S96.199A — Other specified injury of muscle and tendon of long extensor muscle of toe at ankle and foot level, unspecified foot, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When routine foot care needs to meet one of the exclusions, include the applicable Q modifier on the claim: Q7 for 1 Class A finding, Q8 for 2 Class B findings, and Q9 for 1 Class B plus 2 Class C findings.
- For all foot-care claims report an appropriate foot/toe location modifier (e.g., LT, RT, TA, T1-T9) to identify laterality and specific toe when applicable.
- If a significant, separately identifiable evaluation and management service is provided on the same day as routine foot care, append modifier -25 to the E/M claim line.
- Total the number of keratotic lesions debrided and select the most appropriate CPT code 11055-11057 based on that total (example: code 11056 for two to four lesions).
Key Coverage Criteria
- Removal of corns and calluses of the feet must be billed using CPT codes 11055-11057 (paring/cutting of benign hyperkeratotic lesion) and the procedure code that most accurately describes the service performed should be reported.
- Nail debridement (CPT 11720 or 11721) for mycotic nails is covered when billed with ICD-10-CM B35.1 as the primary diagnosis and one of the following as a secondary diagnosis: L02.611, L02.612, L03.031, L03.032, L03.041, L03.042, M79.671, M79.672, M79.674, M79.675, or R26.2.
- Routine foot care services are covered when the patient has one of the specified systemic conditions (e.g., diabetes mellitus; arteriosclerosis obliterans; Buerger's disease; chronic thrombophlebitis; peripheral neuropathies of the feet including those associated with malnutrition, alcoholism, malabsorption, pernicious anemia, carcinoma, drugs/toxins, multiple sclerosis, uremia, traumatic injury, leprosy/neurosyphilis, hereditary disorders including hereditary sensory radicular neuropathy, Fabry [...]
- A presumption of coverage for routine foot care exists when the physician rendering the service documents and bills using modifier Q7 (one Class A finding), Q8 (two Class B findings), or Q9 (one Class B plus two Class C findings) and a systemic condition diagnosis from the listed conditions is present.
- Routine foot care is generally excluded from Medicare coverage but may be covered when a systemic condition justifies the need for routine foot care as defined in CMS manuals.
- Coverage may be allowed when the patient has Amyotrophic Lateral Sclerosis (ALS) resulting in a need for routine foot care.
4 Active Policies
A52996 — Billing and Coding: Routine Foot Care
J12
L35138 — Routine Foot Care
J12
A56680 — Billing and Coding: Routine Foot Care
L37643 — Routine Foot Care
Related Codes
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