Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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.