Podiatry Coding & Billing Alert

Incorrect transition of payable diagnosis codes has compounded the problem.

You are not alone if you have been recently facing Medicare denials for routine foot care or nail debridement claims. Similarly, you may also have been on the wrong side of Medicare claims for preoperative tests that your physician ordered. Recent information from National Government Services (NGS), a Medicare administrative contractor (MAC), has acknowledged the problems and has laid out some possible reasons for these problems and what you can do to solve them.

Scenarios: Your physician  performed debridement of 5 nails for a Medicare patient. You reported 11720 (Debridement of nail[s] by any method[s]; 1 to 5). You face a denial to your claim. In another situation, you report 11719 (Trimming of nondystrophic nails, any number) for routine foot care that your physician performed for another Medicare patient. You got a denial for this claim, too.

In yet another situation, you face a denial for some preoperative tests (like a x-ray or an EKG) that your physician ordered. These tests were not routine preoperative tests but tests that your physician ordered due to medical necessity.

So, what are you doing wrong? According to NGS, you may not be doing anything wrong; the fault may lie with your MAC.

The problem: NGS has identified the following production issues that are causing erroneous denials of these types of claims.

Routine Foot Care and Debridement of Nails

• Some claims for routine foot care and debridement of nails have processed incorrectly since the transition to ICD-10 editing. NGS is adding some diagnoses as payable for these services and correcting edits, which resulted in incorrect denials. The additional diagnoses will be included in the LCD.
• NGS has also identified submitted claims where some services that did not meet coverage criteria have been allowed in error.

Noncovered Services

• Some claims for preoperative tests (e.g., EKGs, X-rays) have been denied in error due to an editing issue.

What you need to do: NGS will be adjusting the denied claims for routine foot care and debridement of nails to pay correctly. No provider action is required. Also, claims for preoperative tests that have been denied incorrectly will be reprocessed by NGS. No provider action is required. If you submit your claims to a MAC other than NGS and are having the same problems, please check with your MAC to see if any action is needed on your part to correct the situation or if your MAC will make the necessary adjustments on its own.