CARTA CIRCULAR #M1303037 18 de marzo de 2013 A TODOS LOS PODIATRAS PARTICIPANTES DE TRIPLE-S SALUD Revisión: Visitas para Cuidado Rutinario del Pie Debido a las dudas generadas por la carta circular M1212251 emitida el día 5 de diciembre del 2012, donde se incluyó la tabla de copagos aplicables a la visitas del Podiatra, queremos aclarar lo siguiente: Las visitas que se excluyen son aquellas que correspondan al cuidado rutinario de los pies dado a que éstas se excluyen de la cubierta de CMS. Los siguientes servicios son normalmente considerados de rutina y no cubiertos por Medicare y los Planes MA de TSS:

• El corte o eliminación de callos y callosidades • El recorte, corte, o desbridamiento de las uñas • Otros como manejo higiénico y atención de mantenimiento preventivo como la limpieza de los pies, el uso de cremas para mantener el tono de la piel ya sea de pacientes ambulatorios o postrados en cama y cualquier otro servicio realizado en ausencia de enfermedad localizada, lesiones o síntomas que afectan el pie

Las visitas para el cuidado rutinario del pie solo se cubren en aquellas excepciones, identificadas como condiciones metabólicas, neurológicas y enfermedades vasculares periféricas (con sinónimos entre paréntesis) que pueden justificar la cobertura de cuidado rutinario de los pies. Las más comunes son:

• Diabetes mellitus * • Arteriosclerosis obliterante (ASO, arteriosclerosis de las extremidades, arteriosclerosis oclusiva periférica) • Enfermedad de Buerger (tromboangitis obliterante) • Tromboflebitis crónica* • Neuropatías periféricas que involucran los pies • Asociada con la desnutrición y deficiencia de vitamina * • Desnutrición (general, pelagra) • Alcoholismo • Mala absorción (enfermedad celíaca, síndrome de malabsorción tropical (sprue)) • Anemia perniciosa

- Asociada con carcinoma * - Asociada con la diabetes mellitus * - Asociada con drogas y toxinas * - Asociada con esclerosis múltiple * - Asociada con uremia (enfermedad renal crónica) * - Asociada con lesión traumática - Asociada con la lepra o la neurosífilis - Asociada con trastornos hereditarios • Neuropatía hereditaria sensorial radicular • Angioqueratoma diffusum (Enfermedad de Fabry) • Neuropatía amiloide

Cuando la condición del paciente sea una de las designadas con un asterisco (*), los procedimientos de cuidado rutinario del pie están cubiertos sólo si el paciente se encuentra bajo el cuidado activo de un doctor en medicina que documenta la condición. Acompañamos la Política L29388 de FCSO que detalla y aclara la información de este beneficio. Si necesita información adicional, comuníquese con nuestro Centro de Llamadas del Departamento de Gerencia de Servicio al 787-749-4700 ó al 1-877-357-9777 (libre de cargos para llamadas de larga distancia). Cordialmente,

Enid M. Mateo Reyes, MD Director Médico Asociado División de Asuntos Médicos y Dentales Anejo

Anejo (Revisado)

Tabla Comparativa sobre beneficios de Triple-S Medicare Advantage 2013

(Cubiertas asignadas, beneficios máximos, copagos, coaseguros, etc.) Triple-S Medicare

Óptimo (PPO)

Triple-S Medicare Óptimo Plus (PPO)

Triple-S Medicare Óptimo Premier (HMO)

Triple-S Medicare Óptimo Basic (PPO)

Triple-S Medicare Óptimo Select (HMO)

Medicare Selecto con Medicare Platino

(HMO-SNP)

Medicare Selecto con Medicare Platino

2 (HMO-SNP)

Cubiertas Asignadas 2013

AI-54 AI-56 AI-58 AI-63 AI-57 AI-60 Nivel 1: AJ-49 Nivel 2: AI-61

Cubiertas Base 2012

AF-06 AF-18 AF-39 AF-38 AF-30 Nivel 1: AF-42 Nivel 2: AF-87

Out-of-pocket máximo para

servicios Parte A y B

Las cantidades máximas de desembolso por servicios cubiertos de la Parte A y la Parte B provistos por proveedores:

dentro de la red es $6,700.00

dentro y fuera de la red (combinado) $10,000

Las cantidades máximas de desembolso por servicios cubiertos de la Parte A y la Parte B provistos por proveedores:

