“I am in Virginia and I have read through the LCD and billing guidelines for Palmetto GBA several times regarding coverage for routine foot care. It is very specific about when CPT 11720 and CPT 11721 will be covered, but it is not specific about CPT 11055, CPT 11056 and CPT 11057. My interpretation is that for coverage of CPT 11055-CPT 11057, there must be a systemic condition with class findings and if there are no systemic conditions that would qualify for coverage, modifier -GY should be used and -GA if an ABN is on file. I am wondering if CPT 11055-CPT 11057 are also covered with primary diagnosis code of L85.1 with appropriate secondary diagnosis similar to how CPT 11720 and CPT 11721 are covered for mycotic nails with primary diagnosis of B35.1 with appropriate secondary diagnosis. Are callus codes (CPT 11055-CPT 11057) covered with the primary diagnosis of L85.1 (or similar) and a secondary diagnosis of infection, pain, or difficulty walking? Or are they only covered with systemic conditions and class findings?
When it comes to “At Risk,” routine foot care, Palmetto GBA and the majority of the Medicare Administrative Carriers have Local Coverage Determinations (LCDs) and associated articles for guidance. The LCDs and the articles are based upon the National Coverage Determination for “At Risk,” routine foot care of CMS and the Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 290 – Foot Care.
The CPT/HCPCS Level II codes that are specific to the above policies are the following:
CPT 11719 Trimming of non-dystrophic nails, any number
G0127 Trimming of dystrophic nails, any number
CPT 11720 Debridement of nail(s) by any method(s); 1 to 5
CPT 11721 Debridement of nail(s) by any method(s); 6 or more
CPT 11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
CPT 11056 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions
CPT 11057 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions
This procedure code set when appropriately performed and documented can be provided to the qualifying patient no sooner than every 60 days. To qualify, the patient in question must have a covered systemic disease, be under the care of physician (MD, DO) for the disease and have Class Findings which are identified based upon the lower extremity physical examination. If the patient does not meet the qualifications for coverage of “At Risk,” routine foot care and still would like the service performed, they would have to pay out of pocket.
There is an option for CPT 11720 and CPT 11721 to be covered. The patient would be classified as an “Otherwise Healthy Individual.” Mycotic toenails can be debrided for this individual if the following criteria are met:
1. Class Findings are not required
2. A covered systemic disease is not required
3. The patient has mycotic toenails
4. The mycotic toenails are symptomatic
a. The patient must suffer from pain due to the thickness of the mycotic nail(s)
b. The patient has a marked limitation of walking due to the thickness of the mycotic nail(s)
c. The patient must suffer from a secondary infection due to the thickness of the mycotic nail(s)
When it comes to codes, CPT 11055, CPT 11056 and CPT 11057, this second option does not exist. They are only covered based upon the coverage criteria for “At Risk,” routine foot care. There is one Medicare Administrative Carrier that does reimburse for painful, hyperkeratotic lesions. Unfortunately, it is not Palmetto GBA. The carrier is Noridian Healthcare Solutions.
This is my opinion.
Michael G. Warshaw, DPM, CPC
THE 2026 PODIATRY CODING MANUAL IS NOW AVAILABLE in either Book or Flash-drive formats. It has been completely updated for the calendar year 2026. Many offices across the country consider this to be their “Bible” when it comes to coding, billing, and documentation. The price is still only 125.00 including shipping! To
purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for 125.00 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 32757
Read Comments