Notes: Routine foot care is not covered under most of Aetna’s HMO-based plans. Please check benefit plan descriptions for details. Under plans that exclude routine foot care, foot care is considered non-routine and covered only in the following circumstances when medically necessary:
The non-professional performance of the service would be hazardous for the member because of an underlying condition or disease; or
Routine foot care is performed as a necessary and integral part of an otherwise covered service (e.g., debriding of a nail to expose a subungual ulcer, or treatment of warts); or
Debridement of mycotic nails is undertaken when the mycosis/dystrophy of the toenail is causing secondary infection and/or pain, which results or would result in marked limitation of ambulation and require the professional skills of a provider.
Routine foot care includes, but is not limited to, the treatment of bunions (except capsular or bone surgery thereof), calluses, clavus, corns, hyperkeratosis and keratotic lesions, keratoderma, nails (except surgery for ingrown nails), plantar keratosis, tyloma or tylomata, and tylosis. The reduction of nails, including the trimming of nails, is also considered routine foot care.
Treatment of these conditions may pose a hazard when performed by a non-professional person on individuals with a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the legs or feet. Some of the underlying conditions that may justify coverage of foot care that would otherwise be considered routine include arteriosclerosis, chronic thrombophlebitis, diabetes, and peripheral neuropathies.
Traditional Plans:
Note: Under most Aetna traditional plans, services of a podiatrist are covered for the treatment of a disease or injury, including but not limited to treatment of corns, calluses, keratoses, bunions, and ingrown nails. Aetna does not consider pedicure services, such as routine cutting of nails, in the absence of disease of nails, as treatment of disease. Please check benefit plan descriptions for details.
Background
The Medicare program also generally does not cover routine foot care. Medicare assumes that patients or their caregivers will perform these services by themselves. Medicare has interpreted routine foot care to include, among other things, any foot care services performed in the absence of localized illness, injury or symptoms involving the foot. Aetna's HMO policy is similar to Medicare policy on routine foot care, in that Medicare also does not cover: cutting or removal of corns and calluses; clipping or trimming of normal or mycotic nails; shaving, paring, cutting or removal of keratoma, tyloma, and heloma; non-definitive simple, palliative treatments like shaving or paring of plantar warts which do not require thermal or chemical cautery and curettage; and other hygienic and preventive maintenance care in the realm of self care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients. Exceptions to this exclusion apply for persons with a systemic condition such as metabolic, neurologic, or peripheral vascular disease resulting in circulatory deficits or areas of decreased sensation in the individual’s legs or feet, such that the performance of routine foot care by a non-professional person may pose a hazard.
CPT Codes / HCPCS Codes / ICD-9 Codes
Routine foot care other than debridement of mycotic nails:
CPT codes covered if selection criteria are met:
11055
11056
11057
11730
+ 11732
11750
11765
Other CPT codes related to the CPB:
17110 - 17111
HCPCS codes covered if selection criteria are met:
G0245
Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in loss of protective sensation (LOPS) which must include: (1) the diagnosis of LOPS, (2) a patient history, (3) a physical examination that consists of at least the following elements: (a) visual inspection of the forefoot, hindfoot and toe web spaces, (b) evaluation of a protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, and (e) evaluation and recommendation of footwear, and (4) patient education
G0246
Follow up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in loss of protective sensation (LOPS) to include at least the following: (1) a patient history, (2), a physical examination that includes: (a) visual inspection of the forefoot, hindfoot and toe web spaces, (b) evaluation of a protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, and (e) evaluation and recommendation of footwear, and (3) patient education
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
S0390
Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific conditions (e.g., diabetes), per visit
ICD-9 codes covered if selection criteria are met:
078.10, 078.19
Viral warts, unspecified and other specified viral warts
111.8 - 111.9
Other and unspecified dermatomycoses
250.00 - 250.93
Diabetes mellitus
337.0 - 337.1
Peripheral autonomic neuropathy
355.0 - 355.8
Mononeuritis of lower limb
356.0 - 356.9
Hereditary and idiopathic peripheral neuropathy
357.0 - 357.9
Inflammatory and toxic neuropathy
440.20 - 440.32
Atherosclerosis of native arteries and bypass graft of extremities
443.0 - 443.1
Raynaud's syndrome and thromboangiitis obliterans [Buerger's disease]
443.81 - 443.9
Other specified and unspecified peripheral vascular diseases
447.1
Stricture of artery
451.0 - 451.2
Phlebitis and thrombophlebitis of lower extremities
457.1
Other lymphedema
459.1 - 459.2
Postphlebitic syndrome and compression of vein
459.81 - 459.89
Other specified disorders of circulatory system
648.00 - 648.04
Diabetes mellitus complicating pregnancy, childbirth, or the puerperium
681.10 - 681.9, 682.6 - 682.7
Cellulitis and abscess of toe, foot, and leg
700
Corns and callosities
701.1
Keratoderma, acquired
703.0
Ingrowing nail
707.15
Ulcer of other part of foot
727.1
Bunion
757.0
Hereditary edema of legs
782.0
Disturbance of skin sensation
782.3
Edema
904.0 - 904.8
Injury to blood vessels of lower extremity
907.5
Late effect of injury to peripheral nerve of pelvic girdle and lower limb
908.3
Late effect of injury to blood vessels of head, neck, and extremities
956.0 - 956.9
Injury to peripheral nerve(s) of pelvic girdle and lower limb
Debridement of mycotic nails:
CPT codes covered if selection criteria are met:
11719
11720
11721
HCPCS codes covered if selection criteria are met:
G0127
Trimming of dystrophic nails, any number
ICD-9 codes covered if selection criteria are met::
110.1
Dermatophytosis of nail
250.00 - 250.93
Diabetes mellitus
356.0 - 356.9
Hereditary and idiopathic peripheral neuropathy
357.2
Polyneuropathy in diabetes
440.20 - 440.32
Atherosclerosis of native arteries and bypass graft of extremities
451.0 - 451.2
Phlebitis and thrombophlebitis of lower extremities
681.10 - 681.9, 682.6 - 682.7
Cellulitis and abscess of toe, foot, and leg
The above policy is based on the following references:
U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Foot care and supportive devices for the feet. Medicare Carriers Manual §2323. Baltimore, MD: HCFA; 2000.
U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Foot care. Medicare Carriers Manual §4120. Baltimore, MD: HCFA; 2000.
Louisiana Medicare Part B. Foot care. Medicare Part B Medical Policy. Baton Rouge, LA: Louisiana Medicare; February 2000. Available at: http://www.lamedicare.com/provider/medpol/footcare.asp. Accessed June 15, 2000.
Neale D, Adams I, eds. Common Foot Disorders. 2nd ed. New York, NY: Churchill Livingstone; 1985.
Melkus GD, Maillet N, Novak J, et al. Primary care cancer and diabetes complications screening of black women with type 2 diabetes. J Am Acad Nurse Pract. 2002;14(1):43-48.
Bending A. Fungal nail infections: Far more than an aesthetic problem. Br J Community Nurs. 2002;7(5):254-259.
Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with diabetes: A randomized controlled trial. JAMA. 2002;287(19):2552-2558.
American Academy of Dermatology, Guidelines/Outcomes Committee. Guidelines of care for superficial mycotic infections of the skin: Onychomycosis. J Am Acad Dermatol. 1996;34(1):116-121.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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