Coverage Policies

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INDEX:

Effective Date: 06/11/2004

Title: Foot Care

Revision Date: 07/01/2017

Document: BI039:00

CPT Code(s):

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Routine foot care, including trimming of nails and care of corns and calluses, is covered 1) only for people with diseases such as diabetes which require careful foot care for optimum health, and 2) for people whose diseases are likely to make self-care very difficult such as those with advanced rheumatoid arthritis.

CHI Employee Health Benefit plans provide coverage for foot care based on medical necessity, regardless of any medical diseases the member may have, including diabetes.

For diabetic shoes and inserts, see BI198.

Medical Statement

Routine foot care is the paring, cutting, trimming of corns and calluses, or debridement and trimming of toenails in the presence or absence of localized illness, injury or symptoms involving the foot. QCA Health Plan allows coverage for routine foot care if the member has certain systemic or local diseases:

Advanced Rheumatoid Arthritis
Arteriosclerosis Obliterans
Buerger’s Disease
Chronic Thrombophlebitis
Coumadin Therapy
Diabetes Mellitus
Multiple Sclerosis
Peripheral Neuropathy of Lower Limb
Peripheral Vascular Disease, Unspecified
Scleroderma

The following codes are not considered routine foot care and are covered only when medically necessary:

· 11730 – 11732 & 11750 – Removal of toenails for ingrown toenail

· 28296 – 28299 – Bunionectomy

· 28001 – 28035 – Foot and toes, incision

· 28043 – 28175 – Foot and toes, excision

· 28190 – 28193 – Foreign body removal

· 28200 – 28899 – Repair, revision or reconstruction, other procedures

CHI Employee Health Benefit plans provide coverage for foot care based on medical necessity, regardless of any medical diseases the member may have, including diabetes.

Codes Used In This BI:

