Wiki 11055-11057 Dx Issues - HELP!

[10mcdowj]

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]

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]

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.

 

[Orthocoderpgu]

This is odd. Your saying that the above example would be paid?

You say that the patient has an underlying medical condition, what is the condition?

 

[10mcdowj]

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

 

[Orthocoderpgu]

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.

I can see why this is driving you crazy. I wished I could be more help. Hopefully someone out knows the answer.

 

[JCraft]

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]

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]

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!

 

[footdoc89]

Hii,

I am working for Florida region and getting denials on 11055-57 for medical necessity when billed with L84 along with any comorbidity, ex diabetes. can anyone help me on that??

 

[CBLENNIE]

Hii,

I am working for Florida region and getting denials on 11055-57 for medical necessity when billed with L84 along with any comorbidity, ex diabetes. can anyone help me on that??

Have you look at the LCD and Billing and Coding Article for the Florida Part B MAC First Coast Service Options? The LCD Routine Foot Care L33941 and the corresponding Billing and Coding Article Routine Foot Care A57188. The billing and coding article A57188 has the lists of various DXs for which 11055-11057 would be covered for depending on the criteria in the LCD L33941.

L84 is not a listed covered DX for these services but diagnoses such as diabetes & ESRD are listed. Here is a snip of the LCD L33941 regarding indications for coverage.

Additionally, 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290 Foot Care has a section titled Exceptions to Routine Foot Care Exclusion that also lists the conditions for which 11055-11057 might be covered.

 

[podcoder70]

FCSO has a very interesting LCD/Article for routine foot care. I don't believe L84 is the issue with your claim. Most likely it is missing other details. Can you please provide the exact denial code you are getting? Is it the same for all claims? Are all claims for diabetes? Please provide some examples.