Podiatry Coding & Billing Alert

Question: When we bill Medicare for nail trimming and/or debridement, can we only use the specific ICD-10-CM codes listed in the Local Coverage Determination (LCD) for our jurisdiction (in our case, LCD A57188)? Or can we use other codes in the same category?

For instance, I73.89 is not on the list of acceptable diagnosis codes. Can we use I73.9 instead (in the instance that the patient doesn’t have I73.89 but rather I73.9) and still have it be covered? I understand the documentation needs to meet the requirements of a Q modifier. I am solely inquiring about the diagnosis codes you can use.

AAPC Forum Participant

Answer: In order to bill Medicare for 11719 (Trimming of nondystrophic nails, any number), 11720 (Debridement of nail(s) by any method(s); 1 to 5), 11721 (… 6 or more), or G0127 (Trimming of dystrophic nails, any number) per the guidelines outlined by LCD A57188, “the patient must have one or more of the diagnoses listed under the ‘ICD-10 Codes that Support Medical Necessity’ section.” (Source: www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57188). This is generally true for all LCDs.

In your specific example, neither I73.89 (Other specified peripheral vascular diseases) or I73.9 (Peripheral vascular disease, unspecified) are listed as codes that support medical necessity for the services as a group 1 code.

These diagnoses are also not listed as group 2 codes, meaning they also do not satisfy the requirements necessary for appending either of the appropriate Q modifiers you mention:

• Q7 (One class A finding), which includes “a nontraumatic amputation of foot or integral skeletal portion,”
• Q8 (Two class B findings), which includes “absent posterior tibial pulse, absent dorsalis pedis pulse, advanced trophic changes which include any three of the following conditions, such as increased or decreased hair growth; nail thickening; or changes in color, texture, or reddening of the skin,”
• Q9 (One class B and two class C findings), which includes the class B findings above plus class C findings including “claudication, burning, coldness of the feet, edema, tingling or abnormal spontaneous sensations in the feet,” according to HCPCS.

The only acceptable diagnoses in the I73 (Other peripheral vascular diseases) category for this group are I73.00 (Raynaud’s syndrome without gangrene), I73.01 (Raynaud’s syndrome with gangrene), and I73.1 (Thromboangiitis obliterans [Buerger’s disease]). 

Codes I73.89 and I73.9 are also not group 3 (peripheral neuropathy) or group 4 (anticoagulation therapy) codes.

So, in your case, if you are providing either 11719, 11720, 11721, or G0127 for a Medicare patient using I73.89 and I73.9, per the language of the LCD, “the service is noncovered and should be coded with a GY modifier (Item or service statutorily excluded or does not meet the definition of any Medicare benefit).”