Showing posts with label ICD. Show all posts
Showing posts with label ICD. Show all posts
CPT CODE 92285 AND COVERED ICD code
Coverage Indications, Limitations, and/or Medical Necessity
External ocular photography is a non-invasive procedure used to photo-document conditions of the external structures of the eye (e.g., eyelids, lashes, sclera, conjunctiva and cornea). External photography techniques may also be used to document conditions related to structures of the anterior segment of the eye. These would include the anterior chamber, iris, crystalline lens and filtration angle.
External ocular photography is accomplished by using a close-up hand-held camera, a slit-lamp-integrated camera, photography through a goniophotography lens or with a close-up stereo camera. In any case, the resulting photographs may be prints, slides, videotapes or digitally stored.
This procedure may be indicated when photo-documentation is required to track the progression or lack of progression of an eye condition, or to document the progression of a particular course of treatment. While many conditions of the eye could be photographed, this procedure should not be used to simply document the existence of a condition in order to enhance the medical record.
CPT/HCPCS Codes 92285 Eye photography
ICD-10 Codes that Support Medical Necessity
A18.52 Tuberculous keratitis
A18.59 Other tuberculosis of eye
B00.50 Herpesviral ocular disease, unspecified
B00.51 Herpesviral iridocyclitis
B00.52 Herpesviral keratitis
B00.59 Other herpesviral disease of eye
B02.30 Zoster ocular disease, unspecified
B02.31 Zoster conjunctivitis
B02.32 Zoster iridocyclitis
B02.33 Zoster keratitis
B02.34 Zoster scleritis
B02.39 Other herpes zoster eye disease
B60.12 Conjunctivitis due to Acanthamoeba
B60.13 Keratoconjunctivitis due to Acanthamoeba
C43.10 Malignant melanoma of unspecified eyelid, including canthus
C43.11 Malignant melanoma of right eyelid, including canthus
C43.12 Malignant melanoma of left eyelid, including canthus
C44.101 Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus
C44.102 Unspecified malignant neoplasm of skin of right eyelid, including canthus
C44.109 Unspecified malignant neoplasm of skin of left eyelid, including canthus
C44.111 Basal cell carcinoma of skin of unspecified eyelid, including canthus
C44.112 Basal cell carcinoma of skin of right eyelid, including canthus
C44.119 Basal cell carcinoma of skin of left eyelid, including canthus
C44.121 Squamous cell carcinoma of skin of unspecified eyelid, including canthus
C44.122 Squamous cell carcinoma of skin of right eyelid, including canthus
C44.129 Squamous cell carcinoma of skin of left eyelid, including canthus
C44.191 Other specified malignant neoplasm of skin of unspecified eyelid, including canthus
C44.192 Other specified malignant neoplasm of skin of right eyelid, including canthus
C44.199 Other specified malignant neoplasm of skin of left eyelid, including canthus
C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C69.00 Malignant neoplasm of unspecified conjunctiva
C69.01 Malignant neoplasm of right conjunctiva
C69.02 Malignant neoplasm of left conjunctiva
C69.10 Malignant neoplasm of unspecified cornea
C69.11 Malignant neoplasm of right cornea
C69.12 Malignant neoplasm of left cornea
C69.40 Malignant neoplasm of unspecified ciliary body
C69.41 Malignant neoplasm of right ciliary body
C69.42 Malignant neoplasm of left ciliary body
D03.10 Melanoma in situ of unspecified eyelid, including canthus
D03.11 Melanoma in situ of right eyelid, including canthus
D03.12 Melanoma in situ of left eyelid, including canthus
D04.10 Carcinoma in situ of skin of unspecified eyelid, including canthus
D04.11 Carcinoma in situ of skin of right eyelid, including canthus
D04.12 Carcinoma in situ of skin of left eyelid, including canthus
D09.20 Carcinoma in situ of unspecified eye
D09.21 Carcinoma in situ of right eye
D09.22 Carcinoma in situ of left eye
D22.10 Melanocytic nevi of unspecified eyelid, including canthus
D22.11 Melanocytic nevi of right eyelid, including canthus
D22.12 Melanocytic nevi of left eyelid, including canthus
D23.10 Other benign neoplasm of skin of unspecified eyelid, including canthus
D23.11 Other benign neoplasm of skin of right eyelid, including canthus
D23.12 Other benign neoplasm of skin of left eyelid, including canthus
D31.00 Benign neoplasm of unspecified conjunctiva
D31.01 Benign neoplasm of right conjunctiva
D31.02 Benign neoplasm of left conjunctiva
D31.10 Benign neoplasm of unspecified cornea
D31.11 Benign neoplasm of right cornea
D31.12 Benign neoplasm of left cornea
D31.40 Benign neoplasm of unspecified ciliary body
D31.41 Benign neoplasm of right ciliary body
D31.42 Benign neoplasm of left ciliary body
D48.5 Neoplasm of uncertain behavior of skin
D48.7 Neoplasm of uncertain behavior of other specified sites
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
H00.011 Hordeolum externum right upper eyelid
H00.012 Hordeolum externum right lower eyelid
H00.013 Hordeolum externum right eye, unspecified eyelid
H00.014 Hordeolum externum left upper eyelid
H00.015 Hordeolum externum left lower eyelid
H00.016 Hordeolum externum left eye, unspecified eyelid
H00.019 Hordeolum externum unspecified eye, unspecified eyelid
H00.021 Hordeolum internum right upper eyelid
H00.022 Hordeolum internum right lower eyelid
H00.023 Hordeolum internum right eye, unspecified eyelid
H00.024 Hordeolum internum left upper eyelid
H00.025 Hordeolum internum left lower eyelid
H00.026 Hordeolum internum left eye, unspecified eyelid
H00.029 Hordeolum internum unspecified eye, unspecified eyelid
H00.031 Abscess of right upper eyelid
H00.032 Abscess of right lower eyelid
H00.033 Abscess of eyelid right eye, unspecified eyelid
H00.034 Abscess of left upper eyelid
H00.035 Abscess of left lower eyelid
H00.036 Abscess of eyelid left eye, unspecified eyelid
H00.039 Abscess of eyelid unspecified eye, unspecified eyelid
H02.001 Unspecified entropion of right upper eyelid
H02.002 Unspecified entropion of right lower eyelid
H02.003 Unspecified entropion of right eye, unspecified eyelid
H02.004 Unspecified entropion of left upper eyelid
H02.005 Unspecified entropion of left lower eyelid
H02.006 Unspecified entropion of left eye, unspecified eyelid
H02.009 Unspecified entropion of unspecified eye, unspecified eyelid
H02.011 Cicatricial entropion of right upper eyelid
H02.012 Cicatricial entropion of right lower eyelid
H02.013 Cicatricial entropion of right eye, unspecified eyelid
H02.014 Cicatricial entropion of left upper eyelid
H02.015 Cicatricial entropion of left lower eyelid
H02.016 Cicatricial entropion of left eye, unspecified eyelid
H02.019 Cicatricial entropion of unspecified eye, unspecified eyelid
H02.021 Mechanical entropion of right upper eyelid
H02.022 Mechanical entropion of right lower eyelid
H02.023 Mechanical entropion of right eye, unspecified eyelid
H02.024 Mechanical entropion of left upper eyelid
H02.025 Mechanical entropion of left lower eyelid
H02.026 Mechanical entropion of left eye, unspecified eyelid
H02.029 Mechanical entropion of unspecified eye, unspecified eyelid
H02.031 Senile entropion of right upper eyelid
H02.032 Senile entropion of right lower eyelid
H02.033 Senile entropion of right eye, unspecified eyelid
H02.034 Senile entropion of left upper eyelid
H02.035 Senile entropion of left lower eyelid
H02.036 Senile entropion of left eye, unspecified eyelid
H02.039 Senile entropion of unspecified eye, unspecified eyelid
H02.041 Spastic entropion of right upper eyelid
H02.042 Spastic entropion of right lower eyelid
H02.043 Spastic entropion of right eye, unspecified eyelid
H02.044 Spastic entropion of left upper eyelid
H02.045 Spastic entropion of left lower eyelid
H02.046 Spastic entropion of left eye, unspecified eyelid
H02.049 Spastic entropion of unspecified eye, unspecified eyelid
H02.051 Trichiasis without entropian right upper eyelid
H02.052 Trichiasis without entropian right lower eyelid
H02.053 Trichiasis without entropian right eye, unspecified eyelid
H02.054 Trichiasis without entropian left upper eyelid
H02.055 Trichiasis without entropian left lower eyelid
H02.056 Trichiasis without entropian left eye, unspecified eyelid
H02.059 Trichiasis without entropian unspecified eye, unspecified eyelid
H02.101 Unspecified ectropion of right upper eyelid
H02.102 Unspecified ectropion of right lower eyelid
H02.103 Unspecified ectropion of right eye, unspecified eyelid
H02.104 Unspecified ectropion of left upper eyelid
H02.105 Unspecified ectropion of left lower eyelid
H02.106 Unspecified ectropion of left eye, unspecified eyelid
H02.109 Unspecified ectropion of unspecified eye, unspecified eyelid
H02.111 Cicatricial ectropion of right upper eyelid
H02.112 Cicatricial ectropion of right lower eyelid
H02.113 Cicatricial ectropion of right eye, unspecified eyelid
H02.114 Cicatricial ectropion of left upper eyelid
H02.115 Cicatricial ectropion of left lower eyelid
H02.116 Cicatricial ectropion of left eye, unspecified eyelid
H02.119 Cicatricial ectropion of unspecified eye, unspecified eyelid
H02.121 Mechanical ectropion of right upper eyelid
H02.122 Mechanical ectropion of right lower eyelid
H02.123 Mechanical ectropion of right eye, unspecified eyelid
H02.124 Mechanical ectropion of left upper eyelid
H02.125 Mechanical ectropion of left lower eyelid
H02.126 Mechanical ectropion of left eye, unspecified eyelid
H02.129 Mechanical ectropion of unspecified eye, unspecified eyelid
H02.131 Senile ectropion of right upper eyelid
H02.132 Senile ectropion of right lower eyelid
H02.133 Senile ectropion of right eye, unspecified eyelid
H02.134 Senile ectropion of left upper eyelid
H02.135 Senile ectropion of left lower eyelid
H02.136 Senile ectropion of left eye, unspecified eyelid
H02.139 Senile ectropion of unspecified eye, unspecified eyelid
H02.141 Spastic ectropion of right upper eyelid
H02.142 Spastic ectropion of right lower eyelid
H02.143 Spastic ectropion of right eye, unspecified eyelid
H02.144 Spastic ectropion of left upper eyelid
H02.145 Spastic ectropion of left lower eyelid
H02.146 Spastic ectropion of left eye, unspecified eyelid
H02.149 Spastic ectropion of unspecified eye, unspecified eyelid
H02.201 Unspecified lagophthalmos right upper eyelid
H02.202 Unspecified lagophthalmos right lower eyelid
H02.203 Unspecified lagophthalmos right eye, unspecified eyelid
H02.204 Unspecified lagophthalmos left upper eyelid
H02.205 Unspecified lagophthalmos left lower eyelid
H02.206 Unspecified lagophthalmos left eye, unspecified eyelid
H02.209 Unspecified lagophthalmos unspecified eye, unspecified eyelid
H02.211 Cicatricial lagophthalmos right upper eyelid
H02.212 Cicatricial lagophthalmos right lower eyelid
H02.213 Cicatricial lagophthalmos right eye, unspecified eyelid
H02.214 Cicatricial lagophthalmos left upper eyelid
H02.215 Cicatricial lagophthalmos left lower eyelid
H02.216 Cicatricial lagophthalmos left eye, unspecified eyelid
H02.219 Cicatricial lagophthalmos unspecified eye, unspecified eyelid
H02.221 Mechanical lagophthalmos right upper eyelid
H02.222 Mechanical lagophthalmos right lower eyelid
H02.223 Mechanical lagophthalmos right eye, unspecified eyelid
H02.224 Mechanical lagophthalmos left upper eyelid
H02.225 Mechanical lagophthalmos left lower eyelid
H02.226 Mechanical lagophthalmos left eye, unspecified eyelid
H02.229 Mechanical lagophthalmos unspecified eye, unspecified eyelid
H02.231 Paralytic lagophthalmos right upper eyelid
H02.232 Paralytic lagophthalmos right lower eyelid
H02.233 Paralytic lagophthalmos right eye, unspecified eyelid
H02.234 Paralytic lagophthalmos left upper eyelid
H02.235 Paralytic lagophthalmos left lower eyelid
H02.236 Paralytic lagophthalmos left eye, unspecified eyelid
H02.239 Paralytic lagophthalmos unspecified eye, unspecified eyelid
H02.30 Blepharochalasis unspecified eye, unspecified eyelid
and Many more....
URIBEL - Drug usage, cost, warning and precautions
URIBEL- methenamine, sodium phosphate, monobasic, monohydrate, phenyls alicylate, methylene blue, and hyoscyamine sulfate capsule
Uribel is a medicine mainly used to cause relief for the pain and discomfort when urinating as well as the frequent urge to urinate. It is also used to help reduce the chance of infection after a medical procedure in the urinary tract. Uribel is mainly made of two components- Methenamine and Salicylate. Patients who have a tendency to have cramps or spasms in their urinary tract are generally prescribed to use this medicine, however, there might be side effects to it so you must use this if only prescribed by a doctor. You are not able to access this medicine without a prescription anyways; just make sure to use as directed. Keep in mind that complications may arise in small children so it is better not to use this medication for children.
A Guide To Using Uribel
Uribel is a rather popular medicine that has been used to cure different kinds of discomfort that can be caused by any irritations or any infections in the urinary tract. It is mostly prescribed to a patient when they are suffering from severe pain, burning or spasms caused by a urinary tract infection.
At the same time it must be noted that Uribel is in no way an antibiotic and this is why it cannot and should not be used to cure a urinary tract infection. It’s main purpose, simply put, is to relieve the patient of the pain that is caused as a result of the infection.
As mentioned earlier, Uribel is made of two major ingredients. The Methenamine is actually a type of antibiotic. There is another variant of this called Methylene blue which is antiseptic in nature. Both of these two are used to help prevent the growth of bacteria in urine and thus it will typically reduce the chance of any infection. Salicylate on the other hand is kind of an Aspirin. It helps to reduce pain and is what helps in giving relief to the user. It also has some additional ingredients like sodium phosphate and benzoic acid which are what helps to make the urine more acidic. What the acidic nature of urine helps with is to make the methenamine work more efficiently. All of these different ingredients work together to give Uribel the helping abilities it has.