dentro de la red es $6,700.00

dentro y fuera de la red (combinado) $10,000

Las cantidades máximas de desembolso por servicios cubiertos de la Parte A y la Parte B provistos por proveedores:

dentro de la red es $6,700.00

Las cantidades máximas de desembolso por servicios cubiertos de la Parte A y la Parte B provistos por proveedores:

dentro de la red es $6,700.00

dentro y fuera de la red (combinado) $10,000

Las cantidades máximas de desembolso por servicios cubiertos de la Parte A y la Parte B provistos por proveedores:

dentro de la red es $6,700.00

Las cantidades máximas de desembolso por servicios cubiertos de la Parte A y la Parte B provistos por proveedores:

dentro de la red es $6,700.00

Las cantidades máximas de desembolso por servicios cubiertos de la Parte A y la Parte B provistos por proveedores:

dentro de la red es $6,700.00

Servicios de Podiatra

$2.00 de copago para las visitas y tratamientos médicamente necesarios de lesiones en los pies o las enfermedades cubiertos por Medicare

$10.00 de copago para tratamientos médicamente necesarios de lesiones en los pies o las enfermedades cubiertos por Medicare.

$5.00 de copago para tratamientos médicamente necesarios de lesiones en los pies o las enfermedades cubiertos por Medicare.

$12.00 de copago para tratamientos médicamente necesarios de lesiones en los pies o las enfermedades cubiertos por Medicare.

$10.00 de copago para las visitas y tratamientos médicamente necesarios de lesiones en los pies o las enfermedades cubiertos por Medicare.

$0.00 copago para las visitas y tratamientos médicamente necesarios de lesiones en los pies o las enfermedades cubiertos por Medicare.

Nivel 1 y 2: $1.00 de copago para las visitas y tratamientos médicamente necesarios de lesiones en los pies o las enfermedades cubiertos por Medicare.

Triple-S Medicare Óptimo (PPO)

Triple-S Medicare Óptimo Plus (PPO)

Triple-S Medicare Óptimo Premier (HMO)

Triple-S Medicare Óptimo Basic (PPO)

Triple-S Medicare Óptimo Select (HMO)

Medicare Selecto con Medicare Platino

(HMO-SNP)

Medicare Selecto con Medicare Platino

2 (HMO-SNP)

Cubiertas Asignadas 2013

AI-54 AI-56 AI-58 AI-63 AI-57 AI-60 Nivel 1: AJ-49 Nivel 2: AI-61

Cubiertas Base 2012

AF-06 AF-18 AF-39 AF-38 AF-30 Nivel 1: AF-42 Nivel 2: AF-87

Visitas para Cuidado Rutinario del Pie están cubiertas si existe criterio clínico de acuerdo a Medicare Cubre hasta seis (6) Visitas para Cuidado Rutinario del Pie, sin aplicar criterio clínico

Visitas para Cuidado Rutinario del Pie están cubiertas si existe criterio clínico de acuerdo a Medicare

Visitas para Cuidado Rutinario del Pie están cubiertas si existe criterio clínico de acuerdo a Medicare

Visitas para Cuidado Rutinario del Pie están cubiertas si existe criterio clínico de acuerdo a Medicare

Sin límite de Visitas para Cuidado Rutinario del Pie. Requiere referido de PCP

Sin límite de Visitas para Cuidado Rutinario del Pie. Requiere referido de PCP.

Sin límite de Visitas para Cuidado Rutinario del Pie.

Requiere referido de PCP.

Rev. 03/13/2013 - MMC

L29388

Contractor Information|LCD Information| Coding Information|General Information

Contractor Information

Contractor Name

First Coast Service Options, Inc.

Contractor Number

09202

Contractor Type

MAC - Part B

[back to top]LCD Information

LCD ID Number

L29388

LCD Title

Routine Foot Care

Contractor's Determination Number

11055

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 290 Medicare Benefit Policy Manual, Pub. 100-02, Chapter 16, Section 30 Primary Geographic Jurisdiction

Puerto Rico

Oversight Region

Region IV

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Original Determination Effective Date

03/02/2009

Original Determination Ending Date

Revision Effective Date

03/02/2009

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Foot care 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. 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. The presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease may require

scrupulous foot care by a podiatrist or other physician. 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, and 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 the absence of a systemic condition, treatment/debridement of symptomatic mycotic nails may be covered.

