Part B Insider (Multispecialty) Coding Alert

Published on Mon Mar 08, 2004 PDF

Understand difference between G0127 and 11719

The HHS Office of Inspector General has warned that Medicare is spending $96.8 million per year on nail debridement and related services that don't have enough documentation to justify payment. The OIG calls for a crackdown in its 2003 Red Book of unimplemented recommendations. Will you be ready?
 
Even old hands can find nail care coding a challenge. To distinguish between G0127 and 11719-21 requires understanding the difference between "systemic conditions" and "sick foot" symptoms. But it can be worthwhile: G0127 reimburses roughly $14 to $26 depending on locality, but CPT 11720 pays $24 to $45 depending on locality.

According to carrier coverage policies and coding experts, you should bill G0127 when a patient has dystrophic nails and a "systemic condition" but not symptoms of a "sick foot." A potentially confusing instance of nail-splitting, but it does make sense.

A "systemic condition" means that the foot has an underlying problem that "makes the trimming of nails a higher than random risk procedure and thus necessitates the scrupulous and expert care of a professional," says carrier Cigna Healthcare in a provider bulletin. But the patient doesn't need to have acute symptoms such as pain or difficulty walking.

If you're billing G0127, you need to document "class findings" that show which kind of systemic condition the patient has. Class A findings mean "non-traumatic amputation" of the foot, or part of the skeleton. Class B findings include absent pulses, changes in skin color and texture or nail thickening. Class C findings include edema, claudication, temperature changes and abnormal sensations such as burning.

You'd use the -Q7 modifier to indicate one Class A finding, the -Q8 modifier to indicate two Class B findings, or the -Q9 modifier to indicate one Class B finding and two Class C findings.

The coverage rules for nail care with a systemic condition are similar to those for trimming calluses with a  systemic condition, says Jessica Peterson, office manager with Podiatry Center of Idaho in Boise.

But if the patient has acute symptoms, then you'd code 11720 (for five or fewer nails) or 11721 (for six or more) instead, notes Peterson. Even if the patient has an underlying condition as described above, you'd still bill 11720-1 if symptoms are present. These include difficulty walking (719.77), pain in limb (729.5), abnormal gait (782.2), paronychia (681.11), cellulites of the toe (681.10) or other unspecified infections (686.9).

If the patient has non-dystrophic toes, with no systemic conditions and none of the symptoms mentioned above, then you should bill 11719.

For patients with systemic conditions, podiatrists should make sure to document that the patient has seen a primary care physician within the last six months, says Peterson. Include the primary care doc's name. "Because they have a systemic condition that is obviously causing circulatory issues," the carrier is "only going to allow coverage if the patient's getting treated by a primary care physician."

Cigna also warns in a recent bulletin that its audit found "difficulties with the adjudication of claims" relating to mycotic nails. Some conditions that cause pain and other symptoms in the toes (such as circulatory problems, neuropathies, bone, skin, soft tissue and other disorders) may represent a reason not to manipulate the patient's toenails -- especially if there's no pressing reason to treat them.

Thus, Cigna instructs providers billing for any intervention on mycotic nails to include in the medical record: the specific findings consistent with the diagnosis of onychomycosis; what is perceived as a complication; evidence that shows a causal relationship between the fungal infection and the symptoms, based on history or physical examination; and evidence that the physician considered other conditions that might be causing the problem.