Part B Insider (Multispecialty) Coding Alert

Reader Question:

Use Appropriate Policy to Justify Modifier 59 Usage

Published on Mon Oct 05, 2015

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Question: I have a Medicare patient that keeps coming back to see the doctor for treatment of a corn. The note indicates that the corn is painful and the patient is diabetic; however, there are no diabetic manifestations marked in the progress note. The note indicates that the corn was shaved with a scalpel and then cryo done on the left foot. He also performed a debridement of four nails on the right foot.

What code should I use for the paring/cutting of the corn and the cryo? In another case, he performed trimming of nails (2) and debridement (4). How should I code these visits? Is modifier 59 applicable here in case of bundling?

Codify Subscriber

Answer: In the first case, you should use code 11055 (Paring or cutting of benign hyperkeratotic lesion [e.g., corn or callus]; single lesion) for the cutting of corn. Debridement of nails calls for code 11720 (Debridement of nail[s] by any method[s]; 1 to 5). However, these are listed as a Column 1 Code/Column 2 CPT^® code combo and are bundled. You can unbundle the combo with modifier 59 (Distinct procedural service). The condition is that the two should be mutually exclusive procedures, which means that modifier 59 is only appropriate if the procedures are performed for lesions anatomically separate from one another or if procedures are performed at separate patient encounters.

In such a case, some payers may accept modifier XS (Separate structure) instead of modifier 59. You will also have to report from modifiers Q7, Q8, or Q9 depending on the class findings, in this case Q8. You have indicated that the cutting and debridement were done for separate locations. Support the foot care with appropriate diagnostic codes.

For the cryo, you should report code 17110 (Destruction [e.g, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions).

Therefore, you can report:

11055-Q8-LT
11720-XS-RT
17110-LT

Caution: You cannot report CPT^® codes 11055-11057 for removal of hyperkeratotic skin adjacent to nails needing debridement.

In the second case, you are looking at a possible combination of CPT^® codes 11719 (Trimming of nondystrophic nails, any number) and 11720, which is again bundled, according to CCI edits. In this case, a different policy is applicable if you want to unbundle the codes: mutually exclusive procedures. You can use modifier 59 or modifier XU (Unusual non-overlapping service) but only if the trimming and the debridement of the nails are performed on different nails or if the two procedures are performed at separate patient encounters.