The dose and use of Uribel tends to vary from person to person depending on their age, symptoms, nature of ailment etc. Normally this medicine is to be taken orally and with a full glass of water; it is highly advisable not to lie down for at least ten minutes after taking this medication. Some may face stomach aches or pains which is quite typical. If that happens to be the case, then it is recommended to then take Uribel with some food or a meal. The normal frequency when it comes to the dosage of this medicine is four times a day, but it may vary according to the symptoms. The medicine usually takes 1 or 2 days to start the seeing improvement in your condition, so if you do not see any improvement even after 2 to 3 days of use, it is important to with your doctor since Uribel might not be the right medication for you. Also if you face pain or any burning sensation while urinating, consult your doctor immediately as this is a serious reaction that should be taken seriously.
Why is Uribel so effective?
Uribel is considered the go to medicine for relieving the above mentioned discomforts by doctors. This is because where other medicines contain just one ingredient, usually an analgesic meant for pain relief, Uribel is power packed with five ingredients i.e. antiseptic agents to avoid the growth of bacteria in the urinary tract, an antispasmodic that relaxes the muscle tissue of the urinary tract and a pain reliever that reduces the discomfort fromburning sensations and relieves pain.
INDICATIONS AND USAGE
Uribel caps ules indicated for the treatment of symptoms of irritative voiding. Indicated for the relief of local symptoms, such as inflammation, hypermotility, and pain, which accompany lower urinary tract infections. Indicated for the relief of urinary tract symptoms caused by diagnostic procedures.
CONTRAINDICATIONS
Hypersensitivity to any of the ingredients is possible. Risk benefits should be carefully considered when the following medical problems exist: cardiac disease (especially cardiac arrhythmias, congestive heart failure, coronary heart disease, and mitral stenosis); gastrointestinal tract obstructive disease; glaucoma; myasthenia gravis, acute urinary retention may be precipitated in obstructive uropathy (such as bladder neck obstruction due to prostatic hypertrophy).
WARNINGS
Do not exceed recommended dosage. If rapid pulse, dizziness or blurring of vision occurs discontinue use immediately.
When to avoid taking Uribel?
As with most medicines, there are precautions that need to be taken with the use of Uribel as well. Before your doctor prescribes this medicine to you, you must reveal to him or her whether you have any of the following conditions: -
-Glaucoma
-Heart diseases
-Stomach ailments
-Bladder obstruction
-Intestine ulcers
-Myasthenia gravis
-Enlarged prostate
-If you are breast feeding
-If you are pregnant
-If you are trying to get pregnant
-If you have trouble passing urine
It is not yet established whether the ingredients present in Uribel harm an unborn baby. This is why it is advised that you avoid this medication if you are pregnant and even if you are breast feeding, as the ingredients can be passed on to the nursing baby via breast milk which can be harmful for the little one.
Similarly, this medicine is not meant for children or infants either. Elderly people who take this medicine might experience side effects like drowsiness, confusion or agitation.
PRECAUTIONS
Cross sensitivity and/or related problem
patients intolerant of belladonna alkaloids or salicylates may be intolerant of this medication also. Delay in gastric emptying could complicate the management of gastric ulcers.
Pregnancy/Reproduction (FDA Pregnancy Category C)
hyoscyamine and methenamine cross the placenta. Studies concerning the effect of hyoscyamine and methenamine on pregnancy and reproduction have not been done in animals or humans. Thus it is not known whether Uribel caps ules cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Uribel caps ules should be given to a pregnant woman only if clearly needed.
Breast feeding
problems in humans have not been documented; however, methenamine and traces of hyoscyamine are excreted in breast milk. Accordingly, Uribel caps ules should be given to a nursing mother with caution and only if clearly needed.
Prolonged use
there have been no studies to establish the safety of prolonged use in humans. No known long-term animal studies have been performed to evaluate carcinogenic potential.
Pediatric
infants and young children are especially susceptible to the toxic effect of the belladonna alkaloids.
Geriatric Use
use with caution in elderly patients as they may respond to usual doses of hyoscyamine with excitement, agitation, drowsiness or confusion.
CPT code J1980 - Injection, hyoscyamine sulfate, up to 0.25 mg - Please double confirm this one
This medicine has a problem when it comes to it’s reaction with caffeine. So it is highly recommended not to ingest any foods or beverages that contain a large amount of caffeine such as tea, coffee or cola. Having these foods and beverages when you are using Uribel would increase the chance of developing negative side effects as well as it will most likely decrease the effectiveness of this medication a great deal.
Dizziness, vomiting and nausea are some of the the main and most common side effects of this medicine. However, depending on the functionality of your body, some of the other side effects can also be observed; these side effects include drowsiness, dry mouth, blurred vision and in some cases constipation. If you have dry mouth, try to have some hard sugarless candy or sugarless chewing gum and make sure to drink enough of water and fluids throughout the day to keep yourself from becoming dehydrated. In some cases, this medicine can turn your stool and urine to a blue-green color, but no need to be worried since this is a totally normal side effect and harmless in nature. This is something that would go away as soon as you stop using this medicine. A few serious side effects include black/tarry stools, abdominal pain, easy bruising or bleeding etc. Contact your doctor immediately if you have any of these more serious side effects. Also, in very rare cases, patients may experience an attack of extremely high blood pressure, but this rarely happens and there are chances only if the patient is already under a lot of different drugs. It is important to be very clear with your doctor about any other medications you may be taking, even if they are over the counter just to make sure there won’t be any negative reactions.
Uribel increases your serotonin levels. This means that if you are already using any medicine that increases serotonin, using Uribel along with it would increase the chance of high amount of serotonin in your body which might result into serotonin syndrome. Serotonin syndrome symptoms include high body temperature, increased reflexes, agitation, dilated pupils, sweating, tremor and diarrhea and they can vary from mild to sever. Like mentioned before, it is always advisable to inform your doctor about all the medicine that you are currently taking so that the doctor can decide whether Uribel would be suitable for you or not. Otherwise, it may lead to unwanted complication and things can get worse.
Serious allergic reactions are very rare among the side effects of Uribel. In rare of the rarest cases, patient may experience severe allergic reaction and he/she should consult the doctor immediately if the symptom persists. Also, it is highly recommended that you ask your doctor about the possible side effects so that you can distinguish between the harmless and harmful side effects and this would reduce any unnecessary unrest among the patient. It is important to be educated about the harmless and harmful side effects of any medication you are taking to make sure you spot any before it is too late.
If you have any kind of allergy to anything, it is advisable to inform your doctor about that as the doctor would be able to determine if any of the substance in the medicine may cause allergic reaction or not. If you have not taken an allergy test, you should get one done immediately since it would not only let you know to which substances are you allergic to, but also decrease the chance of having allergic reaction due to medication. This would minimize a lot of suffering for you and this can even be a life-saver.
Using alcoholic beverages is a strict no while using this medicine, just like with all other prescription medications. Uribel, in some cases, has the ability to cause blurry vision and dizziness; using alcohol would only increase the intensity of this effect and hence it is extremely unsafe to drive, especially you feel any of these symptoms. Do not get involved into any activity that requires you to be on high alert and also do not use any machinery during medication if you feel drowsy. This would greatly impact your normal power and performance to apprehend things and the result may be devastating to yourself and other who may be around you.
It is also advisable for you to inform the doctor of your medical history in detail so that the doctor would be able to decide the dose that is applicable for you, or even if it is appropriate for you to be prescribed this medicine. If you have any liver or kidney problems, doctors may suggest an alternate medicine so that no complication arises. So be informative about your full medical history to your doctor for your own good and don’t keep anything hidden, not even any small thing.
Children who have the chickenpox or flu should not take this medicine. If they are suffering from any other disease or have received a recent vaccine for any flu, they should also avoid this medicine. Though extremely rare, this medicine may cause Reye’s syndrome in children if not used properly. Also, taking this medicine is also not advisable during pregnancy since it may cause harm to the unborn baby. It is very important to know that this medication mixes in with breast milk, so if you are breast feeding, either you have to stop breast feeding or you have to stop the medication. Please consult your doctor in such scenarios to decide which action to take.
Uribel has been known to have interactions with many substances that include, but is not limited to: atomoxetine, bupropion, buspirone, carbamazepine, cyclobenzaprine, dextromethorphan, maprotiline, methotrexate, mifepristone, potassium capsules/tablets, pramlintide and some other narcotic drugs. Any fatal interaction with any of these substances can cause extreme and serious side effects and this is why it is highly advisable not to take this medication without consulting a doctor first and foremost. This medicine may also interfere with a number of laboratory tests and hence may provide false results. It is recommended that you tell your doctor or laboratory operator that you use this medicine beforehand and they would be able to decide whether it is ok to go ahead with the lab test as well as to determine certain test results to be inaccurate.
As an adult, it is always expected that you take any kind of medicine in the specified amount. Anything more than the specified amount may lead to an overdose and the result of overdose can be fatal at times. If you have skipped any dose by mistake, do take the dose as soon as you remember. But if it is too late, you should skip the dose and continue with the next one. Also, never take two doses at once or too close to each other in order to compensate for the previously missed dose. This would only worsen the situation and would highly increase the chance of an overdose. The symptoms of overdose of Uribel consists of fever, fast heartbeat, severe drowsiness, seizures, unusual excitements or hallucinations. So if you experience any of these overdose symptoms, quickly get in touch with an emergency room or a poison control center.
There are certain cautions you need to follow while storing the medicine. This medicine cannot be kept in your bathroom where you normally keep your all other medicines like aspirins. This must be stored in the normal room temperature, in a dry, moist free area and must not be shared with anyone. Also, never pour this medicine, or any other medicines at that, into drains or flush it down in the toilet. Keep it away from extreme light exposure and also from the reach of children and pets. This may prove extremely harmful to them.
This medicine comes in the typical prescription bottles and normally there are 100 capsules in them. This is not an over the counter medicine and can only be used if prescribed by a doctor. Each capsule of Uribel contains 118 mg of methenamine, 40.8 mg of sodium phosphate monobasic, 36 mg of Phenyl salicylate, 10 mg of methylene blue and 0.12 mg of hyocyamine sulfate. This medication should never be used in treatment of a urinary tract infection. Rather, if you have a bacterial infection, some other antibiotic is normally prescribed for the treatment. It is also very dangerous for children under six years of age since they are more vulnerable and sensitive to the normal side effects. So keep the information stored in your mind that using Uribel for children under six years is a strict no. Also, antacids are known to decrease the functionality of this medicine by reducing the absorption rate in blood. So it is highly recommended to have this medicine at least one hour early before you take antacids.
This medication is likely to make you sweat less and thus it increases the chance of getting a heat stroke. You should avoid any hard work while on this medication and also avoid any activity that may increase the heat of your body. If you live in a hot area, try not to go out frequently and avoid standing under direct sunlight. And if you feel that your body is heating up, quickly look for a shade and take rest to allow your body to cool down. This medicine may also cause side effects like confusion, agitation and constipation among the older adults and the combination of drowsiness and confusion may lead to falling and hence it is also not very suitable for aged people.
Uribel is a widely used drug that is prescribed by doctors to help with a patient’s bladder sensitivity as well as any urinary discomfort. Please keep everything we have gone over in mind when making the decision to take this medication once it is prescribed to you.
Generic drug Brand drug Formulary chapter Effective date
Uro-MP Uribel® 1. Antibiotics & Other Drugs Used for Infection December 22, 2014
BRAND Name GENERIC name PRICING (AWP) INDICATION SIMILAR THERAPIES ON FORMULARY/AWP CODE*
UTA CAPS 120MG
methenamine/hyo scyamine/meth blue/sod phoscaps
$3.71/tab
For treatment of urinary tract infections
Uribel ($2.71/tab) and Ustell ($2.41/tab)
covered as T3 Exclude – 13 along with existing 120mg UTA and 90 days notice
ICD 10 CODE FOR URINARY TRACT INFECTIONS
O23.30 - Infections of prt urinary tract in pregnancy, unsp trimester
CODE Z87.440 - Personal history of urinary (tract) infections
O23.31 - Infect of prt urinary tract in pregnancy, first trimester
O23.32 - Infect of prt urinary tract in pregnancy, second trimester
O23.33 - Infect of prt urinary tract in pregnancy, third trimester
. For symptoms of bladder pain, medications such as Pyridium or Uribel can help soothe the bladder. Other medications to help with pain include NSAIDs (Ibuprofen) and Gabapentin. Amitriptyline is a medication that helps with bladder relaxation and pain. Some herbal medications have also been shown to improve symptoms. Cystoprotek has been used for its anti-inflammatory properties and may help the bladder lining to heal. You may find that acidic foods or drinks exacerbate your IC symptoms. Prelief may be recommended to take with meals. Prelief is an over-the-counter acid reducer that can take the acid out of your food and drinks. For chronic prostatitis patients, medications such as Rapaflo or Flomax are used to help relax the muscles of the bladder and prostate making urination easier.
Side effects of Uribel
The most common side effect of Uribel is the effect of the urine (and in some cases the stool) turning to a blue color. This is completely harmless and it ceases once the medicine is discontinued. Some other side effects of Uribel are-
-Vomiting
-Shortness of breath
-Blurred vision
-Dry mouth
-Inability to urinate
-Fast heartbeat
-Flushing
-Nausea
-Dizziness
-Drowsiness
You must immediately contact your doctor if any such side effects turn out to be rather severe. The same applies if you end up suffering from swelling, rash or severe itchiness. Remember, it is important to stick to the dose that has been recommended to you and not over consume the medicine. If you miss a dose then take it as soon as you can, unless it is time for the next dose in which case just forget about the missed one.
As always, please remember that this article is just an informational guide. Please consult with your doctor before you start using Uribel.
Uribel is a medicine mainly used to cause relief for the pain and discomfort when urinating as well as the frequent urge to urinate. It is also used to help reduce the chance of infection after a medical procedure in the urinary tract. Uribel is mainly made of two components- Methenamine and Salicylate. Patients who have a tendency to have cramps or spasms in their urinary tract are generally prescribed to use this medicine, however, there might be side effects to it so you must use this if only prescribed by a doctor. You are not able to access this medicine without a prescription anyways; just make sure to use as directed. Keep in mind that complications may arise in small children so it is better not to use this medication for children.
A Guide To Using Uribel
Uribel is a rather popular medicine that has been used to cure different kinds of discomfort that can be caused by any irritations or any infections in the urinary tract. It is mostly prescribed to a patient when they are suffering from severe pain, burning or spasms caused by a urinary tract infection.
At the same time it must be noted that Uribel is in no way an antibiotic and this is why it cannot and should not be used to cure a urinary tract infection. It’s main purpose, simply put, is to relieve the patient of the pain that is caused as a result of the infection.
As mentioned earlier, Uribel is made of two major ingredients. The Methenamine is actually a type of antibiotic. There is another variant of this called Methylene blue which is antiseptic in nature. Both of these two are used to help prevent the growth of bacteria in urine and thus it will typically reduce the chance of any infection. Salicylate on the other hand is kind of an Aspirin. It helps to reduce pain and is what helps in giving relief to the user. It also has some additional ingredients like sodium phosphate and benzoic acid which are what helps to make the urine more acidic. What the acidic nature of urine helps with is to make the methenamine work more efficiently. All of these different ingredients work together to give Uribel the helping abilities it has.