Please refer to the local LCD for Nail Debridement (11720). The following non-comprehensive list of metabolic, neurologic, and peripheral vascular diseases (with synonyms

in parentheses) most commonly represent the underlying conditions that might justify coverage for routine foot

care. · Diabetes mellitus* · Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis) · Buerger’s disease (thromboangiitis obliterans) · Chronic thrombophlebitis* · Peripheral neuropathies involving feet - Associated with malnutrition and vitamin deficiency* § Malnutrition (general, pellagra) § Alcoholism § Malabsorption (celiac disease, tropical sprue)

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§ Pernicious anemia - Associated with carcinoma* - Associated with diabetes mellitus* - Associated with drugs and toxins* - Associated with multiple sclerosis* - Associated with uremia (chronic renal disease)* - Associated with traumatic injury - Associated with leprosy or neurosyphilis - Associated with hereditary disorders § Hereditary sensory radicular neuropathy § Angiokeratoma corporis diffusum (Fabry’s) § Amyloid neuropathy See corresponding * ICD-9 codes. Active Care Requirements for Asterisked Conditions: When the patient’s condition is one of those listed above designated by an asterisk (*), and a podiatrist renders the service, the following must be met and indicated on the claim form: · The name of the attending physician (M.D., D.O., or non-physician practitioner [PA or NP]) who is actively treating the patient’s condition, and · The date the patient was last seen by the M.D., D.O., or non-physician practitioner (PA or NP) who is actively treating the condition (this date must be within six months), or the patient had come under such care shortly after the services were furnished usually as a result of a referral. Also, for non-asterisked conditions, the name of the M.D., D.O., or non-physician practitioner (PA or NP) who diagnosed the complicating condition must be on the claim form. Physical/Clinical Class Findings In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where

the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and

indicative of severe peripheral involvement. In patients where the presumption of coverage is based on arterial impairment, regardless of the cause, the following class findings are pertinent and must be documented for all underlying conditions. Class A Findings Nontraumatic amputation of foot or integral skeletal portion thereof Class B Findings Absent posterior tibial pulse, or

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Absent dorsalis pedal pulse, or Three of the following advanced tropic changes are required to meet one class B finding: - Hair growth (decrease or absence) - Pigmentary changes (discoloration) - Skin color (rubor and redness) - Nail changes (thickening) - Skin texture (thin, shiny) Class C Findings Claudication (pain in calf when walking) Temperature changes in the feet (e.g., cold feet) Edema Parathesias (abnormal spontaneous sensations in the feet, e.g., tingling) Burning Presumption of Coverage A presumption of coverage will be applied by Medicare when the physician rendering the routine foot care has

identified: 1. A Class A finding 2. Two of the Class B findings; or 3. One Class B and two Class C findings Claims submitted for routine foot care should use the appropriate modifiers (Q7, Q8, or Q9) to indicate the findings they have made on the patient’s condition. · Q7 = One Class A finding · Q8 = Two Class B findings · Q9 = One Class B and two Class C findings Routine foot care may be 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. In such circumstances, claims for medically necessary services would be submitted without the Q7, Q8, or Q9 modifiers that indicate class findings. The medical record must document the patient has an absence of sensation at two or more sites out of five tested on either foot

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when tested with the 5.07 Semmes-Weinstein monofilament to support the diagnosis of peripheral neuropathy with loss of protective sensation. This testing may be performed by the attending physician, non-physician practitioner, or the podiatrist. Other Indications and Limitations of Coverage and/or Medical Necessity: Services or devices directed toward the care or correction of flat foot, including the prescription of supportive devices, are not covered.

[back to top]Coding Information

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this

service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy

should be assumed to apply equally to all claims. Code Description

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used

to report this service. In most instances Revenue Codes are purely advisory; unless specified in the

policy services reported under other Revenue Codes are equally subject to this coverage determination.

Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and

the policy should be assumed to apply equally to all Revenue Codes.

