Question 11055-11057 Dx Issues - HELP!

10mcdowj

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Our podiatrist is constantly wanting to bill 11055-11057 for the debridement of keratomas/hyperkeratotic tissue for diabetic patients or patients with peripheral vascular disease. From reading the guidelines, it sounds like this cpt should be covered as long as the patient has an underlying condition, which they do.

In 2019 and prior we would bill this cpt with L84 as one of the diagnoses. The LCD for 2020 updated (Medicare J5, article #A56232 on CMS) and no longer lists any related codes to L84 and doesn't give any direction on what they want instead. Some insurances have started outright rejecting this cpt if we have diagnosis L84 listed anywhere on the claim. I don't feel E11621 (or any PVD codes with ulceration mentioned) fits, as my doctor specifically mentions that there is no ulceration present, just keratomas or hyperkeratotic tissue. I also wouldn't know what to do for PVD as he often lists this diagnosis as unspecified (I739) and doesn't give any descriptions in the notes to determine a more specific code. Maybe that is another issue in itself.

Additionally, sometimes we can get this code to pay if we bill it with something in diagnosis pointer 3 such as hammertoes, pain, etc. However these codes aren't always given or supported by the notes. It also doesn't quite make sense as the hammertoe diagnoses aren't listed in the LCD either.

Ex. 11055-Q8 E1151 L84 M2041 M2042

I have done so much google/AAPC site searching, have read forum after forum, have asked several of my colleagues, reached out to other coders I know, and I'm at a loss at what to do at this point. Appeals are useless when it's an LCD denial. If it weren't getting paid some of the time, I would let our doctor know this isn't covered and advise him to start getting ABNs.

Is anyone else having this problem? If you have any inkling on what to do, please help!
 

Orthocoderpgu

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Full disclosure I code orthopedic surgeries. After looking at how this is coded I'm wondering if you need to pair E11.51 with a code for PVD? Having a hammertoe would cause excessive rubbing and create a hyperkeratotic lesion on the dorsal aspect. Maybe there just needs to be a PVD diagnosis included?
 

10mcdowj

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So the example I gave is an example of something that would pay. Usually my doc is wanting to bill 11055-Q8 E1151 (or any other diabetes/PVD icd10) L84 - without the hammertoe codes. Are you saying I should be billing it like, 11055-Q8 E1151 I739 L84? What if PVD isn't given by the doc?

I totally get that the hammertoes would be causing the keratomas, but if they're not listed in the LCD either I'm not sure why they would be getting paid if L84 isn't. Medicare has been less than helpful with my questions on this.

Because the patient has an underlying condition I feel like this should be covered. Maybe I'm wrong, and maybe I'm thinking too hard about this.
 

10mcdowj

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Yes, the original example given would be paid. You can see why this doesn't make any sense to me lol. It makes it difficult for me to figure out what the actual problem is.

The underlying condition depending on the patient/situation is always either diabetes mellitus or PVD/peripheral neuropathies. I always list these diagnoses first.

This link is thrown around on this forum a lot as an explanation, but it doesn't help with this specific LCD, and only affirms my thoughts that this should be covered: http://www.qnotes.com/resources/Pod_Medicare_Foot_and_Nail_Care_Services.pdf
 

JCraft

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However L84 code is a callus and 11056 isn't covered for that dx code in my jurisdiction. My providers typically call them hyperkeratotic lesions etc. and L85.1. Hope this helps!
 

eurodurk

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Hello!

I currently bill out of Medicare jurisdiction J8, so please take this with a grain of salt, but what our practice does for these codes is to bill with the most appropriate systemic that is covered under Medicare's LCD, and we use the code L85.9 (epidermal thickening, unspecified). For some reason our Medicare jurisdiction does not like the L84 code, but pays with the L85.9. (And needless to say, the appropriate Q modifier is attached 😋)

Hope this helps!
-Jennifer
 

10mcdowj

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Thanks guys! Unfortunately none of the L8- diagnoses are included in our LCD for 2020, otherwise I would definitely consider using them. It doesn't seem to matter what I use as the secondary diagnosis. I am finding that they are covering when there's a hammertoe or other deformity diagnosis at pointer 3 as long as the underlying condition is the pdx. So I'm just going to accept it for what it is at this point. Hopefully working with my doc I can get these to pay without a problem going forward. But also at this point we'll see what other obstacles 2021 guidelines throw at me for this issue, haha!
 
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