The dose and use of Uribel tends to vary from person to person depending on their age, symptoms, nature of ailment etc. Normally this medicine is to be taken orally and with a full glass of water; it is highly advisable not to lie down for at least ten minutes after taking this medication. Some may face stomach aches or pains which is quite typical. If that happens to be the case, then it is recommended to then take Uribel with some food or a meal. The normal frequency when it comes to the dosage of this medicine is four times a day, but it may vary according to the symptoms. The medicine usually takes 1 or 2 days to start the seeing improvement in your condition, so if you do not see any improvement even after 2 to 3 days of use, it is important to with your doctor since Uribel might not be the right medication for you. Also if you face pain or any burning sensation while urinating, consult your doctor immediately as this is a serious reaction that should be taken seriously.
Why is Uribel so effective?
Uribel is considered the go to medicine for relieving the above mentioned discomforts by doctors. This is because where other medicines contain just one ingredient, usually an analgesic meant for pain relief, Uribel is power packed with five ingredients i.e. antiseptic agents to avoid the growth of bacteria in the urinary tract, an antispasmodic that relaxes the muscle tissue of the urinary tract and a pain reliever that reduces the discomfort fromburning sensations and relieves pain.
INDICATIONS AND USAGE
Uribel caps ules indicated for the treatment of symptoms of irritative voiding. Indicated for the relief of local symptoms, such as inflammation, hypermotility, and pain, which accompany lower urinary tract infections. Indicated for the relief of urinary tract symptoms caused by diagnostic procedures.
CONTRAINDICATIONS
Hypersensitivity to any of the ingredients is possible. Risk benefits should be carefully considered when the following medical problems exist: cardiac disease (especially cardiac arrhythmias, congestive heart failure, coronary heart disease, and mitral stenosis); gastrointestinal tract obstructive disease; glaucoma; myasthenia gravis, acute urinary retention may be precipitated in obstructive uropathy (such as bladder neck obstruction due to prostatic hypertrophy).
WARNINGS
Do not exceed recommended dosage. If rapid pulse, dizziness or blurring of vision occurs discontinue use immediately.
When to avoid taking Uribel?
As with most medicines, there are precautions that need to be taken with the use of Uribel as well. Before your doctor prescribes this medicine to you, you must reveal to him or her whether you have any of the following conditions: -
-Glaucoma
-Heart diseases
-Stomach ailments
-Bladder obstruction
-Intestine ulcers
-Myasthenia gravis
-Enlarged prostate
-If you are breast feeding
-If you are pregnant
-If you are trying to get pregnant
-If you have trouble passing urine
It is not yet established whether the ingredients present in Uribel harm an unborn baby. This is why it is advised that you avoid this medication if you are pregnant and even if you are breast feeding, as the ingredients can be passed on to the nursing baby via breast milk which can be harmful for the little one.
Similarly, this medicine is not meant for children or infants either. Elderly people who take this medicine might experience side effects like drowsiness, confusion or agitation.
PRECAUTIONS
Cross sensitivity and/or related problem
patients intolerant of belladonna alkaloids or salicylates may be intolerant of this medication also. Delay in gastric emptying could complicate the management of gastric ulcers.
Pregnancy/Reproduction (FDA Pregnancy Category C)
hyoscyamine and methenamine cross the placenta. Studies concerning the effect of hyoscyamine and methenamine on pregnancy and reproduction have not been done in animals or humans. Thus it is not known whether Uribel caps ules cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Uribel caps ules should be given to a pregnant woman only if clearly needed.
Breast feeding
problems in humans have not been documented; however, methenamine and traces of hyoscyamine are excreted in breast milk. Accordingly, Uribel caps ules should be given to a nursing mother with caution and only if clearly needed.
Prolonged use
there have been no studies to establish the safety of prolonged use in humans. No known long-term animal studies have been performed to evaluate carcinogenic potential.
Pediatric
infants and young children are especially susceptible to the toxic effect of the belladonna alkaloids.
Geriatric Use
use with caution in elderly patients as they may respond to usual doses of hyoscyamine with excitement, agitation, drowsiness or confusion.
CPT code J1980 - Injection, hyoscyamine sulfate, up to 0.25 mg - Please double confirm this one
This medicine has a problem when it comes to it’s reaction with caffeine. So it is highly recommended not to ingest any foods or beverages that contain a large amount of caffeine such as tea, coffee or cola. Having these foods and beverages when you are using Uribel would increase the chance of developing negative side effects as well as it will most likely decrease the effectiveness of this medication a great deal.
Dizziness, vomiting and nausea are some of the the main and most common side effects of this medicine. However, depending on the functionality of your body, some of the other side effects can also be observed; these side effects include drowsiness, dry mouth, blurred vision and in some cases constipation. If you have dry mouth, try to have some hard sugarless candy or sugarless chewing gum and make sure to drink enough of water and fluids throughout the day to keep yourself from becoming dehydrated. In some cases, this medicine can turn your stool and urine to a blue-green color, but no need to be worried since this is a totally normal side effect and harmless in nature. This is something that would go away as soon as you stop using this medicine. A few serious side effects include black/tarry stools, abdominal pain, easy bruising or bleeding etc. Contact your doctor immediately if you have any of these more serious side effects. Also, in very rare cases, patients may experience an attack of extremely high blood pressure, but this rarely happens and there are chances only if the patient is already under a lot of different drugs. It is important to be very clear with your doctor about any other medications you may be taking, even if they are over the counter just to make sure there won’t be any negative reactions.
Uribel increases your serotonin levels. This means that if you are already using any medicine that increases serotonin, using Uribel along with it would increase the chance of high amount of serotonin in your body which might result into serotonin syndrome. Serotonin syndrome symptoms include high body temperature, increased reflexes, agitation, dilated pupils, sweating, tremor and diarrhea and they can vary from mild to sever. Like mentioned before, it is always advisable to inform your doctor about all the medicine that you are currently taking so that the doctor can decide whether Uribel would be suitable for you or not. Otherwise, it may lead to unwanted complication and things can get worse.
Serious allergic reactions are very rare among the side effects of Uribel. In rare of the rarest cases, patient may experience severe allergic reaction and he/she should consult the doctor immediately if the symptom persists. Also, it is highly recommended that you ask your doctor about the possible side effects so that you can distinguish between the harmless and harmful side effects and this would reduce any unnecessary unrest among the patient. It is important to be educated about the harmless and harmful side effects of any medication you are taking to make sure you spot any before it is too late.
If you have any kind of allergy to anything, it is advisable to inform your doctor about that as the doctor would be able to determine if any of the substance in the medicine may cause allergic reaction or not. If you have not taken an allergy test, you should get one done immediately since it would not only let you know to which substances are you allergic to, but also decrease the chance of having allergic reaction due to medication. This would minimize a lot of suffering for you and this can even be a life-saver.
Using alcoholic beverages is a strict no while using this medicine, just like with all other prescription medications. Uribel, in some cases, has the ability to cause blurry vision and dizziness; using alcohol would only increase the intensity of this effect and hence it is extremely unsafe to drive, especially you feel any of these symptoms. Do not get involved into any activity that requires you to be on high alert and also do not use any machinery during medication if you feel drowsy. This would greatly impact your normal power and performance to apprehend things and the result may be devastating to yourself and other who may be around you.
It is also advisable for you to inform the doctor of your medical history in detail so that the doctor would be able to decide the dose that is applicable for you, or even if it is appropriate for you to be prescribed this medicine. If you have any liver or kidney problems, doctors may suggest an alternate medicine so that no complication arises. So be informative about your full medical history to your doctor for your own good and don’t keep anything hidden, not even any small thing.
Children who have the chickenpox or flu should not take this medicine. If they are suffering from any other disease or have received a recent vaccine for any flu, they should also avoid this medicine. Though extremely rare, this medicine may cause Reye’s syndrome in children if not used properly. Also, taking this medicine is also not advisable during pregnancy since it may cause harm to the unborn baby. It is very important to know that this medication mixes in with breast milk, so if you are breast feeding, either you have to stop breast feeding or you have to stop the medication. Please consult your doctor in such scenarios to decide which action to take.
Uribel has been known to have interactions with many substances that include, but is not limited to: atomoxetine, bupropion, buspirone, carbamazepine, cyclobenzaprine, dextromethorphan, maprotiline, methotrexate, mifepristone, potassium capsules/tablets, pramlintide and some other narcotic drugs. Any fatal interaction with any of these substances can cause extreme and serious side effects and this is why it is highly advisable not to take this medication without consulting a doctor first and foremost. This medicine may also interfere with a number of laboratory tests and hence may provide false results. It is recommended that you tell your doctor or laboratory operator that you use this medicine beforehand and they would be able to decide whether it is ok to go ahead with the lab test as well as to determine certain test results to be inaccurate.
As an adult, it is always expected that you take any kind of medicine in the specified amount. Anything more than the specified amount may lead to an overdose and the result of overdose can be fatal at times. If you have skipped any dose by mistake, do take the dose as soon as you remember. But if it is too late, you should skip the dose and continue with the next one. Also, never take two doses at once or too close to each other in order to compensate for the previously missed dose. This would only worsen the situation and would highly increase the chance of an overdose. The symptoms of overdose of Uribel consists of fever, fast heartbeat, severe drowsiness, seizures, unusual excitements or hallucinations. So if you experience any of these overdose symptoms, quickly get in touch with an emergency room or a poison control center.
There are certain cautions you need to follow while storing the medicine. This medicine cannot be kept in your bathroom where you normally keep your all other medicines like aspirins. This must be stored in the normal room temperature, in a dry, moist free area and must not be shared with anyone. Also, never pour this medicine, or any other medicines at that, into drains or flush it down in the toilet. Keep it away from extreme light exposure and also from the reach of children and pets. This may prove extremely harmful to them.
This medicine comes in the typical prescription bottles and normally there are 100 capsules in them. This is not an over the counter medicine and can only be used if prescribed by a doctor. Each capsule of Uribel contains 118 mg of methenamine, 40.8 mg of sodium phosphate monobasic, 36 mg of Phenyl salicylate, 10 mg of methylene blue and 0.12 mg of hyocyamine sulfate. This medication should never be used in treatment of a urinary tract infection. Rather, if you have a bacterial infection, some other antibiotic is normally prescribed for the treatment. It is also very dangerous for children under six years of age since they are more vulnerable and sensitive to the normal side effects. So keep the information stored in your mind that using Uribel for children under six years is a strict no. Also, antacids are known to decrease the functionality of this medicine by reducing the absorption rate in blood. So it is highly recommended to have this medicine at least one hour early before you take antacids.
This medication is likely to make you sweat less and thus it increases the chance of getting a heat stroke. You should avoid any hard work while on this medication and also avoid any activity that may increase the heat of your body. If you live in a hot area, try not to go out frequently and avoid standing under direct sunlight. And if you feel that your body is heating up, quickly look for a shade and take rest to allow your body to cool down. This medicine may also cause side effects like confusion, agitation and constipation among the older adults and the combination of drowsiness and confusion may lead to falling and hence it is also not very suitable for aged people.
Uribel is a widely used drug that is prescribed by doctors to help with a patient’s bladder sensitivity as well as any urinary discomfort. Please keep everything we have gone over in mind when making the decision to take this medication once it is prescribed to you.
Generic drug Brand drug Formulary chapter Effective date
Uro-MP Uribel® 1. Antibiotics & Other Drugs Used for Infection December 22, 2014
BRAND Name GENERIC name PRICING (AWP) INDICATION SIMILAR THERAPIES ON FORMULARY/AWP CODE*
UTA CAPS 120MG
methenamine/hyo scyamine/meth blue/sod phoscaps
$3.71/tab
For treatment of urinary tract infections
Uribel ($2.71/tab) and Ustell ($2.41/tab)
covered as T3 Exclude – 13 along with existing 120mg UTA and 90 days notice
ICD 10 CODE FOR URINARY TRACT INFECTIONS
O23.30 - Infections of prt urinary tract in pregnancy, unsp trimester
CODE Z87.440 - Personal history of urinary (tract) infections
O23.31 - Infect of prt urinary tract in pregnancy, first trimester
O23.32 - Infect of prt urinary tract in pregnancy, second trimester
O23.33 - Infect of prt urinary tract in pregnancy, third trimester
. For symptoms of bladder pain, medications such as Pyridium or Uribel can help soothe the bladder. Other medications to help with pain include NSAIDs (Ibuprofen) and Gabapentin. Amitriptyline is a medication that helps with bladder relaxation and pain. Some herbal medications have also been shown to improve symptoms. Cystoprotek has been used for its anti-inflammatory properties and may help the bladder lining to heal. You may find that acidic foods or drinks exacerbate your IC symptoms. Prelief may be recommended to take with meals. Prelief is an over-the-counter acid reducer that can take the acid out of your food and drinks. For chronic prostatitis patients, medications such as Rapaflo or Flomax are used to help relax the muscles of the bladder and prostate making urination easier.
Side effects of Uribel
The most common side effect of Uribel is the effect of the urine (and in some cases the stool) turning to a blue color. This is completely harmless and it ceases once the medicine is discontinued. Some other side effects of Uribel are-
-Vomiting
-Shortness of breath
-Blurred vision
-Dry mouth
-Inability to urinate
-Fast heartbeat
-Flushing
-Nausea
-Dizziness
-Drowsiness
You must immediately contact your doctor if any such side effects turn out to be rather severe. The same applies if you end up suffering from swelling, rash or severe itchiness. Remember, it is important to stick to the dose that has been recommended to you and not over consume the medicine. If you miss a dose then take it as soon as you can, unless it is time for the next dose in which case just forget about the missed one.
As always, please remember that this article is just an informational guide. Please consult with your doctor before you start using Uribel.
ICD-10 codes that support medical necessity for chiropractor services
The chiropractic local coverage determinations (LCDs) for MACs include ICD-10 coding Information for ICD-10 codes that support the medical necessity for chiropractor
services. There may be additional documentation information in your LCD. There are links to the chiropractic LCDs in the Additional information section of this article.
The group 1 (primary) codes are the only covered ICD-10-CM codes that support medical necessity for chiropractor services.
*** Primary: ICD-10-CM codes (names of vertebrae)
*** The precise level of subluxation must be listed as the primary diagnosis.
The groups 2, 3, and 4 ICD-10-CM codes support the medical necessity for diagnoses and involve short, moderate, and long term treatment:
*** Group 2 codes: Category I - ICD-10-CM diagnosis (diagnoses that generally require short-term treatment)
*** Group 3 codes: Category II - ICD-10-CM diagnosis (diagnoses that generally require moderate-term treatment)
*** Group 4 codes: Category III - ICD-10-CM diagnosis (diagnoses that may require long-term treatment) ICD-10 codes that do not support medical necessity are all ICD-10-CM codes not listed in LCDs under ICD-10-CM codes that support medical necessity.