Code Description

99999 Not Applicable

CPT/HCPCS Codes

Code Description

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

11719 TRIMMING OF NONDYSTROPHIC 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 TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER

ICD-9 Codes that Support Medical Necessity

Code Description

030.0 LEPROMATOUS LEPROSY (TYPE L)

030.1 TUBERCULOID LEPROSY (TYPE T)

030.2 INDETERMINATE LEPROSY (GROUP I)

030.3 BORDERLINE LEPROSY (GROUP B)

030.8 OTHER SPECIFIED LEPROSY

030.9 LEPROSY UNSPECIFIED

094.0 TABES DORSALIS

094.1 GENERAL PARESIS

094.9 NEUROSYPHILIS UNSPECIFIED

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250.40 DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.50 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.60 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.61 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.62 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.63* DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.70 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.71 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.72 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.73* DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED

263.9* UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

265.0* BERIBERI

265.2* PELLAGRA

266.1* VITAMIN B6 DEFICIENCY

266.2* OTHER B-COMPLEX DEFICIENCIES

272.7 LIPIDOSES

277.30 AMYLOIDOSIS, UNSPECIFIED

277.39 OTHER AMYLOIDOSIS

281.0* PERNICIOUS ANEMIA

281.3* OTHER SPECIFIED MEGALOBLASTIC ANEMIAS NOT ELSEWHERE CLASSIFIED

286.9* OTHER AND UNSPECIFIED COAGULATION DEFECTS

334.0 FRIEDREICH'S ATAXIA

340* MULTIPLE SCLEROSIS

356.0 HEREDITARY PERIPHERAL NEUROPATHY

356.1 PERONEAL MUSCULAR ATROPHY

356.2 HEREDITARY SENSORY NEUROPATHY

356.3 REFSUM'S DISEASE

356.4 IDIOPATHIC PROGRESSIVE POLYNEUROPATHY

356.8 OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

356.9 UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

357.0 ACUTE INFECTIVE POLYNEURITIS

357.1 POLYNEUROPATHY IN COLLAGEN VASCULAR DISEASE

357.2 POLYNEUROPATHY IN DIABETES

357.3 POLYNEUROPATHY IN MALIGNANT DISEASE

357.4 POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

357.5 ALCOHOLIC POLYNEUROPATHY

357.6 POLYNEUROPATHY DUE TO DRUGS

357.7* POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS

358.1* MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE

358.2* TOXIC MYONEURAL DISORDERS

440.20 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED

440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION

440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN

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440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

443.0 RAYNAUD'S SYNDROME

443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY

446.0 POLYARTERITIS NODOSA

446.7* TAKAYASU'S DISEASE

451.0* PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES

451.11* PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL)

451.19* PHLEBITIS AND THROMBOPHLEBITIS OF OTHER

579.0* CELIAC DISEASE

579.1* TROPICAL SPRUE

579.2* BLIND LOOP SYNDROME

579.3* OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

579.4* PANCREATIC STEATORRHEA

585.1 CHRONIC KIDNEY DISEASE, STAGE I

585.2 CHRONIC KIDNEY DISEASE, STAGE II (MILD)

585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)

585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)

585.5 CHRONIC KIDNEY DISEASE, STAGE V

585.6 END STAGE RENAL DISEASE

585.9* CHRONIC KIDNEY DISEASE, UNSPECIFIED

586* RENAL FAILURE UNSPECIFIED

952.00 C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.01 C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.02 C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME

952.03 C1-C4 LEVEL WITH CENTRAL CORD SYNDROME

952.04 C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.05 C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.06 C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.07 C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME

952.08 C5-C7 LEVEL WITH CENTRAL CORD SYNDROME

952.09 C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.10 T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.11 T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.12 T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME

952.13 T1-T6 LEVEL WITH CENTRAL CORD SYNDROME

952.14 T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.15 T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.16 T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.17 T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME

952.18 T7-T12 LEVEL WITH CENTRAL CORD SYNDROME

952.19 T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.2 LUMBAR SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

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952.3 SACRAL SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.4 CAUDA EQUINA SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.8 MULTIPLE SITES OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.9 UNSPECIFIED SITE OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

953.2 INJURY TO LUMBAR NERVE ROOT

953.3 INJURY TO SACRAL NERVE ROOT

953.5 INJURY TO LUMBOSACRAL PLEXUS

953.8 INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS

956.0 INJURY TO SCIATIC NERVE

956.1 INJURY TO FEMORAL NERVE

956.2 INJURY TO POSTERIOR TIBIAL NERVE

956.3 INJURY TO PERONEAL NERVE

956.4 INJURY TO CUTANEOUS SENSORY NERVE LOWER LIMB

956.5 INJURY TO OTHER SPECIFIED NERVE(S) OF PELVIC GIRDLE AND LOWER LIMB

956.8 INJURY TO MULTIPLE NERVES OF PELVIC GIRDLE AND LOWER LIMB

956.9 INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB The following diagnoses require a Q modifier:

250.70 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.71 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.72 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.73* DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED

440.20 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED

440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION

440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN

440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

443.0 RAYNAUD'S SYNDROME

443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY

446.0 POLYARTERITIS NODOSA

446.7* TAKAYASU'S DISEASE The following diagnoses related to peripheral neuropathy do not require a Q modifier: 030.0 LEPROMATOUS LEPROSY (TYPE L)

030.1 TUBERCULOID LEPROSY (TYPE T)

030.2 INDETERMINATE LEPROSY (GROUP I)

030.3 BORDERLINE LEPROSY (GROUP B)

030.8 OTHER SPECIFIED LEPROSY

030.9 LEPROSY UNSPECIFIED

094.0 TABES DORSALIS

094.1 GENERAL PARESIS

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094.9 NEUROSYPHILIS UNSPECIFIED

250.40 DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.50 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.60 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.61 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.62 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.63* DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

263.9* UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

265.0* BERIBERI

265.2* PELLAGRA

266.1* VITAMIN B6 DEFICIENCY

266.2* OTHER B-COMPLEX DEFICIENCIES

272.7 LIPIDOSES

277.30 AMYLOIDOSIS, UNSPECIFIED

277.39 OTHER AMYLOIDOSIS

281.0* PERNICIOUS ANEMIA

281.3* OTHER SPECIFIED MEGALOBLASTIC ANEMIAS NOT ELSEWHERE CLASSIFIED

286.9* OTHER AND UNSPECIFIED COAGULATION DEFECTS

334.0 FRIEDREICH'S ATAXIA

340* MULTIPLE SCLEROSIS

356.0 HEREDITARY PERIPHERAL NEUROPATHY

356.1 PERONEAL MUSCULAR ATROPHY

356.2 HEREDITARY SENSORY NEUROPATHY

356.3 REFSUM'S DISEASE

356.4 IDIOPATHIC PROGRESSIVE POLYNEUROPATHY

356.8 OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

356.9 UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

357.0 ACUTE INFECTIVE POLYNEURITIS

357.1 POLYNEUROPATHY IN COLLAGEN VASCULAR DISEASE

357.2 POLYNEUROPATHY IN DIABETES

357.3 POLYNEUROPATHY IN MALIGNANT DISEASE

357.4 POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

357.5 ALCOHOLIC POLYNEUROPATHY

357.6 POLYNEUROPATHY DUE TO DRUGS

357.7* POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS

358.1* MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE

358.2* TOXIC MYONEURAL DISORDERS

451.0* PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES

451.11* PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL)

451.19* PHLEBITIS AND THROMBOPHLEBITIS OF OTHER

579.0* CELIAC DISEASE

579.1* TROPICAL SPRUE

579.2* BLIND LOOP SYNDROME

579.3* OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

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579.4* PANCREATIC STEATORRHEA

585.1 CHRONIC KIDNEY DISEASE, STAGE I

585.2 CHRONIC KIDNEY DISEASE, STAGE II (MILD)

585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)

585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)

585.5 CHRONIC KIDNEY DISEASE, STAGE V

585.6 END STAGE RENAL DISEASE

585.9* CHRONIC KIDNEY DISEASE, UNSPECIFIED

586* RENAL FAILURE UNSPECIFIED

952.00 C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.01 C1-C4 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.02 C1-C4 LEVEL WITH ANTERIOR CORD SYNDROME

952.03 C1-C4 LEVEL WITH CENTRAL CORD SYNDROME

952.04 C1-C4 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.05 C5-C7 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.06 C5-C7 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.07 C5-C7 LEVEL WITH ANTERIOR CORD SYNDROME

952.08 C5-C7 LEVEL WITH CENTRAL CORD SYNDROME

952.09 C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.10 T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.11 T1-T6 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.12 T1-T6 LEVEL WITH ANTERIOR CORD SYNDROME

952.13 T1-T6 LEVEL WITH CENTRAL CORD SYNDROME

952.14 T1-T6 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.15 T7-T12 LEVEL SPINAL CORD INJURY UNSPECIFIED

952.16 T7-T12 LEVEL WITH COMPLETE LESION OF SPINAL CORD

952.17 T7-T12 LEVEL WITH ANTERIOR CORD SYNDROME

952.18 T7-T12 LEVEL WITH CENTRAL CORD SYNDROME

952.19 T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

952.2 LUMBAR SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.3 SACRAL SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.4 CAUDA EQUINA SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.8 MULTIPLE SITES OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

