Indications and Limitations of Coverage and/or Medical Necessity

CPT codes 11040-11044 should be used for debridement of non-hyperkeratotic lesions, such as ulcerations, burns, or skin wounds.

Diabetic Peripheral Neuropathy (Effective July 1st, 2002)
Presently, peripheral neuropathy, or diabetic sensory neuropathy, is the most common factor leading to amputation in people with diabetes. In diabetes, sensory neuropathy is an anatomically diffuse process primarily affecting sensory and autonomic fibers; however, distal motor findings may be present in advanced cases. Long nerves are affected first, with symptoms typically beginning insidiously in the toes and then advancing proximally. This leads to loss of protective sensation (LOPS), whereby a person is unable to feel minor trauma from mechanical, thermal, or chemical sources. When foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing.

Diabetic sensory neuropathy with LOPS is a localized illness of the feet and falls within the regulation’s exception to the general exclusionary rule [see 42 C.F.R. § 411.15 (1)(1)(i)]. Foot exams for people with diabetic sensory neuropathy with LOPS are reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease.

Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim. LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines. The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically. Heavily callused areas should be avoided. As suggested by the American Podiatric Medicine Association, an absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes-Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation.

· The examination includes:
1) a patient history, and
2) a physical examination that must consist of at least the following elements:
a. visual inspection of forefoot and hindfoot (including toe web spaces);
b. evaluation of protective sensation;
c. evaluation of foot structure and biomechanics;
d. evaluation of vascular status and skin integrity;
e. evaluation of the need for special footwear; and
3) patient education

.Treatment includes, but is not limited to:
1) local care of superficial wounds;
2)debridement of corns and calluses; and
3)trimming and debridement of nails.

The diagnosis of diabetic sensory neuropathy with LOPS should be established and documented prior to coverage of foot care. Other causes of peripheral neuropathy should be considered and investigated by the primary care physician prior to initiating or referring for foot care for persons with LOPS. 

Coverage Topic

Foot Care
 

Coding Information

CPT/HCPCS Codes

ICD-9 Codes that Support Medical Necessity

General Information

Documentation Requirements

Medical records should clearly document patient complaints, physical findings, diagnoses, and procedures performed to substantiate medical necessity.