Additional information
If you have any questions, please contact your MAC at their toll-free number. That number is available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html under - How Does It Work.
CPT CODE G0296, G0297 COVERAGE and payment Guide
Lung Cancer Screening Counseling and Annual
Screening for Lung Cancer With Low Dose Computed Tomography (LDCT)
Refer to “Medicare Coverage of Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)” for more information.
HCPCS/CPT Codes
G0296 – Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)
G0297 – Low dose CT scan (LDCT) for lung cancer screening ICD-10 Codes Z87.891
Who Is Covered
Medicare beneficiaries who fall into all of the following categories:
* Age 55–77 years
* Asymptomatic
* Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes)
* Current smoker or one who has quit smoking within the last 15 years
* Receive a written order for lung cancer screening with LDCT Frequency
Annually for covered Medicare beneficiaries
* First year: Before the first lung cancer LDCT screening, Medicare beneficiaries must receive a counseling and shared decision making visit
* Subsequent years: The Medicare beneficiary must receive a written order furnished during an appropriate visit with a physician or NPP Medicare Beneficiary Pays
* Copayment/coinsurance waived
* Deductible waived
Health Care Common Procedure Coding System (HCPCS) Codes
Effective for claims with dates of service on and after February 5, 2015, the following HCPCS codes are used for lung cancer screening with LDCT:
** G0296 – Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)
** G0297 – Low dose CT scan (LDCT) for lung cancer screening
In addition to the HCPCS code, these services must be billed with ICD-10 diagnosis code Z87.891 (personal history of tobacco use/personal history of nicotine dependence), ICD-9 diagnosis code V15.82.
NOTE: Contractors shall apply contractor-pricing to claims containing HCPCS G0296 and G0297 with dates of service February 5, 2015, through December 31, 2015.
CMS reviewed the evidence for lung cancer screening with low dose computed tomography (LDCT) and determined that the criteria listed above were met, enabling CMS to cover this “additional preventive service” under Medicare Part B.
CMS issued NCD 210.14 on August 21, 2105, that provides for Medicare coverage of screening for lung cancer with LDCT. Effective for claims with dates of service on and after February 5, 2015, Medicare beneficiaries must meet all of the following criteria:
** Be 55–77 years of age;
** Be asymptomatic (no signs or symptoms of lung cancer);
** Have a tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
** Be a current smoker or one who has quit smoking within the last 15 years; and,
** Receive a written order for lung cancer screening with LDCT that meets the requirements described in the NCD.
Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary’s medical record, and must contain the following information:
** Date of birth;
** Actual pack–year smoking history (number);
** Current smoking status, and for former smokers, the number of years since quitting smoking;
** A statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and,
** The National Provider Identifier (NPI) of the ordering practitioner.
Counseling and Shared Decision-Making Visit
Before the first lung cancer LDCT screening occurs, the beneficiary must receive a written order for LDCT lung cancer screening during a lung cancer screening counseling and shared decision-making visit that includes the following elements and is appropriately documented in the beneficiary’s medical records:
** Must be furnished by a physician (as defined in section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) as defined in section1861(aa)(5) of the Act); and
** Must include all of the following elements:
o Determination of beneficiary eligibility including age, absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;
o Shared decision-making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure;
o Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of co-morbidities, and ability or willingness to undergo diagnosis and treatment;
o Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions; and,
o If appropriate, the furnishing of a written order for lung cancer screening with LDCT. Written orders for subsequent annual LDCT screens may be furnished during any appropriate
visit with a physician or qualified non-physician practitioner (PA, NP, or CNS)
CPT CODE 99183 AND G0277 - COVERAGE AND ICD code
Coverage Indications, Limitations, and/or Medical Necessity
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere (atm) pressure. Either a mono-place chamber pressurized with pure O2 or a larger multi-place chamber pressurized with compressed air where the patient receives pure O2 by mask, head tent, or endotracheal tube may be used.
Hyperbaric Oxygen Therapy serves four primary functions:
It increases the concentration of dissolved oxygen in the blood, which augments oxygenation to all parts of the body; and
It replaces inert gas in the bloodstream with oxygen, which is then metabolized by the body; and
It may stimulate the formation of a collagen matrix and angiogenesis; and
It acts as a bactericide for certain susceptible bacteria.
Developed as treatment for decompression illness, this modality is an established therapy for treating medical disorders such as carbon monoxide poisoning, gas gangrene, acute decompression illness and air embolism. HBO is also considered acceptable as adjunctive therapy in the treatment of sequelae of acute vascular compromise and in the management of some disorders that are refractory to standard medical and surgical care or the result of radiation injury.
Covered Conditions:
Program reimbursement for HBO therapy is limited to the following conditions:
Acute carbon monoxide intoxication,
Decompression illness,
Gas embolism,
Gas gangrene,
Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.
Progressive necrotizing infections (necrotizing fasciitis),
Acute peripheral arterial insufficiency,
Preparation and preservation of compromised skin grafts (not for primary management of wounds),
Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management,
Osteoradionecrosis as an adjunct to conventional treatment,
Soft tissue radionecrosis as an adjunct to conventional treatment,
Cyanide poisoning,
Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment,
Diabetic wounds of the lower extremities in patients who meet the following three criteria:
a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
b. Patient has a wound classified as Wagner grade III or higher; and
c. Patient has failed an adequate course of standard wound therapy.
The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 –days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.
Limitations
Topical Application of Oxygen
This method of administering oxygen does not meet the definition of HBO therapy as stated above, as its clinical efficacy has not been established. Therefore, Medicare considers the topical application of oxygen not reasonable and necessary. Medicare reimbursement will be limited to therapy that is administered in a chamber (including single or multi-place units)
CPT/HCPCS Codes
99183 Hyperbaric oxygen therapy
G0277 Hbot, full body chamber, 30m
Covered ICD-10 diagnoses codes may be downloaded at:
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR9252.zip, choose the spreadsheet 20.29 HBO Therapy.
PFT CPT 94010, 94750, 94250, 94200. 94060 AND 94010
CPT/HCPCS Codes
Group 1 Codes
94010 Breathing capacity test
94060 Evaluation of wheezing
94070 Evaluation of wheezing
94150 Vital capacity test
94200 Lung function test (MBC/MVV)
94250 Expired gas collection
94375 Respiratory flow volume loop
94620 Pulmonary stress test/simple
94621 Pulm stress test/complex
94726 Pulm funct tst plethysmograp
94727 Pulm function test by gas
94728 Pulm funct test oscillometry
94729 Co/membane diffuse capacity
94750 Pulmonary compliance study
Group 2 Paragraph
Part B
Group 2 Codes
94750 Pulmonary compliance study
94729 Co/membane diffuse capacity
94728 Pulm funct test oscillometry
94727 Pulm function test by gas
94726 Pulm funct tst plethysmograp
94621 Pulm stress test/complex
94620 Pulmonary stress test/simple
94375 Respiratory flow volume loop
94250 Expired gas collection
94200 Lung function test (MBC/MVV)
94070 Evaluation of wheezing
94060 Evaluation of wheezing
94010 Breathing capacity test
Group 1 Codes
B44.81 Allergic bronchopulmonary aspergillosis
C33 Malignant neoplasm of trachea
C34.00 Malignant neoplasm of unspecified main bronchus
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
C78.00 Secondary malignant neoplasm of unspecified lung
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.30 Secondary malignant neoplasm of unspecified respiratory organ
C78.39 Secondary malignant neoplasm of other respiratory organs
D14.2 Benign neoplasm of trachea
D14.30 Benign neoplasm of unspecified bronchus and lung
D14.31 Benign neoplasm of right bronchus and lung
D14.32 Benign neoplasm of left bronchus and lung
D57.01 Hb-SS disease with acute chest syndrome
D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
D57.411 Sickle-cell thalassemia with acute chest syndrome
D57.811 Other sickle-cell disorders with acute chest syndrome
D86.0 Sarcoidosis of lung
D86.1 Sarcoidosis of lymph nodes
D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.3 Sarcoidosis of skin
D86.81 Sarcoid meningitis
D86.82 Multiple cranial nerve palsies in sarcoidosis
D86.83 Sarcoid iridocyclitis
D86.84 Sarcoid pyelonephritis
D86.85 Sarcoid myocarditis
D86.86 Sarcoid arthropathy
D86.87 Sarcoid myositis
D86.89 Sarcoidosis of other sites
D86.9 Sarcoidosis, unspecified
E84.0 Cystic fibrosis with pulmonary manifestations
E84.19 Cystic fibrosis with other intestinal manifestations
G02 Meningitis in other infectious and parasitic diseases classified elsewhere
G47.30 Sleep apnea, unspecified
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.90 Septic pulmonary embolism without acute cor pulmonale
I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
J17 Pneumonia in diseases classified elsewhere
J18.8 Other pneumonia, unspecified organism
J18.9 Pneumonia, unspecified organism
J20.0 Acute bronchitis due to Mycoplasma pneumoniae
J20.1 Acute bronchitis due to Hemophilus influenzae
J20.2 Acute bronchitis due to streptococcus
J20.3 Acute bronchitis due to coxsackievirus
J20.4 Acute bronchitis due to parainfluenza virus
J20.5 Acute bronchitis due to respiratory syncytial virus
J20.6 Acute bronchitis due to rhinovirus
J20.7 Acute bronchitis due to echovirus
J20.8 Acute bronchitis due to other specified organisms
J20.9 Acute bronchitis, unspecified
J21.0 Acute bronchiolitis due to respiratory syncytial virus
J21.1 Acute bronchiolitis due to human metapneumovirus
J21.8 Acute bronchiolitis due to other specified organisms
J21.9 Acute bronchiolitis, unspecified
J22 Unspecified acute lower respiratory infection
J39.8 Other specified diseases of upper respiratory tract
J40 Bronchitis, not specified as acute or chronic
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J43.9 Emphysema, unspecified
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J60 Coalworker's pneumoconiosis
J61 Pneumoconiosis due to asbestos and other mineral fibers
J62.0 Pneumoconiosis due to talc dust
J62.8 Pneumoconiosis due to other dust containing silica
J63.0 Aluminosis (of lung)
J63.1 Bauxite fibrosis (of lung)
J63.2 Berylliosis
J63.3 Graphite fibrosis (of lung)
J63.4 Siderosis
J63.5 Stannosis
J63.6 Pneumoconiosis due to other specified inorganic dusts
J64 Unspecified pneumoconiosis
J65 Pneumoconiosis associated with tuberculosis
J66.0 Byssinosis
J66.1 Flax-dressers' disease
J66.2 Cannabinosis
J66.8 Airway disease due to other specific organic dusts
J67.0 Farmer's lung
J67.1 Bagassosis
J67.2 Bird fancier's lung
J67.3 Suberosis
J67.4 Maltworker's lung
J67.5 Mushroom-worker's lung
J67.6 Maple-bark-stripper's lung
J67.7 Air conditioner and humidifier lung
J67.8 Hypersensitivity pneumonitis due to other organic dusts
J67.9 Hypersensitivity pneumonitis due to unspecified organic dust
J68.4 Chronic respiratory conditions due to chemicals, gases, fumes and vapors
J68.8 Other respiratory conditions due to chemicals, gases, fumes and vapors
J68.9 Unspecified respiratory condition due to chemicals, gases, fumes and vapors
J70.0 Acute pulmonary manifestations due to radiation
J70.1 Chronic and other pulmonary manifestations due to radiation
J70.2 Acute drug-induced interstitial lung disorders
J70.3 Chronic drug-induced interstitial lung disorders
J70.4 Drug-induced interstitial lung disorders, unspecified
J70.5 Respiratory conditions due to smoke inhalation
J70.8 Respiratory conditions due to other specified external agents
J70.9 Respiratory conditions due to unspecified external agent
J80 Acute respiratory distress syndrome
J81.0 Acute pulmonary edema
J82 Pulmonary eosinophilia, not elsewhere classified
J84.01 Alveolar proteinosis
J84.02 Pulmonary alveolar microlithiasis
J84.09 Other alveolar and parieto-alveolar conditions
J84.10 Pulmonary fibrosis, unspecified
J84.111 Idiopathic interstitial pneumonia, not otherwise specified
J84.112 Idiopathic pulmonary fibrosis
J84.113 Idiopathic non-specific interstitial pneumonitis
J84.114 Acute interstitial pneumonitis
J84.115 Respiratory bronchiolitis interstitial lung disease
J84.116 Cryptogenic organizing pneumonia
J84.117 Desquamative interstitial pneumonia
J84.17 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
J84.2 Lymphoid interstitial pneumonia
J84.81 Lymphangioleiomyomatosis
J84.82 Adult pulmonary Langerhans cell histiocytosis
J84.89 Other specified interstitial pulmonary diseases
J84.9 Interstitial pulmonary disease, unspecified
J95.1 Acute pulmonary insufficiency following thoracic surgery
J95.2 Acute pulmonary insufficiency following nonthoracic surgery
J95.3 Chronic pulmonary insufficiency following surgery
J95.821 Acute postprocedural respiratory failure
J95.822 Acute and chronic postprocedural respiratory failure
J95.84 Transfusion-related acute lung injury (TRALI)
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.11 Chronic respiratory failure with hypoxia
J96.12 Chronic respiratory failure with hypercapnia
J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.91 Respiratory failure, unspecified with hypoxia
J96.92 Respiratory failure, unspecified with hypercapnia
J98.01 Acute bronchospasm
J98.09 Other diseases of bronchus, not elsewhere classified
J98.11 Atelectasis
J98.19 Other pulmonary collapse
J98.2 Interstitial emphysema
J98.3 Compensatory emphysema
J98.4 Other disorders of lung
J98.6 Disorders of diaphragm
J98.8 Other specified respiratory disorders
J99 Respiratory disorders in diseases classified elsewhere
M31.0 Hypersensitivity angiitis
M32.13 Lung involvement in systemic lupus erythematosus
M33.01 Juvenile dermatopolymyositis with respiratory involvement
M33.11 Other dermatopolymyositis with respiratory involvement
M33.21 Polymyositis with respiratory involvement
M33.91 Dermatopolymyositis, unspecified with respiratory involvement
M34.81 Systemic sclerosis with lung involvement
M35.02 Sicca syndrome with lung involvement
R04.2 Hemoptysis
R04.89 Hemorrhage from other sites in respiratory passages
R04.9 Hemorrhage from respiratory passages, unspecified
R05 Cough
R06.00 Dyspnea, unspecified
R06.01 Orthopnea
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.2 Wheezing
R06.3 Periodic breathing
R06.81 Apnea, not elsewhere classified
R06.82 Tachypnea, not elsewhere classified