952.9 UNSPECIFIED SITE OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY

953.2 INJURY TO LUMBAR NERVE ROOT

953.3 INJURY TO SACRAL NERVE ROOT

953.5 INJURY TO LUMBOSACRAL PLEXUS

953.8 INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS

956.0 INJURY TO SCIATIC NERVE

956.1 INJURY TO FEMORAL NERVE

956.2 INJURY TO POSTERIOR TIBIAL NERVE

956.3 INJURY TO PERONEAL NERVE

956.4 INJURY TO CUTANEOUS SENSORY NERVE LOWER LIMB

956.5 INJURY TO OTHER SPECIFIED NERVE(S) OF PELVIC GIRDLE AND LOWER LIMB

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956.8 INJURY TO MULTIPLE NERVES OF PELVIC GIRDLE AND LOWER LIMB

956.9 INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB The following diagnosis related to anticoagulation therapy does not require a Q modifier: 286.9* OTHER AND UNSPECIFIED COAGULATION DEFECTS

See corresponding * underlying conditions.

Diagnoses that Support Medical Necessity

N/A

ICD-9 Codes that DO NOT Support Medical Necessity

Code Description

Diagnoses that DO NOT Support Medical Necessity

N/A

[back to top]General Information

Documentation Requirements

The provider must document in the medical record the appropriate signs and symptoms as outlined in Class Findings A, B, and/or C along with the complicating condition(s). In addition, when services are performed by a podiatrist, the medical record must contain the name of the treating and/or diagnosing physician. If the complicating condition is one that is asterisked, the date the patient was last seen by the treating physician must also be included on the claim. For diagnoses of peripheral neuropathy that do not require a Q modifier, and the presumption of coverage is based on loss of protective sensation, documentation must be available in the medical record of an absence of sensation at two or more sites out of five tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament to support the diagnosis of peripheral neuropathy with loss of protective sensation. This test may be performed by the attending physician, non-physician practitioner, or the podiatrist. Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity. Sources of Information and Basis for Decision

Akhtar, N., Chazin, H., Eisenschenk, S., Fine-Edelstein, J., Gorson, K., & Jacobs, D. (2004). Neuropathy. Neurology Channel. Retrieved Oct. 20, 2004, from www.helathcommunities.com Curtin Health Science, Department of Podiatry. Podiatry Encyclopedia, 2001. Retrieved from internet 04/16/2004. From www.podiatry.curtin.edu.au/encyclopedia/#podology. Goldman: Cecil Textbook of Medicine, 21st Edition, Copyright 2000. Diabetes Mellitus – Part II, Chapter 242a. W.B. Saunders Company. Harari, A.E., & Rush, M.D., (2003). Diabetic Foot Care. Emedicine Consumer Health. Retrieved Oct. 20, 2004 from www.emedicinehealth.com Advisory Committee Meeting Notes

This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

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Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

12/04/2008

Revision History Number

Original

Revision History Explanation

Revision Number:Original Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:03/02/2009 LCR B2009- December 2008 Bulletin This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO). For Puerto Rico (00973) this LCD (L29388) replaces LCD L12903 as the policy in notice. This document (L29388) is effective on 03/02/2009. For Virgin Islands (00974) this LCD (L29388) replaces LCD L13041 as the policy in notice. This document (L29388) is effective on 03/02/2009. 11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: 11056 descriptor was changed in Group 1 11057 descriptor was changed in Group 1 11720 descriptor was changed in Group 1 11721 descriptor was changed in Group 1 11/25/2012 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: 11719 descriptor was changed in Group 1

Reason For Change

Last Reviewed On Date

06/07/2012

Related Documents

This LCD has no Related Documents.

LCD Attachments

Attachments such as Coding Guidelines and Comment Summaries are available in the Medicare coverage database located on the Centers for Medicare & Medicaid Services (CMS) website. To view attachments, go to http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?clickon=search and enter the LCD ID in the search window; when the LCD is displayed select LCD Attachments from the "Jump to Section" dropdown list.

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[back to top]

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/ . The LCD data hosted on this site is an exact match of what appears on the MCD.

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