G0127	Trimming of dystrophic nails, any number
11055	Paring or cutting of benign hyperkeratotic lesion; single lesion
11056	Paring or cutting of benign hyperleratotic lesion; 2 - 4 Lesions
11057	Paring or cutting of benign hyperleratotic lesion; more than 4 Lesions
11719	Trimming of non-dystrophic nails, any number
11720	Debridement of nail(s) by any method(s); 1 - 5
11721	Debridement of nail(s) by any method(s); 6 or more
11730	Avulsion of nail plate, part or compl, simple; single
11732	Avulsion of nail plate, part or compl, simple; each addt’l nail place (add-on)
11750	Excision of nail and nail matrix, part or compl, for prmnt rmvl
28001	Incision & Drainage, bursa, foot
28002	Incision & Drainage below fascia, w or w/out tendon sheath involvement, foot; single bursal space
28003	Multiple areas
28005	Incision, bone cortex, foot
28008	Fasciotomy, foot and/or toe
28010	Tenotomy, percutaneous, toe; single tendon
28011	Multiple tendons
28020	Arthrotomy, incl exploration, drainage, or rmvl of loose/foreign body; intratarsal or tars metatarsal joint
28022	Metatarsophalangeal joint
28024	Interphalangeal joint
28035	Release, tarsal tunnel
28043	Excision, tumor, soft tissue of foot or toe, sub cut; <1.5 cm
28045	Excision, tumor, soft tissue of foot or toe, subfasc; <1.5 cm
28046	Radical resection of tumor, soft tissue of foot or toe; <3 cm
28047	3 cm or >
28050	Arthrotomy w/biopsy; intratarsal or tars metatarsal joint
28052	Metatarsophalangeal joint
28054	Interphalangeal joint
28055	Neurectomy, intrinsic musculature of foot
28060	Fasciotomy, plantar fascia; partial (sep proc)
28062	Radical (sep proc)
28070	Synovectomy; intratarsal or tars metatarsal joint, ea
28072	Metatarsophalangeal joint, ea
28080	Excision, interdigital neuroma, single, ea
28086	Synovectomy, tendon sheath, foot; flexor
28088	Extensor
28090	Excision of lesion, tendon, tendon sheath, or capsule; foot
28092	Toe(s), ea
28100	Excision or curettage of bone cyst or benign tumor, talus or calcaneus;
28102	W/iliac or other autograft (incl obtain graft)
28103	W/allograft
28104	Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus;
28106	W/iliac or other autograft (incl obtain graft)
28107	W/allograft
28108	Excision or curettage of bone cyst or benign tumor, phalanges of foot
28110	Osteotomy, partial excision, fifth metatarsal head (sep proc)
28111	Osteotomy, compl excision, first metatarsal head
28112	Other metatarsal head (2nd, 3rd or 4th)
28113	Fifth metatarsal head
28114	All metatarsal heads, w/partl proximal phalangectomy, excl first metatarsal
28116	Osteotomy, excision of tarsal coalition
28118	Osteotomy, calcaneus;
28119	For spur, w or w/out plantar fascial release
28120	Partial excision bone; talus or calcaneus
28122	Tarsal or metatarsal bone, except talus or calcaneus
28124	Phalanx of toe
28126	Resection, partial or compl, phalangeal base, ea toe
28130	Talectomy
28140	Metatarsectomy
28150	Phalangectomy, toe, ea toe
28153	Resection, condyle(s), distal end of phalanx, ea toe
28160	Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, ea
28171	Radical resection of tumor; tarsal
28173	Metatarsal
28175	Phalanx of toe
28190 28192	Removal of foreign body, foot; sub cut deep
28193	Complicated
28200	Repair, tendon, flexor, foot; pri or second, w/out free graft, ea tendon
28202	Secondary w/free graft, ea tendon (incl obtaining graft)
28208	Repair, tendon, extensor, foot; pri or second, ea tendon
28210	Secondary w/free graft, ea tendon (incl obtaining graft)
28220	Tenolysis, flexor, foot; single tendon
28222	Multiple tendons
28225	Tenolysis, extensor, foot; single tendon
28226	Multiple tendons
28230	Tenotomy, open, tendon flexor; foot, single or mult tendon(s) (sep proc)
28232	Toe, single tendon (sep proc)
28234	Tenotomy, open, extensor, foot or toe, ea tendon
28238	Reconstruction (advancement), post tibial tendon w/excision of accessory tarsal navicular bone
28240	Tenotomy, lengthening, or release, abductor halluces muscle
28250	Division of plantar fascia and muscle (sep proc)
28260	Capsulotomy, midfoot; medial release only (sep proc)
28261	W/tendon lengthening
28262	Extensive, incl post talotibial capsulotomy & tendon(s) lengthening w/tendon lengthening
28264	Capsulotomy, midtarsal
28270	Capsulotomy; metatarsophalangeal joint, w or w/out tenorrhaphy, ea joint (sep proc)
28272	Interphalangeal joint, ea joint (sep proc)
28280	Syndactylization, toes
28285	Correction, hammertoe
28286	Correction, cock-up fifth toe, w/plastic skin closure
28288	Osteotomy, partial, exostectomy or condylectomy, metatarsal head, ea metatarsal head
28289	Hallux rigidus correction w/cheilectomy, dbrdmnt & capslr release of the 1st metatarsophalangeal jt; w/out implant
28290 28291	Hallux valgus correction, w or w/out sesamoidectmy; smpl exostectmy (deleted 1/1/17) w/implant (new code 1/1/17)
28292	Hallux valgus correction, w/sesamoidectmy w/resctn of prox phalanx base, any method
28293	Resection of joint with implant (deleted 1/1/17)
28294 28295	With tendon transplants (deleted 1/1/17) w/proximal metatarsal osteotomy, any method (new code 1/1/17)
28296	w/distal metatarsal osteotomy, any method
28297	w/1st metatarsal & medial cuneiform jt arthrodesis, any method
28298	w/proximal phalanx osteotomy, any method
28299	w/double osteotomy, any method
28300	Osteotomy; calcaneus, w or w/out internal fixation
28302	Talus
28304	Osteotomy, tarsal bones, other than calcaneus or talus;
28305	W/autograft (incl obtaining graft)
28306	Osteotomy, w or w/out lengthening, shortening or angular correction, metatarsal; first metatarsal