R06.83 Snoring
R06.89 Other abnormalities of breathing
R09.2 Respiratory arrest
R91.1 Solitary pulmonary nodule
R91.8 Other nonspecific abnormal finding of lung field
Z01.811 Encounter for preprocedural respiratory examination
Z51.81 Encounter for therapeutic drug level monitoring
Group 1 Codes
94010 Breathing capacity test
94060 Evaluation of wheezing
94070 Evaluation of wheezing
94150 Vital capacity test
94200 Lung function test (MBC/MVV)
94250 Expired gas collection
94375 Respiratory flow volume loop
94620 Pulmonary stress test/simple
94621 Pulm stress test/complex
94726 Pulm funct tst plethysmograp
94727 Pulm function test by gas
94728 Pulm funct test oscillometry
94729 Co/membane diffuse capacity
94750 Pulmonary compliance study
Group 2 Paragraph
Part B
Group 2 Codes
94750 Pulmonary compliance study
94729 Co/membane diffuse capacity
94728 Pulm funct test oscillometry
94727 Pulm function test by gas
94726 Pulm funct tst plethysmograp
94621 Pulm stress test/complex
94620 Pulmonary stress test/simple
94375 Respiratory flow volume loop
94250 Expired gas collection
94200 Lung function test (MBC/MVV)
94070 Evaluation of wheezing
94060 Evaluation of wheezing
94010 Breathing capacity test
Group 1 Codes
B44.81 Allergic bronchopulmonary aspergillosis
C33 Malignant neoplasm of trachea
C34.00 Malignant neoplasm of unspecified main bronchus
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
C78.00 Secondary malignant neoplasm of unspecified lung
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.30 Secondary malignant neoplasm of unspecified respiratory organ
C78.39 Secondary malignant neoplasm of other respiratory organs
D14.2 Benign neoplasm of trachea
D14.30 Benign neoplasm of unspecified bronchus and lung
D14.31 Benign neoplasm of right bronchus and lung
D14.32 Benign neoplasm of left bronchus and lung
D57.01 Hb-SS disease with acute chest syndrome
D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
D57.411 Sickle-cell thalassemia with acute chest syndrome
D57.811 Other sickle-cell disorders with acute chest syndrome
D86.0 Sarcoidosis of lung
D86.1 Sarcoidosis of lymph nodes
D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.3 Sarcoidosis of skin
D86.81 Sarcoid meningitis
D86.82 Multiple cranial nerve palsies in sarcoidosis
D86.83 Sarcoid iridocyclitis
D86.84 Sarcoid pyelonephritis
D86.85 Sarcoid myocarditis
D86.86 Sarcoid arthropathy
D86.87 Sarcoid myositis
D86.89 Sarcoidosis of other sites
D86.9 Sarcoidosis, unspecified
E84.0 Cystic fibrosis with pulmonary manifestations
E84.19 Cystic fibrosis with other intestinal manifestations
G02 Meningitis in other infectious and parasitic diseases classified elsewhere
G47.30 Sleep apnea, unspecified
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.90 Septic pulmonary embolism without acute cor pulmonale
I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
J17 Pneumonia in diseases classified elsewhere
J18.8 Other pneumonia, unspecified organism
J18.9 Pneumonia, unspecified organism
J20.0 Acute bronchitis due to Mycoplasma pneumoniae
J20.1 Acute bronchitis due to Hemophilus influenzae
J20.2 Acute bronchitis due to streptococcus
J20.3 Acute bronchitis due to coxsackievirus
J20.4 Acute bronchitis due to parainfluenza virus
J20.5 Acute bronchitis due to respiratory syncytial virus
J20.6 Acute bronchitis due to rhinovirus
J20.7 Acute bronchitis due to echovirus
J20.8 Acute bronchitis due to other specified organisms
J20.9 Acute bronchitis, unspecified
J21.0 Acute bronchiolitis due to respiratory syncytial virus
J21.1 Acute bronchiolitis due to human metapneumovirus
J21.8 Acute bronchiolitis due to other specified organisms
J21.9 Acute bronchiolitis, unspecified
J22 Unspecified acute lower respiratory infection
J39.8 Other specified diseases of upper respiratory tract
J40 Bronchitis, not specified as acute or chronic
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J43.9 Emphysema, unspecified
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J60 Coalworker's pneumoconiosis
J61 Pneumoconiosis due to asbestos and other mineral fibers
J62.0 Pneumoconiosis due to talc dust
J62.8 Pneumoconiosis due to other dust containing silica
J63.0 Aluminosis (of lung)
J63.1 Bauxite fibrosis (of lung)
J63.2 Berylliosis
J63.3 Graphite fibrosis (of lung)
J63.4 Siderosis
J63.5 Stannosis
J63.6 Pneumoconiosis due to other specified inorganic dusts
J64 Unspecified pneumoconiosis
J65 Pneumoconiosis associated with tuberculosis
J66.0 Byssinosis
J66.1 Flax-dressers' disease
J66.2 Cannabinosis
J66.8 Airway disease due to other specific organic dusts
J67.0 Farmer's lung
J67.1 Bagassosis
J67.2 Bird fancier's lung
J67.3 Suberosis
J67.4 Maltworker's lung
J67.5 Mushroom-worker's lung
J67.6 Maple-bark-stripper's lung
J67.7 Air conditioner and humidifier lung
J67.8 Hypersensitivity pneumonitis due to other organic dusts
J67.9 Hypersensitivity pneumonitis due to unspecified organic dust
J68.4 Chronic respiratory conditions due to chemicals, gases, fumes and vapors
J68.8 Other respiratory conditions due to chemicals, gases, fumes and vapors
J68.9 Unspecified respiratory condition due to chemicals, gases, fumes and vapors
J70.0 Acute pulmonary manifestations due to radiation
J70.1 Chronic and other pulmonary manifestations due to radiation
J70.2 Acute drug-induced interstitial lung disorders
J70.3 Chronic drug-induced interstitial lung disorders
J70.4 Drug-induced interstitial lung disorders, unspecified
J70.5 Respiratory conditions due to smoke inhalation
J70.8 Respiratory conditions due to other specified external agents
J70.9 Respiratory conditions due to unspecified external agent
J80 Acute respiratory distress syndrome
J81.0 Acute pulmonary edema
J82 Pulmonary eosinophilia, not elsewhere classified
J84.01 Alveolar proteinosis
J84.02 Pulmonary alveolar microlithiasis
J84.09 Other alveolar and parieto-alveolar conditions
J84.10 Pulmonary fibrosis, unspecified
J84.111 Idiopathic interstitial pneumonia, not otherwise specified
J84.112 Idiopathic pulmonary fibrosis
J84.113 Idiopathic non-specific interstitial pneumonitis
J84.114 Acute interstitial pneumonitis
J84.115 Respiratory bronchiolitis interstitial lung disease
J84.116 Cryptogenic organizing pneumonia
J84.117 Desquamative interstitial pneumonia
J84.17 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
J84.2 Lymphoid interstitial pneumonia
J84.81 Lymphangioleiomyomatosis
J84.82 Adult pulmonary Langerhans cell histiocytosis
J84.89 Other specified interstitial pulmonary diseases
J84.9 Interstitial pulmonary disease, unspecified
J95.1 Acute pulmonary insufficiency following thoracic surgery
J95.2 Acute pulmonary insufficiency following nonthoracic surgery
J95.3 Chronic pulmonary insufficiency following surgery
J95.821 Acute postprocedural respiratory failure
J95.822 Acute and chronic postprocedural respiratory failure
J95.84 Transfusion-related acute lung injury (TRALI)
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.11 Chronic respiratory failure with hypoxia
J96.12 Chronic respiratory failure with hypercapnia
J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.91 Respiratory failure, unspecified with hypoxia
J96.92 Respiratory failure, unspecified with hypercapnia
J98.01 Acute bronchospasm
J98.09 Other diseases of bronchus, not elsewhere classified
J98.11 Atelectasis
J98.19 Other pulmonary collapse
J98.2 Interstitial emphysema
J98.3 Compensatory emphysema
J98.4 Other disorders of lung
J98.6 Disorders of diaphragm
J98.8 Other specified respiratory disorders
J99 Respiratory disorders in diseases classified elsewhere
M31.0 Hypersensitivity angiitis
M32.13 Lung involvement in systemic lupus erythematosus
M33.01 Juvenile dermatopolymyositis with respiratory involvement
M33.11 Other dermatopolymyositis with respiratory involvement
M33.21 Polymyositis with respiratory involvement
M33.91 Dermatopolymyositis, unspecified with respiratory involvement
M34.81 Systemic sclerosis with lung involvement
M35.02 Sicca syndrome with lung involvement
R04.2 Hemoptysis
R04.89 Hemorrhage from other sites in respiratory passages
R04.9 Hemorrhage from respiratory passages, unspecified
R05 Cough
R06.00 Dyspnea, unspecified
R06.01 Orthopnea
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.2 Wheezing
R06.3 Periodic breathing
R06.81 Apnea, not elsewhere classified
R06.82 Tachypnea, not elsewhere classified
R06.83 Snoring
R06.89 Other abnormalities of breathing
R09.2 Respiratory arrest
R91.1 Solitary pulmonary nodule
R91.8 Other nonspecific abnormal finding of lung field
Z01.811 Encounter for preprocedural respiratory examination
Z51.81 Encounter for therapeutic drug level monitoring
CPT code 10060 , 10061, 11055 With ICD code
procedure code and description
10060- INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE - average fee payment- $120 - $130
10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
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
Coding and Billing Guideliens
1. Report the appropriate procedure code and modifiers for the service(s) performed.
a. When reporting foot/nail care report the applicable “Q” modifier.
b. These services should be reported with quantity of one in the quantity/units field.
2. Report the ICD-9 code for which the service(s) is performed in the first position in the diagnosis field of the CMS 1500 claim form or electronic equivalent; report the systemic condition(s) in the remaining positions. Where the systemic condition is marked with an (*) (see below) and the services were rendered by a podiatrist, include the 8-digit (MM/DD/CCYY) date the patient was last seen and the NPI of his/her attending (MD/DO) physician who diagnosed the complicating condition in item 19 of the CMS 1500 claim form or electronic equivalent field, diabetes mellitus*
Chronic Thrombophlebitis*
Peripheral neuropathies involving the feet - Associated with malnutrition and vitamin deficiency*
Malnutrition (general, pellagra)
Alcoholism
Malabsorption (celiac disease, tropical sprue)
Pernicious anemia
Associated with carcinoma*
Associated with diabetes mellitus*
Associated with drugs and toxins*
Associated with multiple sclerosis*
Associated with uremia (chronic renal disease)* Hereditary sensory radicular neuropathy
Angiokeratoma corporis diffusum (fabry's)
Amyloid neuropathy
Long term oral anticoagulant therapy (e.g. Coumadin, Dicoumaral, etc.)* Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections.
3. When billing for services, requested by the beneficiary for denial, that are statutorily excluded by Medicare (i.e. Routine foot care), report an ICD-9 code that best describes the patients condition and the GY modifier (items or services statutorily excluded or does not meet the definition of any Medicare benefit)
4. When billing for services, requested by the beneficiary for denial, that would be considered not reasonable and necessary, report an ICD-9 code that best describes the patients condition and the GA modifier if an ABN signed by the beneficiary is on file or the GZ modifier (items or services expected to be denied as not reasonable) when there is no ABN for the service on file.
5. For patients on long term oral anticoagulant therapy, report the ICD-9 related to the performed service in the first position, the drug ICD-9 (V58.61) in the second position and the condition being treated with the anticoagulant in the third position of item 21 of the CMS 1500 claim form or electronic equivalent.
6. It is inappropriate and incorrect to report an E&M code when routine foot care or a nail trimming/debridement service is the service actually performed.
7. The following class finding modifiers should usually be used with G0127, 11055, 11056, 11057, 11719, and when appropriate, CPT codes 11720, 11721.
A Class A finding (Modifier Q7) Two of the Class B findings (Modifier Q8); or One Class B and two Class C findings (Modifier Q9).
8. Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the ICD-9 CM codes in list three of “ICD-9 Codes that Support
Medical Necessity” listed in the LCD.
9. A diagnosis of onychomycosis can allow 11720 or 11721 if it has either a Q modifier (but does not need a MD or DO last seen) or if it has one of the 6 ICD-9 codes listed in the special section for onychomycosis, i.e. difficulty with walking (681.10, 681.11, 703.0, 719.7, 729.5, 781.2).
Routine Foot Care
Except as provided above, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following:
The cutting or removal of corns and calluses;
The trimming, cutting, clipping, or debriding of nails; and Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.
Exceptions To Routine Foot Care Exclusion
1 - Necessary And Integral Part Of Otherwise Covered Services
In certain circumstances, services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.
2 - Presence Of Systemic Condition
The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from coverage). Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet.
In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions.
Coding Information
Date Last Seen by Attending Physician (for those ICD-9 CM codes which fall under the active care requirement): CPT codes 11055, 11056, 11057, 11719, and G0127 or 11720, 11721. The approximate date when the beneficiary was last seen by the M.D., D.O., who diagnosed the complicating condition (attending physician) must be reported in an 8-digit (MM/DD/YYYY) format in Item 19 of the CMS-1500 claim form or the electronic equivalent or if the patient sees their primary care physician no later than 30 days after the services were furnished.
For claims submitted to the fiscal intermediary:
Hospital Inpatient Claims:
The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB- 04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67. For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69.
Hospital Outpatient Claims:
• The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
• The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. RHC/FQHC encounters billed on TOBs 071x or 073x do not require HCPCS coding. Home health claims billed on 12X or 22X TOBs do not require HCPCS coding.
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number Care is considered routine unless the patient has a secondary diagnosis of a systemic disease and is under the active care of a doctor.
NATIONAL FOOT CARE MODIFIERS:
Q7 -- One (1) Class A finding
Q8 --Two (2) Class B findings
Q9 --One (1) Class B and Two (2) Class C findings
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
Coverage Indications, Limitations, and/or Medical Necessity
An abscess is a cavity containing pus surrounded by inflamed tissue. It is generally associated with pain, swelling and erythema. An abscess often requires incision and drainage to remove the purulent material in order for healing to occur.
Procedure codes 10060 and 10061 represent incision and drainage of an abscess involving the skin, subcutaneous and/or accessory structures. This includes the following types of abscess: furuncle, carbuncle, suppurative hidradenitis, an abscessed cyst, an abscessed paronychia, and/or other abscess involving the cutaneous and/or subcutaneous structures.
The use of incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures will be considered to be medically reasonable and necessary for the treatment of a symptomatic abscess (e.g. inflamed, painful, tender) involving these structures. This includes the incision and drainage of the following types of abscess:
furuncle;
carbuncle;
suppurative hidradenitis;
an abscessed cyst;
an abscessed paronychia; and/or
other abscess of cutaneous and/or subcutaneous structures.
