infected toenail plate

Both criteria required for ambulatory patients

Mycotic nail — non-ambulatory patients: Clinical evidence of toenail mycosis AND the patient suffers pain or secondary infection resulting from thickening and dystrophy of the infected toenail plate

Both criteria required for non-ambulatory patients

Additional covered nail conditions: Procedures for treating toenails are covered for onychogryphosis or onychauxis when symptomatic (e.g., causing marked limitation of ambulation, pain, or secondary infection)

Document condition and symptoms in record

LOPS-specific Coverage

Diabetic patients with documented loss of protective sensation (LOPS) have a different annual evaluation allowance.

LOPS evaluation frequency: Diagnosis of diabetic sensory neuropathy with loss of protective sensation (LOPS) documented in the medical record

Patients with LOPS may receive two foot evaluations (examination and treatment) per year specifically for diabetic peripheral neuropathy with LOPS, provided they have not seen a foot care professional for another reason

All routine foot care indications that do not meet the policy's specified medical necessity criteria are not covered. Specifically, routine foot care is considered covered only when the patient has a qualifying systemic disease (for example metabolic, neurologic, or peripheral vascular disease) of sufficient severity that nonprofessional care would place the patient at risk. All other indications are not covered for BlueCHiP for Medicare and are not medically necessary for Commercial Products.

An annual foot evaluation for diabetics who are being treated with diabetic medication is covered once per year for patients not otherwise receiving podiatric services. Frequency greater than once per year is not covered for BlueCHiP for Medicare and is not medically necessary for Commercial Products unless the patient meets the policy's Loss of Protective Sensation (LOPS) criteria allowing additional evaluation frequency. Providers should verify member-specific benefits with the call center as benefit documents supersede this policy.

Services that are determined to be not medically necessary, as well as medically necessary services that are non-covered benefits under a member's subscriber agreement or employer agreement, are not covered under this policy. Providers must follow member benefit documents for coverage determinations and obtain prior written member agreement before billing a member for non-covered services.

Routine foot care provided for indications other than a qualifying systemic disease or documented qualifying class findings is considered not medically necessary. Coverage is limited to situations where the systemic condition or neuropathy severity makes nonprofessional care unsafe; routine maintenance/hygienic care absent these findings is not covered.

Procedure and Billing Codes

Medically necessary procedure codes when submitted with covered diagnosesCPT | HCPCSCovered

11055	Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056	Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions
11057	Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions
11719	Trimming of nondystrophic nails, any number
11720	Debridement of nail(s) by any mothod(s); 1 to 5
11721	Debridement of nail(s) by any method(s); 6 or more
G0127	Trimming of dystrophic nails, any number

Provider Responsibilities and Billing Guidance

Note

Prior Authorization

Prior authorization review is not required.

Billing Rule

Annual diabetic foot exam frequency

An annual evaluation of diabetic patients treated with diabetic medication is covered for patients not otherwise receiving podiatric services. Frequency greater than once per year is not covered for BlueCHiP for Medicare and is considered not medically necessary for Commercial products unless documentation shows loss of protective sensation (LOPS) or other qualifying clinical criteria that justify more frequent exams.

Documentation Required

Required documentation of class findings

The following physical and clinical findings indicative of severe peripheral involvement must be documented and maintained in the patient record for routine foot care services to be reimbursable. Documentation must clearly state which Class findings are present and support the medical necessity of the services billed.

Class A findings: Non‑traumatic amputation of foot or integral skeletal portion thereof.
Class B findings: Absent posterior tibial pulse; absent dorsalis pedis pulse; advanced trophic changes (three required): decreased/absent hair growth; nail changes (thickening); pigmentary changes (discoloration); thin, shiny skin; skin color changes (rubor/redness).
Class C findings: Claudication; temperature changes (e.g., cold feet); edema; paresthesias; burning.
Reimbursement criteria: physician must identify either (1) a Class A finding, (2) two Class B findings, or (3) one Class B and two Class C findings. Benefits also apply for peripheral neuropathy of the feet when neuropathy is severe enough that care by a nonprofessional would put the patient at risk.

Note

Benefits & Eligibility Verification

For member‑specific benefits and eligibility, providers must verify coverage prior to rendering services by contacting the provider call center. The member's subscriber agreement, member certificate, and/or employer agreement determine benefits and supersede this policy. If services are determined to be not medically necessary or non‑covered, members may be financially responsible unless informed and they agree in writing in advance.

Background and Scope

Routine foot care services include cutting or removal of corns and calluses; clipping, trimming, or debridement of nails (including treatment of mycotic nails when criteria are met); paring, shaving, or removal of keratoma/tyloma/heloma; palliative treatment of plantar warts that do not require curettage or cautery; and hygienic or preventive maintenance care performed in the absence of localized illness or symptoms. These services are covered only when the medical necessity criteria in this policy are satisfied.

Key Definitions

Routine foot care — included services

Included servicesCutting or removal of corns and calluses; clipping, trimming, or debridement of nails (including mycotic nails); shaving, paring, cutting or removal of keratoma/tyloma/heloma; non‑definitive palliative treatments of plantar warts not requiring cautery/curettage; hygienic and preventive maintenance care (cleaning, soaking, skin creams) performed in absence of localized illness or symptoms.

ScopeApplies regardless of the provider rendering the service (ambulatory or bedfast patients).

Exclusions within routine careServices performed for localized illness, injury, or symptoms of the foot are not classified as routine maintenance in this definition.

Nail debridement — distinguishing features

DefinitionSignificant reduction in thickness and length of the toenail with the aim of allowing the patient to ambulate without pain; distinct from routine foot care.

Not debridement: simple trimming or buffingSimple trimming of the end of the toenails by cutting or grinding, or buffing the surface/edges of manually trimmed mycotic nails, is not considered debridement.

Not debridement: reduction of normal elongated nailsReduction in length of normal or thickened elongated toenails (whether with an electric burr or by hand) is not debridement.

Loss of protective sensation (LOPS)

LOPS definitionDiagnosis of diabetic sensory neuropathy with loss of protective sensation (LOPS) requiring early intervention to prevent serious diabetic complications.

Evaluation frequency allowancePatients with LOPS may receive two foot evaluations per year (no more often than every six months) specifically for diabetic peripheral neuropathy with LOPS, provided they have not been seen by a foot care professional for another reason.

Care coordinationA DO/MD diagnosis or comprehensive diabetic care plan is not required, but the podiatric professional should coordinate care with the physician managing the patient's diabetes.