Currentpriority healthPolicy 113

Foot Care & Onychomycosis Testing

Defines billing, documentation and coding guidance for routine foot care, nail debridement/trimming, and related modifier and reimbursement instructions for Priority Health providers. Affects providers submitting claims to Priority Health (including Medicare-related guidance).

Policy Summary

Payerpriority health

PolicyFoot Care & Onychomycosis Testing

Policy CodePolicy 113

Change TypeClarified

Effective Date

Next Review Date

Key ActionFor Medicare: when indications don't meet NCD/LCD or medical policy criteria, complete a Pre-Service Organization Determination (PSOD); authorization does not guarantee payment and coding/billing requirements must still be met.

SourceLink

POLICY UPDATE CHANGES

Added clarifying information including definition, modifiers and references to what was previously available in the Provider Manual.

3procedure code groups listed

NCCI referencedcoding edit guidance applied

25modifier noted

requiredMedicare PSOD

Documentation, Coding & Reimbursement Rules

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Documentation, coding and reimbursement rules

Priority Health billing policy specifies documentation, coding and reimbursement requirements; services may be restricted from separate reimbursement in certain combinations and require specific documentation to support payment.

ALL of the following

ALL of the following
- Provider must maintain complete and thorough documentation to substantiate the procedure performed; consult any applicable guideline-specific documentation requirements.
- Operative note should resemble the lay description of the CPT or HCPCS code selected; repeated procedures on different anatomical sites must clearly detail each distinct procedure and support medical necessity.
ALL of the following
- The digit/location needing debridement
- The size of the lesion/debridement area
- The size (including thickness) and color of each affected nail
- Medical necessity for the debridement
- Debridement approach/surgical technique
ALL of the following
- Documentation only notes location(s) within physical exam/objective area without procedural detail
- Notes that state only 'debridement of all affected nails' or 'all hyperkeratotic lesions were debrided' without specifying which nails or the extent of debridement
ALL of the following
- Hyperkeratotic lesion debridement (CPT 11055-11057) is not separately reimbursable when performed with nail debridement (CPT 11720-11721) on the same digit per NCCI guidance, Chapter 3.
- A modifier appended to indicate distinct services will not override this edit.
ALL of the following
- Priority Health follows CMS NCCI guidelines; apply modifiers only when supported by documentation and CMS/NCCI guidance.
- A significant, separately identifiable evaluation and management service on the same day as routine care can be submitted with modifier 25 when appropriately documented.
- Incorrect application of modifiers may result in denials; see Provider Manual for additional modifier guidance.
ALL of the following
- Reimbursement rates for listed codes are available in Priority Health standard fee schedules for your contract (login required).

ALL of the following

CPT 11720-11721: Payable when performed without hyperkeratotic lesion debridement on the same digit and submitted with required documentation; not payable when performed with hyperkeratotic lesion debridement on the same digit; modifier will not override the edit.

ALL of the following

Review dates noted: 7/2025 and 4/2026 (policy review and clarifications).

Procedure Codes and Reimbursement Guidance

Hyperkeratotic lesion debridementCPTCovered

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

Nail debridementCPTCovered

11720	Debridement of nail(s) by any method(s); 1 to 5
11721	Debridement of nail(s) by any method(s); 6 or more

Nail trimmingCPT | HCPCSCovered

G0127	Trimming of dystrophic nails, any number
11719	Trimming of nondystrophic nails, any number

inv-05: Separate reimbursement restriction

Separate reimbursement ruleHyperkeratotic lesion debridement (CPT 11055-11057) is not separately reimbursable when performed with nail debridement (CPT 11720-11721) on the same digit per NCCI Chapter 3 guidance.

Modifier guidanceA modifier appended to indicate distinct services will not override this edit; modifier will not make hyperkeratotic lesion debridement separately payable with same-digit nail debridement.

Documentation requirementDocumentation should include digit/location, size of lesion/debridement area, and operative note that resembles the lay description of the CPT/HCPCS code to support reimbursement.

Authorization and Prior-Action Requirements

Documentation Required

Medicare PSOD required when NCD/LCD or policy criteria are not met

For Medicare beneficiaries, when the clinical indications do not meet an NCD, local LCD, or a specific medical policy, the provider must complete a Pre‑Service Organization Determination (PSOD) before rendering services. Note that an authorization or PSOD does not guarantee payment — coding, billing, documentation and medical necessity requirements still apply.

Complete a PSOD for Medicare cases that do not meet NCD/LCD or specific medical policy criteria.
Ensure full documentation and correct coding accompany any authorization; an authorization/PSOD does not guarantee payment and failure to follow billing requirements may result in denial or recoupment.

Key Definitions

inv-07: Routine foot care

DefinitionRoutine foot care: treatment of calluses, corns, keratotic and hyperkeratosis lesions, keratoderma, bunions (except capsular or bone surgery) and nails (except surgery for ingrown nails).

Exclusions/see alsoSurgery for ingrown nails and capsular or bone surgery for bunions are excluded; coverage and medical necessity details are in Priority Health Foot Care (#91121) medical policy.

Documentation noteProviders must follow documentation requirements to substantiate procedures performed (see operative note guidance).

inv-08: Onychomycosis

DefinitionOnychomycosis: fungal infection of the nail plate, nail bed, or both; may present as distal subungual (nail thickening, yellowing, keratin/debris under nail), proximal subungual, or white superficial (chalky white scale beneath nail).

Common causesCan be caused by dermatophytes (ringworm) or other fungi such as yeast.

Clinical presentationMay include nail thickening, discoloration, accumulation of keratinous debris, or white superficial scaling beneath the nail surface.