It would not generally be expected to see incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures to be repeated frequently and/or multiple times. If frequent repeated incision and drainage is required, the medical record must reflect the reason for persistent/recurrent abscess formation, as well as any measures taken to prevent reoccurrence.
CPT/HCPCS Codes
10060 Drainage of skin abscess
10061 Drainage of skin abscess
Limitations
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.
The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.
Coding for Mycotic Nails
Although CPT coding does not exclusively apply CPT codes 11720 and 11721 to mycotic nails or to the feet, Medicare assumes these are the CPT codes usually used to code for services related to debriding mycotic nails.
Assuming services are being provided based on this indication, and the above requirements are documented, the claim should be coded with ICD-10 diagnosis code B35.1 as a primary code AND L02.611- L02.612, L03.031-L03.032, L03.041-L03.042, M79.671- M79.672, M79.674-M79.675 or R26.2 as a secondary code. Systemic condition modifiers are not necessary for services performed for this indication with these diagnosis codes.
The nail debridement procedure codes (11720-11721) are considered noncovered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care they must meet the same criteria as all other routine foot care services to be considered for payment.
Coding for Systemic Conditions
Foot care services are covered in the presence of a systemic condition based on the list of illnesses described in Chapter 15, Section 290 of the Benefit Policy Manual and coded by the following ICD-10 codes:
Diabetes mellitus*
E08.00-E13.9
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
I70.201-I70.92
I73.00-I73.01
I73.9
Buerger’s disease (thromboangiitis obliterans)
I73.1
Chronic thrombophlebitis*
I80.00-I80.3
Peripheral neuropathies involving the feet:
Associated with malnutrition and vitamin deficiency*
E56.9 and G63
Malnutrition (general, pellagra)*
E46, E52, or E64.0 and G63
Alcoholism*
G62.1
Malabsorption (celiac disease, tropical sprue)*
K90.0 or K90.1 and G63
Pernicious Anemia*
D51.0 and G63
Associated with carcinoma*
G13.0
Associated with diabetes mellitus*
E08.40
E08.42
E09.40
E09.42
E10.40
E10.42
E11.40
E11.42
E13.40
E13.42
Associated with drugs and toxins*
G62.0
G62.2
G62.82
Associated with multiple sclerosis*
G35 and G63
Associated with uremia (chronic renal disease)*
N18.1-N18.9 and G63
Associated with traumatic injury
S86.001A-S86.009S
S86.091A-S86.109S
S86.191A-S86.201S
S86.209A-S86.209S
S86.291A-S86.309S
S86.391A-S86.809S
S86.891A-S86.909S
S86.991A-S86.999S
S89.80XA-S89.92XS
S96.001A-S96.009S
S96.091A-S96.109S
S96.191A-S96.209S
S96.291A-S96.809S
S96.891A-S96.909S
S96.991A-S96.999S
S99.811A-S99.929S
and G63
Associated with leprosy or neurosyphilis
A30.0-A30.9 and G63
A52.10-A52.3 and G63
Associated with hereditary disorders
G60.0-G60.9
Heredity sensory radicular neuropathy
G60.0
Angiokeratoma corporis diffusum (Fabry's)
E75.21 and G63
Amyloid neuropathy
E85.0-E85.9 and G63
When the patient’s condition is one of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition. This must be indicated by the name and NPI of the attending physician in block 17 and 17B of the CMS-1500 or the equivalent electronic claim format. The date the patient was last seen by the attending physician should be billed in block 19. Claims for such routine services should show the complicating systemic disease in block 21 of the CMS-1500.
A presumption of coverage will be applied when the physician rendering the routine foot care has identified:
one (1) Class A finding using modifier Q7;
two (2) Class B findings using modifier Q8; or
one (1) Class B and two (2) Class C findings using modifier Q9.
In addition to a valid billing indicator, these services must include a systemic condition diagnosis listed above. All claims for routine foot care based on the presence of a systemic condition should have a billing indicator of Q7, Q8 or Q9 to be considered for payment.
Claims without a systemic diagnosis listed will be denied as noncovered routine-type foot care services.
Services not meeting the instructions and criteria in this statement of national coverage will be denied as statutory noncovered services. For ICD-10 codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the doctor of medicine or osteopathy.
Loss of protective sensation (LOPS) is not the subject of this LCD.
The following class finding modifiers should usually be used with G0127, 11055, 11056, 11057, 11719, and when appropriate, CPT codes 11720, 11721.
A Class A finding (Modifier Q7) Two of the Class B findings (Modifier Q8); or One Class B and two Class C findings (Modifier Q9).
Routine foot care CPT codes
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number Care is considered routine unless the patient has a secondary diagnosis of a systemic disease and is under the active care of a doctor.
NATIONAL FOOT CARE MODIFIERS:
Q7 -- One (1) Class A finding
Q8 --Two (2) Class B findings
Q9 --One (1) Class B and Two (2) Class C findings
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
ICD-10 Codes that Support Medical Necessity
K13.0 Diseases of lips
L02.01 Cutaneous abscess of face
L02.02 Furuncle of face
L02.03 Carbuncle of face
L02.11 Cutaneous abscess of neck
L02.12 Furuncle of neck
L02.13 Carbuncle of neck
L02.211 Cutaneous abscess of abdominal wall
L02.212 Cutaneous abscess of back [any part, except buttock]
L02.213 Cutaneous abscess of chest wall
L02.214 Cutaneous abscess of groin
L02.215 Cutaneous abscess of perineum
L02.216 Cutaneous abscess of umbilicus
L02.221 Furuncle of abdominal wall
L02.222 Furuncle of back [any part, except buttock]
L02.223 Furuncle of chest wall
L02.224 Furuncle of groin
L02.225 Furuncle of perineum
L02.226 Furuncle of umbilicus
L02.231 Carbuncle of abdominal wall
L02.232 Carbuncle of back [any part, except buttock]
L02.233 Carbuncle of chest wall
L02.234 Carbuncle of groin
L02.235 Carbuncle of perineum
L02.236 Carbuncle of umbilicus
L02.31 Cutaneous abscess of buttock
L02.32 Furuncle of buttock
L02.33 Carbuncle of buttock
L02.411 Cutaneous abscess of right axilla
L02.412 Cutaneous abscess of left axilla
L02.413 Cutaneous abscess of right upper limb
L02.414 Cutaneous abscess of left upper limb
L02.415 Cutaneous abscess of right lower limb
L02.416 Cutaneous abscess of left lower limb
L02.421 Furuncle of right axilla
L02.422 Furuncle of left axilla
L02.423 Furuncle of right upper limb
L02.424 Furuncle of left upper limb
L02.425 Furuncle of right lower limb
L02.426 Furuncle of left lower limb
L02.431 Carbuncle of right axilla
L02.432 Carbuncle of left axilla
L02.433 Carbuncle of right upper limb
L02.434 Carbuncle of left upper limb
L02.435 Carbuncle of right lower limb
L02.436 Carbuncle of left lower limb
L02.511 Cutaneous abscess of right hand
L02.512 Cutaneous abscess of left hand
L02.521 Furuncle right hand
L02.522 Furuncle left hand
L02.531 Carbuncle of right hand
L02.532 Carbuncle of left hand
L02.611 Cutaneous abscess of right foot
L02.612 Cutaneous abscess of left foot
L02.619 Cutaneous abscess of unspecified foot
L02.621 Furuncle of right foot
L02.622 Furuncle of left foot
L02.631 Carbuncle of right foot
L02.632 Carbuncle of left foot
L02.811 Cutaneous abscess of head [any part, except face]
L02.818 Cutaneous abscess of other sites
L02.821 Furuncle of head [any part, except face]
L02.828 Furuncle of other sites
L02.831 Carbuncle of head [any part, except face]
L02.838 Carbuncle of other sites
L02.91 Cutaneous abscess, unspecified
L02.92 Furuncle, unspecified
L02.93 Carbuncle, unspecified
L03.011 Cellulitis of right finger
L03.012 Cellulitis of left finger
L03.019 Cellulitis of unspecified finger
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.039 Cellulitis of unspecified toe
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.211 Cellulitis of face
L03.221 Cellulitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.811 Cellulitis of head [any part, except face]
L03.818 Cellulitis of other sites
L03.90 Cellulitis, unspecified
L73.2 Hidradenitis suppurativa
N48.21 Abscess of corpus cavernosum and penis
N48.22 Cellulitis of corpus cavernosum and penis
N48.29 Other inflammatory disorders of penis
N61 Inflammatory disorders of breast
Comment: A commenter stated if paronychia is considered a nail margin inflammation, then removing a portion of the nail plate and relieve the pressure with packing is appropriate. However, if there is an infection, then an incision and drainage is needed. CPT code 10060 or 10061 is appropriate in this case
Response: We agree if an infection is present and incision and drainage is necessary, then it is appropriate to report CPT code 10060. If no infection is present, and the nail plate is removed to relieve pressure, then it is inappropriate to use the incision and drainage CPT codes.
Comment: A commenter stated there are times when the nail (plate total or partial) needs to be avulsed in order to perform the incision and drainage for the abscess. Therefore, CPT codes10060 or 10061 is the appropriate and CPT code 11730 is incidental. This is consistent with the National Correct Coding Initiative (NCCI) which bundles CPT code 11730 into CPT codes 10060 and10061. We believe the LCD should be consistent with NCCI.
Response: If the avulsion of the nail plate alone is sufficient to drain the abscess, this is the service which should be billed, (i.e. 11730). If, however, it is necessary to remove part of the nail plate in order to complete the drainage of the abscess, then the incision and drainage codes are appropriate. We believe this is appropriately explained in the LCD and no change is necessary.
CPT CODE FOR Treatment of Ulcers and Symptomatic hyperkeratoses CPT 11042, 11043, 11044, 97597
For Medicare purposes, an "ulcer" does not exist until there is a partial thickness skin loss involving epidermis with or without dermis. Some authors will define a "pre-ulcer" condition and others even a "Stage 1 Ulcer" (e.g. "Wagner 0") where the skin is still intact. Such changes do not constitute an "ulcer" for Medicare payment purposes under this policy.
Ulcers may develop because of a combination of ischemia, infection, abscess, trauma, prolonged pressure, repetitive stress, edema, and loss of sensation.
The management of skin ulcers includes:
1. Overall medical and surgical treatment of the cause and
2. Meticulous care of the ulcerated skin and other associated soft tissue with application of medications and dressings, and
3. When reasonable and necessary, debridement of the necrotic and devitalized tissue and
4. Offloading of the external pressure source(s).
The management of a symptomatic hyperkeratosis may involve medical treatment, paring or cutting, shaving, excision, or destruction. This policy addresses only the paring or cutting approach.
This policy does not address treatment of burns or debridement of nails. For treatment of burns, including debridement, refer to the CPT 16000 series. For debridement of nails, refer to CPT codes 11720 and 11721.
When the only service provided is the non-surgical cleansing of the ulcer site with or without the application of a surgical dressing, the provider should bill this service with the appropriate evaluation and management (E/M) code and not bill a debridement code(s).
CPT codes 11042-11043, 97597 and 97598 describe debridement of relatively localized areas with or without their contiguous underlying structures. These codes are appropriate for treatment of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and debridement of ground-in dirt such as from road abrasions.
CPT codes 11042-11047 do not refer solely to ulcer size, but also to levels of actual tissue debridement levels (based on tissue type; e.g., partial skin, full thickness skin, subcutaneous tissue, etc.) of independent (non contiguous) skin and other deeper tissue structures.
When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of wounds that are the same depth, but do not combine wounds from different depths. This A/B MAC allows payment for an aggregate total of one independent tissue debridement on a given day of service. Any number greater than the aggregate total of four for one or both feet per date of service will result in a denial which may be appealed with documentation justifying the additional services. Once debridement is properly done repeat debridement is not expected for several days afterward.
CPT 97597 and 97598 may be used for the medically reasonable and necessary debridement with utilization consistent with this LCD and within scope of practice of the performing provider.
As is the case in all unusual and complicated procedures, the use of Modifier 22 may be appropriate to report and describe inordinately complex services performed. When used, the procedure note should contain a separate section that describes the "unusual" nature of the procedure.
When addressing a specific toe(s) or finger(s) use the respective CPT® HCPCS Level II modifier to identify them on the claim.
Other modifiers may include (but are not to be used alone when the more specific above modifiers are needed to clarify the procedure):
LT Left
RT Right
59 Independent Anatomical Site
XE Separate encounter
XS Separate Structure
XP Separate Practitioner
XU Unusual Non-Overlapping Service
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
CPT codes 11055, 11056, and 11057 will also be covered when billed with one of the diabetes, neurological or vascular disease diagnosis codes listed below any one of the following routine foot care diagnosis codes: B35.3, L60.1-L60.5, L60.8, L62, L84, M21.6X1, M21.6X2 or M21.6X9.
CPT/HCPCS Codes
Group 1 Codes:
10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE
10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS
11043 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS
11044 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS
11045 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
11046 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
11047 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
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
97597 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS
97598 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
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
E10.65* Type 1 diabetes mellitus with hyperglycemia
E10.69* Type 1 diabetes mellitus with other specified complication
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
E11.628* Type 2 diabetes mellitus with other skin complications
E11.65* Type 2 diabetes mellitus with hyperglycemia
E11.69* Type 2 diabetes mellitus with other specified complication
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
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
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
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
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I87.011 Postthrombotic syndrome with ulcer of right lower extremity
I87.012 Postthrombotic syndrome with ulcer of left lower extremity
I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity
I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity
I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity
I96* Gangrene, not elsewhere classified
K12.2 Cellulitis and abscess of mouth
K62.6 Ulcer of anus and rectum
L03.011 Cellulitis of right finger
L03.012 Cellulitis of left finger
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.211 Cellulitis of face
L03.221 Cellulitis of neck
L03.222 Acute lymphangitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.811 Cellulitis of head [any part, except face]
L05.01 Pilonidal cyst with abscess
L08.0 Pyoderma
L08.89 Other specified local infections of the skin and subcutaneous tissue
L12.0 Bullous pemphigoid
L59.8 Other specified disorders of the skin and subcutaneous tissue related to radiation
L73.8 Other specified follicular disorders
L89.012 Pressure ulcer of right elbow, stage 2
L89.013 Pressure ulcer of right elbow, stage 3
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *For ICD-10-CM codes E10.65, E10.620, E10.621, E10.622, E10.628, E10.69, E11.620, E11.621, E11.622, E11.628, E11.65, E11.69, the "specified manifestation" is skin ulcer. For clarity one should consider adding a 2nd ICD-10 code (L97.111, L97.112,
L97.113, L97.114, L97.121, L97.122, L697.123, L97.124, L97.211, L97.212, L97.213, L97.214, L97.221, L97.222, L97.223, L97.224, L97.311, L97.312, L97.13, L97.314, L97.321, L97.322, L97.323, L97.324, L97.411, L97.412, L97.413, L97.414, L97.421
L97.422, L97.423, L97.424, L97.511
L97.512, L97.513, L97.514, L97.521
L97.522, L97.523, L97.524, L97.811
L97.812, L97.813, L97.814, L97.821
L97.822, L97.823, L97.824, L98.411
L98.412, L98.413, L98.414, L98.421
L98.422, L98.423, L98.424, L98.491
L98.492, L98.493, L98.494) to define the ulcer.
