Routine foot care, encompassing services like nail trimming and callus removal, is often considered a part of personal hygiene. However, for individuals with certain medical conditions, what seems like routine care can become medically necessary. This article delves into understanding when routine foot care is considered more than just routine and how a diagnosis plays a crucial role in determining insurance coverage, particularly within the context of policies like those from Aetna.
What Constitutes Routine Foot Care?
Routine foot care generally includes common procedures aimed at maintaining foot hygiene and comfort. These services, typically performed by individuals themselves or in non-medical settings, are often excluded from insurance coverage. Examples of routine foot care include:
- Trimming, cutting, or clipping of nails (both normal and mycotic nails in some contexts)
- Removal or reduction of corns and calluses
- Shaving, paring, or cutting of keratomas, tylomas, and helomas
- Non-definitive, palliative treatments for plantar warts (like simple paring without cautery)
- General hygienic and preventive maintenance care, such as cleaning and soaking feet, and using skin creams
These procedures are typically considered preventive or cosmetic when performed on healthy individuals without underlying medical conditions. Insurance policies often assume these are part of self-care and personal responsibility.
When Routine Foot Care Becomes Medically Necessary: The Diagnosis
The key to understanding coverage for routine foot care lies in the concept of medical necessity. For many insurance plans, including some Aetna plans, routine foot care becomes eligible for coverage only when it is deemed medically necessary. This typically occurs under specific circumstances where a patient’s health condition elevates the risk associated with self-administered foot care. These circumstances are generally categorized as follows:
1. Hazardous Non-Professional Performance
If performing routine foot care at home poses a significant health risk to the individual due to an underlying condition or disease, professional foot care may be considered medically necessary. This is particularly relevant for individuals with systemic conditions that compromise circulation or sensation in their lower extremities. Conditions that may justify coverage under this criterion include:
- Arteriosclerosis
- Chronic Thrombophlebitis
- Diabetes mellitus
- Peripheral neuropathies (hereditary, idiopathic, inflammatory, autonomic)
- Peripheral vascular diseases (atherosclerosis, stricture of artery, aortitis)
- Posthrombotic syndrome
- Venous insufficiency
For patients with these conditions, even seemingly simple procedures like nail trimming can lead to complications such as infections, ulcers, or other injuries due to impaired healing or lack of sensation. A diagnosis of one of these conditions, coupled with the need for foot care, can establish medical necessity.
2. Integral Part of a Covered Service
Routine foot care can also be covered when it is an essential component of a separately covered medical service. For instance, if a patient requires debridement of a nail to access and treat a subungual ulcer, or if wart treatment necessitates the paring of surrounding skin, the routine foot care aspect becomes integral to the overall covered treatment. In these cases, the diagnosis is not solely for routine foot care, but for the primary condition requiring the covered service, and the routine care is a necessary step in that process.
3. Debridement of Mycotic Nails with Secondary Complications
Debridement of mycotic (fungal) nails, which is typically considered routine, can be deemed medically necessary and covered when the fungal infection causes secondary issues. Specifically, if the mycosis or dystrophy of the toenails leads to secondary infection and/or pain that significantly limits ambulation and necessitates professional intervention, debridement becomes a covered service. The diagnosis here involves not just the fungal nail infection (Tinea unguium), but also the resulting secondary complications and functional limitations. Underlying conditions like diabetes and peripheral neuropathy can further support the medical necessity in these cases.
Coding and Diagnosis: CPT, HCPCS, and ICD-10 Codes
To ensure proper billing and coverage, healthcare providers use specific coding systems. The original article provides tables of relevant codes. Understanding these codes helps clarify what types of services and diagnoses are associated with routine and non-routine foot care.
CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) codes specify the procedures performed. For routine foot care, codes like 11055-11057 (paring of lesions), 11730 & 11732 (nail avulsion), 11750 (nail excision), and 11765 (wedge excision for ingrown nail) may be covered if medical necessity criteria are met. For debridement of mycotic nails, codes like 11719-11721 and HCPCS code G0127 are relevant. Code G0247 specifically addresses routine foot care for diabetic patients with loss of protective sensation (LOPS), highlighting the link between diagnosis (diabetes with neuropathy) and covered routine care.
ICD-10 (International Classification of Diseases, 10th Revision) codes are used to diagnose the patient’s condition. Certain ICD-10 codes, particularly those indicating systemic conditions like diabetes (E08-E13), peripheral neuropathies (G60-G62, G90, G99), and peripheral vascular diseases (I70-I73, I77, I79, I80, I87, I89, I99), are crucial in establishing medical necessity for routine foot care. Conversely, codes like L84 (corns and callosities), L85.1 (keratosis), and M21.6 (bunion without surgery) are often associated with routine foot care that is typically not covered. For mycotic nails, B35.1 (Tinea unguium) along with systemic condition codes can support coverage for debridement.
Background on Coverage Policies
The approach to routine foot care coverage is often influenced by policies similar to Medicare. Medicare generally excludes routine foot care, assuming it’s part of self-care. However, exceptions are made when systemic conditions create a hazard for self-care. This principle is echoed in many private insurance policies, emphasizing that the presence of a qualifying medical diagnosis is often the key to unlocking coverage for services that would otherwise be considered routine and non-covered.
Conclusion
Determining whether routine foot care is covered by insurance hinges on establishing medical necessity. This “diagnosis” for routine foot care coverage isn’t about identifying a new foot ailment, but rather demonstrating that a pre-existing medical condition makes professional routine foot care essential for preventing complications and maintaining the patient’s overall health. By understanding the criteria of hazardous self-performance, integral service components, and complications from mycotic nails, and by utilizing appropriate CPT, HCPCS, and ICD-10 codes, both patients and providers can navigate the complexities of insurance coverage for what might initially seem like simple foot care.
References
- American Academy of Dermatology, Guidelines/Outcomes Committee. Guidelines of care for superficial mycotic infections of the skin: Onychomycosis. J Am Acad Dermatol. 1996;34(1):116-121.
- Bending A. Fungal nail infections: Far more than an aesthetic problem. Br J Community Nurs. 2002;7(5):254-259.
- Louisiana Medicare Part B. Foot care. Medicare Part B Medical Policy. Baton Rouge, LA: Louisiana Medicare; February 2000.
- Melkus GD, Maillet N, Novak J, et al. Primary care cancer and diabetes complications screening of black women with type 2 diabetes. J Am Acad Nurse Pract. 2002;14(1):43-48.
- Neale D, Adams I, eds. Common Foot Disorders. 2nd ed. New York, NY: Churchill Livingstone; 1985.
- O’Connor JJ, Deroche CB, Wipke-Tevis DD, et al. Foot care self-management in non-diabetic older adults: A pilot controlled trial. West J Nurs Res. 2021;43(8):751-761.
- Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with diabetes: A randomized controlled trial. JAMA. 2002;287(19):2552-2558.
- U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Foot care and supportive devices for the feet. Medicare Carriers Manual §2323. Baltimore, MD: HCFA; 2000.
- U.S. Department of Health and Human Services, Health Care Financing Administration (HCFA). Foot care. Medicare Carriers Manual §4120. Baltimore, MD: HCFA; 2000.
- Yale JF. Yale’s Podiatric Medicine. 3rd ed. Baltimore, MD: Williams & Wilkins; 1987.
