Podiatry Coding & Billing Alert

Question: I submitted a claim for codes 11056 and 11721, but my MAC denied my claim. Do you have any insight into why?

Pennsylvania Subscriber

Answer: Without more information, it’s difficult to say exactly why your claim was denied. However, there could be several culprits.

First, a procedure to procedure (PTP) pair exists with codes 11056 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions) and 11721 (Debridement of nail(s) by any method(s); 6 or more). Code 11721 is a column 2 code for 11056. This usually means that if you report these two codes together, code 11721 would be bundled into 11056. However, since the modifier indicator for this PTP pair is “1,” you can use a modifier to override this edit when appropriate. If you did not append the appropriate modifier, this may be a reason why your claim was denied.

Some examples of modifiers you can use to override PTP edits include modifier 59 (Distinct procedural service); modifier XE (Separate encounter, a service that is distinct because it occurred during a separate encounter); modifier XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner); modifier XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure); and modifier XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service).

Remember: To override an edit, the documentation and clinical circumstances must always support your decision to use the modifier. Examples include separate sites or sessions for the services. Never append a modifier just to bypass the edit.

Also, you should check to see if you need to append the Q9 (One class b and two class c findings) modifier to code 11721 on your claim.

Another solution is to check the diagnoses your podiatrist documented and make sure these ICD-10-CM codes fit into your MAC’s LCD requirements for these CPT^® codes.