E75.21* Fabry (-Anderson) disease
G60.0* Hereditary motor and sensory neuropathy
G60.1* Refsum's disease
G60.2* Neuropathy in association with hereditary ataxia
G60.3* Idiopathic progressive neuropathy
G60.8* Other hereditary and idiopathic neuropathies
L11.0* Acquired keratosis follicularis
L84* Corns and callosities
L85.0* Acquired ichthyosis
L85.1* Acquired keratosis [keratoderma] palmaris et plantaris
L85.2* Keratosis punctata (palmaris et plantaris)
L85.8* Other specified epidermal thickening
L86* Keratoderma in diseases classified elsewhere
L87.0* Keratosis follicularis et parafollicularis in cutem penetrans
L87.2* Elastosis perforans serpiginosa
Q81.9* Epidermolysis bullosa, unspecified
Q82.8* Other specified congenital malformations of skin
Guidelines for Foot care
UnitedHealthcare has assigned Service Code 8101 to represent the codes for Medicare Covered Foot Care. Service Code 8100 has been assigned for Non-Medicare covered foot care. Only certain individual and/or group plans provide benefits for Non-Medicare covered foot care. The line item coding criteria directs a foot care service line to the proper service code using a complex set of criteria including CPT/HCPCS codes, ICD-10 diagnosis codes and modifiers when applicable. Codes and policies for routine foot care and supportive devices for the feet are not exclusively for the use of Podiatrists. These codes must be used to report foot care services regardless of the specialty of the physician who furnishes the services. Physicians should use the most appropriate code available when billing for routine foot care. Relatively few claims for routine-type care are anticipated considering the severity of conditions contemplated as the basis for this exception. Claims for this type of foot care should not be paid in the absence of convincing evidence that nonprofessional performance of the service would have been hazardous for the beneficiary because of an underlying systemic disease. The mere statement of a diagnosis such as those mentioned above does not of itself indicate severity of the condition. Where development is indicated to verify diagnosis and/or severity, records may be requested to review the history and medical conditions of the patient as well as any physician contacts for management of those conditions.
“Q” Modifiers (Q7, Q8, and Q9) are utilized to denote Class A (Q7), Class B (Q8) and Class C (Q9) findings. These modifiers may be used with procedure codes 11055, 11056, 11057, 11719, 11720, 11721 or G0127. Submitting claims using Q7, Q8, or Q9 modifiers indicates the findings related to the patient’s condition. However, the provider is still responsible for documenting the findings in the patient’s record. Failure to provide documentation supporting the use of the Q modifiers on any claim may result in denial of that claim.
Hyperkeratotic Lesions Coding Criteria Procedure Code 11055, 11056, or 11057 will be included in the Medicare covered foot care service code (8101) when billed with a diagnosis from the Diagnosis List 1. Refer to the ICD-10 Diagnosis Codes attachment.
APPLICABLE CODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.
CPT Code Description
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 non-dystrophic 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
G0127, 11055, 11056, 11057, 11719, 11720, 11721 While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits. These include:
1. Routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient’s legs or feet).
2. Treatment of warts on foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.
3. Services normally considered routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.
4. Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. (Treatment of mycotic nails for patients without systemic illnesses may also be covered and are defined in a separate local coverage determination (LCD) for Debridement of Mycotic Nails) The following physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the patient record, in order for routine foot care services to be reimbursable. The presumption of coverage is applied when the physician rendering the routine foot care has identified either (1) the Class A finding (Q7); (2) two of the Class B findings (Q8); or (3) one Class B and two Class C findings, in addition to a primary condition (Q9).
10060- INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE - average fee payment- $120 - $130
10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
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
Coding and Billing Guideliens
1. Report the appropriate procedure code and modifiers for the service(s) performed.
a. When reporting foot/nail care report the applicable “Q” modifier.
b. These services should be reported with quantity of one in the quantity/units field.
2. Report the ICD-9 code for which the service(s) is performed in the first position in the diagnosis field of the CMS 1500 claim form or electronic equivalent; report the systemic condition(s) in the remaining positions. Where the systemic condition is marked with an (*) (see below) and the services were rendered by a podiatrist, include the 8-digit (MM/DD/CCYY) date the patient was last seen and the NPI of his/her attending (MD/DO) physician who diagnosed the complicating condition in item 19 of the CMS 1500 claim form or electronic equivalent field, diabetes mellitus*
Chronic Thrombophlebitis*
Peripheral neuropathies involving the feet - Associated with malnutrition and vitamin deficiency*
Malnutrition (general, pellagra)
Alcoholism
Malabsorption (celiac disease, tropical sprue)
Pernicious anemia
Associated with carcinoma*
Associated with diabetes mellitus*
Associated with drugs and toxins*
Associated with multiple sclerosis*
Associated with uremia (chronic renal disease)* Hereditary sensory radicular neuropathy
Angiokeratoma corporis diffusum (fabry's)
Amyloid neuropathy
Long term oral anticoagulant therapy (e.g. Coumadin, Dicoumaral, etc.)* Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections.
3. When billing for services, requested by the beneficiary for denial, that are statutorily excluded by Medicare (i.e. Routine foot care), report an ICD-9 code that best describes the patients condition and the GY modifier (items or services statutorily excluded or does not meet the definition of any Medicare benefit)
4. When billing for services, requested by the beneficiary for denial, that would be considered not reasonable and necessary, report an ICD-9 code that best describes the patients condition and the GA modifier if an ABN signed by the beneficiary is on file or the GZ modifier (items or services expected to be denied as not reasonable) when there is no ABN for the service on file.
5. For patients on long term oral anticoagulant therapy, report the ICD-9 related to the performed service in the first position, the drug ICD-9 (V58.61) in the second position and the condition being treated with the anticoagulant in the third position of item 21 of the CMS 1500 claim form or electronic equivalent.
6. It is inappropriate and incorrect to report an E&M code when routine foot care or a nail trimming/debridement service is the service actually performed.
7. The following class finding modifiers should usually be used with G0127, 11055, 11056, 11057, 11719, and when appropriate, CPT codes 11720, 11721.
A Class A finding (Modifier Q7) Two of the Class B findings (Modifier Q8); or One Class B and two Class C findings (Modifier Q9).
8. Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of class findings modifiers is not necessary. This condition would be represented by the ICD-9 CM codes in list three of “ICD-9 Codes that Support
Medical Necessity” listed in the LCD.
9. A diagnosis of onychomycosis can allow 11720 or 11721 if it has either a Q modifier (but does not need a MD or DO last seen) or if it has one of the 6 ICD-9 codes listed in the special section for onychomycosis, i.e. difficulty with walking (681.10, 681.11, 703.0, 719.7, 729.5, 781.2).
Routine Foot Care
Except as provided above, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following:
The cutting or removal of corns and calluses;
The trimming, cutting, clipping, or debriding of nails; and Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot.
Exceptions To Routine Foot Care Exclusion
1 - Necessary And Integral Part Of Otherwise Covered Services
In certain circumstances, services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.
2 - Presence Of Systemic Condition
The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require scrupulous foot care by a professional that in the absence of such condition(s) would be considered routine (and, therefore, excluded from coverage). Accordingly, foot care that would otherwise be considered routine may be covered when systemic condition(s) result in severe circulatory embarrassment or areas of diminished sensation in the individual’s legs or feet.
In these instances, certain foot care procedures that otherwise are considered routine (e.g., cutting or removing corns and calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions.
Coding Information
Date Last Seen by Attending Physician (for those ICD-9 CM codes which fall under the active care requirement): CPT codes 11055, 11056, 11057, 11719, and G0127 or 11720, 11721. The approximate date when the beneficiary was last seen by the M.D., D.O., who diagnosed the complicating condition (attending physician) must be reported in an 8-digit (MM/DD/YYYY) format in Item 19 of the CMS-1500 claim form or the electronic equivalent or if the patient sees their primary care physician no later than 30 days after the services were furnished.
For claims submitted to the fiscal intermediary:
Hospital Inpatient Claims:
The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB- 04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67. For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69.
Hospital Outpatient Claims:
• The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
• The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. RHC/FQHC encounters billed on TOBs 071x or 073x do not require HCPCS coding. Home health claims billed on 12X or 22X TOBs do not require HCPCS coding.
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number Care is considered routine unless the patient has a secondary diagnosis of a systemic disease and is under the active care of a doctor.
NATIONAL FOOT CARE MODIFIERS:
Q7 -- One (1) Class A finding
Q8 --Two (2) Class B findings
Q9 --One (1) Class B and Two (2) Class C findings
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
Coverage Indications, Limitations, and/or Medical Necessity
An abscess is a cavity containing pus surrounded by inflamed tissue. It is generally associated with pain, swelling and erythema. An abscess often requires incision and drainage to remove the purulent material in order for healing to occur.
Procedure codes 10060 and 10061 represent incision and drainage of an abscess involving the skin, subcutaneous and/or accessory structures. This includes the following types of abscess: furuncle, carbuncle, suppurative hidradenitis, an abscessed cyst, an abscessed paronychia, and/or other abscess involving the cutaneous and/or subcutaneous structures.
The use of incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures will be considered to be medically reasonable and necessary for the treatment of a symptomatic abscess (e.g. inflamed, painful, tender) involving these structures. This includes the incision and drainage of the following types of abscess:
furuncle;
carbuncle;
suppurative hidradenitis;
an abscessed cyst;
an abscessed paronychia; and/or
other abscess of cutaneous and/or subcutaneous structures.
It would not generally be expected to see incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures to be repeated frequently and/or multiple times. If frequent repeated incision and drainage is required, the medical record must reflect the reason for persistent/recurrent abscess formation, as well as any measures taken to prevent reoccurrence.
CPT/HCPCS Codes
10060 Drainage of skin abscess
10061 Drainage of skin abscess
Limitations
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.
The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.
Coding for Mycotic Nails
Although CPT coding does not exclusively apply CPT codes 11720 and 11721 to mycotic nails or to the feet, Medicare assumes these are the CPT codes usually used to code for services related to debriding mycotic nails.
Assuming services are being provided based on this indication, and the above requirements are documented, the claim should be coded with ICD-10 diagnosis code B35.1 as a primary code AND L02.611- L02.612, L03.031-L03.032, L03.041-L03.042, M79.671- M79.672, M79.674-M79.675 or R26.2 as a secondary code. Systemic condition modifiers are not necessary for services performed for this indication with these diagnosis codes.
The nail debridement procedure codes (11720-11721) are considered noncovered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care they must meet the same criteria as all other routine foot care services to be considered for payment.
Coding for Systemic Conditions
Foot care services are covered in the presence of a systemic condition based on the list of illnesses described in Chapter 15, Section 290 of the Benefit Policy Manual and coded by the following ICD-10 codes:
Diabetes mellitus*
E08.00-E13.9
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
I70.201-I70.92
I73.00-I73.01
I73.9
Buerger’s disease (thromboangiitis obliterans)
I73.1
Chronic thrombophlebitis*
I80.00-I80.3
Peripheral neuropathies involving the feet:
Associated with malnutrition and vitamin deficiency*
E56.9 and G63
Malnutrition (general, pellagra)*
E46, E52, or E64.0 and G63
Alcoholism*
G62.1
Malabsorption (celiac disease, tropical sprue)*
K90.0 or K90.1 and G63
Pernicious Anemia*
D51.0 and G63
Associated with carcinoma*
G13.0
Associated with diabetes mellitus*
E08.40
E08.42
E09.40
E09.42
E10.40
E10.42
E11.40
E11.42
E13.40
E13.42
Associated with drugs and toxins*
G62.0
G62.2
G62.82
Associated with multiple sclerosis*
G35 and G63
Associated with uremia (chronic renal disease)*
N18.1-N18.9 and G63
Associated with traumatic injury
S86.001A-S86.009S
S86.091A-S86.109S
S86.191A-S86.201S
S86.209A-S86.209S
S86.291A-S86.309S
S86.391A-S86.809S
S86.891A-S86.909S
S86.991A-S86.999S
S89.80XA-S89.92XS
S96.001A-S96.009S
S96.091A-S96.109S
S96.191A-S96.209S
S96.291A-S96.809S
S96.891A-S96.909S
S96.991A-S96.999S
S99.811A-S99.929S
and G63
Associated with leprosy or neurosyphilis
A30.0-A30.9 and G63
A52.10-A52.3 and G63
Associated with hereditary disorders
G60.0-G60.9
Heredity sensory radicular neuropathy
G60.0
Angiokeratoma corporis diffusum (Fabry's)
E75.21 and G63
Amyloid neuropathy
E85.0-E85.9 and G63
When the patient’s condition is one of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition. This must be indicated by the name and NPI of the attending physician in block 17 and 17B of the CMS-1500 or the equivalent electronic claim format. The date the patient was last seen by the attending physician should be billed in block 19. Claims for such routine services should show the complicating systemic disease in block 21 of the CMS-1500.
A presumption of coverage will be applied when the physician rendering the routine foot care has identified:
one (1) Class A finding using modifier Q7;
two (2) Class B findings using modifier Q8; or
one (1) Class B and two (2) Class C findings using modifier Q9.
In addition to a valid billing indicator, these services must include a systemic condition diagnosis listed above. All claims for routine foot care based on the presence of a systemic condition should have a billing indicator of Q7, Q8 or Q9 to be considered for payment.
Claims without a systemic diagnosis listed will be denied as noncovered routine-type foot care services.
Services not meeting the instructions and criteria in this statement of national coverage will be denied as statutory noncovered services. For ICD-10 codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the doctor of medicine or osteopathy.
Loss of protective sensation (LOPS) is not the subject of this LCD.
The following class finding modifiers should usually be used with G0127, 11055, 11056, 11057, 11719, and when appropriate, CPT codes 11720, 11721.
A Class A finding (Modifier Q7) Two of the Class B findings (Modifier Q8); or One Class B and two Class C findings (Modifier Q9).
Routine foot care CPT codes
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number Care is considered routine unless the patient has a secondary diagnosis of a systemic disease and is under the active care of a doctor.