28307	First metatarsal w/autograft (other than first toe)
28308	Other than first metatarsal, ea
28309	Multiple tendons
28310	Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (sep proc)
28312	Other phalanges, any toe
28313	Reconstruction, angular deformity of toe, soft tissue proc only
28315	Sesamoidectmy, first toe (sep proc)
28320	Repair, nonunion or malunion; tarsal bones
28322	Metatarsal, w or w/out bone graft (incl obtaining graft)
28340	Reconstruction, toe, macrodactyly; soft tissue resection
28341	Requiring bone resection
28344	Reconstruction, toe(s); polydactyly
28345	Syndactyly, w or w/out skin graft(s), ea web
28360	Reconstruction, cleft foot
28400	Closed treatment of calcaneal fracture; w/out manipulation
28405	W/manipulation
28406	Percutaneous skeletal fixation of calcaneal fracture, w/manipulation
28415	Open treatment of calcaneal fracture, includes internal fixation, when performed;
28420	W/primarily iliac or other autogenous bone graft (incl obtaining graft)
28430	Closed treatment of talus fracture; w/out manipulation
28435	W/manipulation
28436	Percutaneous skeletal fixation of talus fracture, w/manipulation
28445	Open treatment of talus fracture, incl internal fixation, when performed
28446	Open osteochondral autograft, talus (incl obtaining graft[s])
28450	Treatment of tarsal bone fracture; w/out manipulation, ea
28455	W/manipulation, ea
28456	Percutaneous skeletal fixation of tarsal bone fracture, incl internal fixation, when performed, ea
28465	Open treatment of tarsal bone fracture, incl internal fixation, when performed, ea
28470	Closed treatment of metatarsal fracture; w/out manipulation, ea
28475	W/manipulation, ea
28476	Percutaneous skeletal fixation of metatarsal fracture, w/manipulation, ea
28485	Open treatment of metatarsal fracture, incl internal fixation, when performed, ea
28490	Closed treatment of fracture of great toe, phalanx or phalanges; w/out manipulation
28495	W/manipulation
28496	Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, w/manipulation
28505	Open treatment of fracture, great toe, phalanx or phalanges, incl internal fixation, when performed
28510	Closed treatment of fracture, phalanx or phalanges, other than great toe, w/out manipulation, ea
28515	W/manipulation, ea
28525	Open trtmt of fracture, phalanx or phalanges, other than great toe, incl Internl fixatn, when perf, ea
28530	Closed treatment of sesamoid fracture
28531	Open treatment of sesamoid fracture, with or w/out internal fixation
28540	Closed treatment of tarsal bone dislocation, other than talotarsal; w/out anesthesia
28545	Requiring anesthesia
28546	Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, w/manipulation
28555	Open treatment of tarsal bone dislocation, incl internal fixation, when performed
28570	Closed treatment of talotarsal joint dislocation; w/out anesthesia
28575	Requiring anesthesia
28576	Percutaneous skeletal fixation of talotarsal joint dislocation, w/manipulation
28585	Open treatment of talotarsal joint dislocation, incl internal fixation, when performed
28600	Closed treatment of tars metatarsal joint dislocation; w/out anesthesia
28605	Requiring anesthesia
28606	Percutaneous skeletal fixation of tars metatarsal joint dislocation, w/manipulation
28615	Open treatment of tars metatarsal joint dislocation, incl internal fixation, when performed
28630	Closed treatment of metatarsophalangeal joint dislocation; w/out anesthesia
28635	Requiring anesthesia
28636	Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, w/manipulation
28645	Open treatment of metatarsophalangeal joint dislocation, incl internal fixation, when performed
28660	Closed treatment of interphalangeal joint dislocation; w/out anesthesia
28665	Requiring anesthesia
28666	Percutaneous skeletal fixation of interphalangeal joint dislocation, w/manipulation
28675	Open treatment of interphalangeal joint dislocation, incl internal fixation, when performed
28705	Arthrodesis; pantalar
28715	Triple
28725	Subtalar
28730	Arthrodesis; midtarsal or tars metatarsal, multiple or transverse;
28735	W/osteotomy
28737	Arthrodesis, w/tendon lengthening and advancement, midtarsal, tarsal navicular-cuneiform
28740	Arthrodesis, midtarsal or tars metatarsal, single joint
28750	Arthrodesis, great toe; metatarsophalangeal joint
28755	Interphalangeal joint
28760	Arthrodesis, w/extensor halluces longus transfer to first metatarsal neck, great toe, interphalangeal jt
28800	Amputation, foot; midtarsal
28805	Trans metatarsal
28810	Amputation, metatarsal, with toe, single
28820	Amputation, toe; metatarsophalangeal joint
28825	Interphalangeal joint
28890	Extracorporeal shock wave, high energy, performed by a physician or other qualified hlth care prof, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia
28899	Unlisted procedure, foot or toes

Reference

American Diabetes Association, Position Statement: Preventive Foot Care in People with Diabetes; http://journal.diabetes.org/FullText/Supplements/DiabetesCare/Supplement100/s55.htm

Addendum:

1. Effective 01/01/17: 2017 Code Updates to Codes Used in This BI section: Updated code descriptions for the following CPT codes: 28289, 28296 – 28299 & added 28192. Added new CPT codes 28295 & 28291 & noted deleted CPT codes 28290, 28293 – 28294.

2. Effective 07/01/2017: Made reference to BI198 for Diabetic Shoes and Shoes inserts. For diabetic shoes and inserts, see BI198 Diabetic Shoes and Shoe Inserts and BI039 Foot Care

Application to Products

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.