NATIONAL FOOT CARE MODIFIERS:
Q7 -- One (1) Class A finding
Q8 --Two (2) Class B findings
Q9 --One (1) Class B and Two (2) Class C findings
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
ICD-10 Codes that Support Medical Necessity
K13.0 Diseases of lips
L02.01 Cutaneous abscess of face
L02.02 Furuncle of face
L02.03 Carbuncle of face
L02.11 Cutaneous abscess of neck
L02.12 Furuncle of neck
L02.13 Carbuncle of neck
L02.211 Cutaneous abscess of abdominal wall
L02.212 Cutaneous abscess of back [any part, except buttock]
L02.213 Cutaneous abscess of chest wall
L02.214 Cutaneous abscess of groin
L02.215 Cutaneous abscess of perineum
L02.216 Cutaneous abscess of umbilicus
L02.221 Furuncle of abdominal wall
L02.222 Furuncle of back [any part, except buttock]
L02.223 Furuncle of chest wall
L02.224 Furuncle of groin
L02.225 Furuncle of perineum
L02.226 Furuncle of umbilicus
L02.231 Carbuncle of abdominal wall
L02.232 Carbuncle of back [any part, except buttock]
L02.233 Carbuncle of chest wall
L02.234 Carbuncle of groin
L02.235 Carbuncle of perineum
L02.236 Carbuncle of umbilicus
L02.31 Cutaneous abscess of buttock
L02.32 Furuncle of buttock
L02.33 Carbuncle of buttock
L02.411 Cutaneous abscess of right axilla
L02.412 Cutaneous abscess of left axilla
L02.413 Cutaneous abscess of right upper limb
L02.414 Cutaneous abscess of left upper limb
L02.415 Cutaneous abscess of right lower limb
L02.416 Cutaneous abscess of left lower limb
L02.421 Furuncle of right axilla
L02.422 Furuncle of left axilla
L02.423 Furuncle of right upper limb
L02.424 Furuncle of left upper limb
L02.425 Furuncle of right lower limb
L02.426 Furuncle of left lower limb
L02.431 Carbuncle of right axilla
L02.432 Carbuncle of left axilla
L02.433 Carbuncle of right upper limb
L02.434 Carbuncle of left upper limb
L02.435 Carbuncle of right lower limb
L02.436 Carbuncle of left lower limb
L02.511 Cutaneous abscess of right hand
L02.512 Cutaneous abscess of left hand
L02.521 Furuncle right hand
L02.522 Furuncle left hand
L02.531 Carbuncle of right hand
L02.532 Carbuncle of left hand
L02.611 Cutaneous abscess of right foot
L02.612 Cutaneous abscess of left foot
L02.619 Cutaneous abscess of unspecified foot
L02.621 Furuncle of right foot
L02.622 Furuncle of left foot
L02.631 Carbuncle of right foot
L02.632 Carbuncle of left foot
L02.811 Cutaneous abscess of head [any part, except face]
L02.818 Cutaneous abscess of other sites
L02.821 Furuncle of head [any part, except face]
L02.828 Furuncle of other sites
L02.831 Carbuncle of head [any part, except face]
L02.838 Carbuncle of other sites
L02.91 Cutaneous abscess, unspecified
L02.92 Furuncle, unspecified
L02.93 Carbuncle, unspecified
L03.011 Cellulitis of right finger
L03.012 Cellulitis of left finger
L03.019 Cellulitis of unspecified finger
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.039 Cellulitis of unspecified toe
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.211 Cellulitis of face
L03.221 Cellulitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.811 Cellulitis of head [any part, except face]
L03.818 Cellulitis of other sites
L03.90 Cellulitis, unspecified
L73.2 Hidradenitis suppurativa
N48.21 Abscess of corpus cavernosum and penis
N48.22 Cellulitis of corpus cavernosum and penis
N48.29 Other inflammatory disorders of penis
N61 Inflammatory disorders of breast
Comment: A commenter stated if paronychia is considered a nail margin inflammation, then removing a portion of the nail plate and relieve the pressure with packing is appropriate. However, if there is an infection, then an incision and drainage is needed. CPT code 10060 or 10061 is appropriate in this case
Response: We agree if an infection is present and incision and drainage is necessary, then it is appropriate to report CPT code 10060. If no infection is present, and the nail plate is removed to relieve pressure, then it is inappropriate to use the incision and drainage CPT codes.
Comment: A commenter stated there are times when the nail (plate total or partial) needs to be avulsed in order to perform the incision and drainage for the abscess. Therefore, CPT codes10060 or 10061 is the appropriate and CPT code 11730 is incidental. This is consistent with the National Correct Coding Initiative (NCCI) which bundles CPT code 11730 into CPT codes 10060 and10061. We believe the LCD should be consistent with NCCI.
Response: If the avulsion of the nail plate alone is sufficient to drain the abscess, this is the service which should be billed, (i.e. 11730). If, however, it is necessary to remove part of the nail plate in order to complete the drainage of the abscess, then the incision and drainage codes are appropriate. We believe this is appropriately explained in the LCD and no change is necessary.
CPT CODE FOR Treatment of Ulcers and Symptomatic hyperkeratoses CPT 11042, 11043, 11044, 97597
For Medicare purposes, an "ulcer" does not exist until there is a partial thickness skin loss involving epidermis with or without dermis. Some authors will define a "pre-ulcer" condition and others even a "Stage 1 Ulcer" (e.g. "Wagner 0") where the skin is still intact. Such changes do not constitute an "ulcer" for Medicare payment purposes under this policy.
Ulcers may develop because of a combination of ischemia, infection, abscess, trauma, prolonged pressure, repetitive stress, edema, and loss of sensation.
The management of skin ulcers includes:
1. Overall medical and surgical treatment of the cause and
2. Meticulous care of the ulcerated skin and other associated soft tissue with application of medications and dressings, and
3. When reasonable and necessary, debridement of the necrotic and devitalized tissue and
4. Offloading of the external pressure source(s).
The management of a symptomatic hyperkeratosis may involve medical treatment, paring or cutting, shaving, excision, or destruction. This policy addresses only the paring or cutting approach.
This policy does not address treatment of burns or debridement of nails. For treatment of burns, including debridement, refer to the CPT 16000 series. For debridement of nails, refer to CPT codes 11720 and 11721.
When the only service provided is the non-surgical cleansing of the ulcer site with or without the application of a surgical dressing, the provider should bill this service with the appropriate evaluation and management (E/M) code and not bill a debridement code(s).
CPT codes 11042-11043, 97597 and 97598 describe debridement of relatively localized areas with or without their contiguous underlying structures. These codes are appropriate for treatment of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and debridement of ground-in dirt such as from road abrasions.
CPT codes 11042-11047 do not refer solely to ulcer size, but also to levels of actual tissue debridement levels (based on tissue type; e.g., partial skin, full thickness skin, subcutaneous tissue, etc.) of independent (non contiguous) skin and other deeper tissue structures.
When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of wounds that are the same depth, but do not combine wounds from different depths. This A/B MAC allows payment for an aggregate total of one independent tissue debridement on a given day of service. Any number greater than the aggregate total of four for one or both feet per date of service will result in a denial which may be appealed with documentation justifying the additional services. Once debridement is properly done repeat debridement is not expected for several days afterward.
CPT 97597 and 97598 may be used for the medically reasonable and necessary debridement with utilization consistent with this LCD and within scope of practice of the performing provider.
As is the case in all unusual and complicated procedures, the use of Modifier 22 may be appropriate to report and describe inordinately complex services performed. When used, the procedure note should contain a separate section that describes the "unusual" nature of the procedure.
When addressing a specific toe(s) or finger(s) use the respective CPT® HCPCS Level II modifier to identify them on the claim.
Other modifiers may include (but are not to be used alone when the more specific above modifiers are needed to clarify the procedure):
LT Left
RT Right
59 Independent Anatomical Site
XE Separate encounter
XS Separate Structure
XP Separate Practitioner
XU Unusual Non-Overlapping Service
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
CPT CODES: 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
11056 two to four lesions
11057 more than four lesions
11719 Trimming of non-dystrophic nails, any number
11720 Debridement of nail(s) by any method(s); one to five
11721 six or more
G0127 Trimming of dystrophic nails, any number
One of the following combinations is necessary to allow payment for routine foot care:
1. 11055, 11056, 11057 Primary diagnosis – 700 Secondary diagnosis- one of the systemic diagnoses
2. G0127, 11720, 11721 Primary diagnosis – 110.1, 703.8, or 703.9 Secondary diagnosis – one of the systemic diagnoses
3. 11719 Primary diagnosis – one of the systemic diagnoses
CPT codes 11055, 11056, and 11057 will also be covered when billed with one of the diabetes, neurological or vascular disease diagnosis codes listed below any one of the following routine foot care diagnosis codes: B35.3, L60.1-L60.5, L60.8, L62, L84, M21.6X1, M21.6X2 or M21.6X9.
CPT/HCPCS Codes
Group 1 Codes:
10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE
10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE
11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS
11043 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS
11044 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS
11045 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
11046 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
11047 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
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
97597 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS
97598 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
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
E10.65* Type 1 diabetes mellitus with hyperglycemia
E10.69* Type 1 diabetes mellitus with other specified complication
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
E11.628* Type 2 diabetes mellitus with other skin complications
E11.65* Type 2 diabetes mellitus with hyperglycemia
E11.69* Type 2 diabetes mellitus with other specified complication
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
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
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
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
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I87.011 Postthrombotic syndrome with ulcer of right lower extremity
I87.012 Postthrombotic syndrome with ulcer of left lower extremity
I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity
I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity
I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity
I96* Gangrene, not elsewhere classified
K12.2 Cellulitis and abscess of mouth
K62.6 Ulcer of anus and rectum
L03.011 Cellulitis of right finger
L03.012 Cellulitis of left finger
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.211 Cellulitis of face
L03.221 Cellulitis of neck
L03.222 Acute lymphangitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.811 Cellulitis of head [any part, except face]
L05.01 Pilonidal cyst with abscess
L08.0 Pyoderma
L08.89 Other specified local infections of the skin and subcutaneous tissue
L12.0 Bullous pemphigoid
L59.8 Other specified disorders of the skin and subcutaneous tissue related to radiation
L73.8 Other specified follicular disorders
L89.012 Pressure ulcer of right elbow, stage 2
L89.013 Pressure ulcer of right elbow, stage 3
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *For ICD-10-CM codes E10.65, E10.620, E10.621, E10.622, E10.628, E10.69, E11.620, E11.621, E11.622, E11.628, E11.65, E11.69, the "specified manifestation" is skin ulcer. For clarity one should consider adding a 2nd ICD-10 code (L97.111, L97.112,
L97.113, L97.114, L97.121, L97.122, L697.123, L97.124, L97.211, L97.212, L97.213, L97.214, L97.221, L97.222, L97.223, L97.224, L97.311, L97.312, L97.13, L97.314, L97.321, L97.322, L97.323, L97.324, L97.411, L97.412, L97.413, L97.414, L97.421
L97.422, L97.423, L97.424, L97.511
L97.512, L97.513, L97.514, L97.521
L97.522, L97.523, L97.524, L97.811
L97.812, L97.813, L97.814, L97.821
L97.822, L97.823, L97.824, L98.411
L98.412, L98.413, L98.414, L98.421
L98.422, L98.423, L98.424, L98.491
L98.492, L98.493, L98.494) to define the ulcer.
E75.21* Fabry (-Anderson) disease
G60.0* Hereditary motor and sensory neuropathy
G60.1* Refsum's disease
G60.2* Neuropathy in association with hereditary ataxia
G60.3* Idiopathic progressive neuropathy
G60.8* Other hereditary and idiopathic neuropathies
L11.0* Acquired keratosis follicularis
L84* Corns and callosities
L85.0* Acquired ichthyosis
L85.1* Acquired keratosis [keratoderma] palmaris et plantaris
L85.2* Keratosis punctata (palmaris et plantaris)
L85.8* Other specified epidermal thickening
L86* Keratoderma in diseases classified elsewhere
L87.0* Keratosis follicularis et parafollicularis in cutem penetrans
L87.2* Elastosis perforans serpiginosa
Q81.9* Epidermolysis bullosa, unspecified
Q82.8* Other specified congenital malformations of skin
Guidelines for Foot care
UnitedHealthcare has assigned Service Code 8101 to represent the codes for Medicare Covered Foot Care. Service Code 8100 has been assigned for Non-Medicare covered foot care. Only certain individual and/or group plans provide benefits for Non-Medicare covered foot care. The line item coding criteria directs a foot care service line to the proper service code using a complex set of criteria including CPT/HCPCS codes, ICD-10 diagnosis codes and modifiers when applicable. Codes and policies for routine foot care and supportive devices for the feet are not exclusively for the use of Podiatrists. These codes must be used to report foot care services regardless of the specialty of the physician who furnishes the services. Physicians should use the most appropriate code available when billing for routine foot care. Relatively few claims for routine-type care are anticipated considering the severity of conditions contemplated as the basis for this exception. Claims for this type of foot care should not be paid in the absence of convincing evidence that nonprofessional performance of the service would have been hazardous for the beneficiary because of an underlying systemic disease. The mere statement of a diagnosis such as those mentioned above does not of itself indicate severity of the condition. Where development is indicated to verify diagnosis and/or severity, records may be requested to review the history and medical conditions of the patient as well as any physician contacts for management of those conditions.
“Q” Modifiers (Q7, Q8, and Q9) are utilized to denote Class A (Q7), Class B (Q8) and Class C (Q9) findings. These modifiers may be used with procedure codes 11055, 11056, 11057, 11719, 11720, 11721 or G0127. Submitting claims using Q7, Q8, or Q9 modifiers indicates the findings related to the patient’s condition. However, the provider is still responsible for documenting the findings in the patient’s record. Failure to provide documentation supporting the use of the Q modifiers on any claim may result in denial of that claim.
Hyperkeratotic Lesions Coding Criteria Procedure Code 11055, 11056, or 11057 will be included in the Medicare covered foot care service code (8101) when billed with a diagnosis from the Diagnosis List 1. Refer to the ICD-10 Diagnosis Codes attachment.
APPLICABLE CODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.
CPT Code Description
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 non-dystrophic 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
G0127, 11055, 11056, 11057, 11719, 11720, 11721 While the Medicare program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are program benefits. These include:
1. Routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient’s legs or feet).
2. Treatment of warts on foot is covered to the same extent as services provided for the treatment of warts located elsewhere on the body.
3. Services normally considered routine may be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of ulcers, wounds, or infections.
4. Treatment of mycotic nails may be covered under the exceptions to the routine foot care exclusion. The class findings, outlined below, or the presence of qualifying systemic illnesses causing a peripheral neuropathy, must be present. (Treatment of mycotic nails for patients without systemic illnesses may also be covered and are defined in a separate local coverage determination (LCD) for Debridement of Mycotic Nails) The following physical and clinical findings, which are indicative of severe peripheral involvement, must be documented and maintained in the patient record, in order for routine foot care services to be reimbursable. The presumption of coverage is applied when the physician rendering the routine foot care has identified either (1) the Class A finding (Q7); (2) two of the Class B findings (Q8); or (3) one Class B and two Class C findings, in addition to a primary condition (Q9).
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