Wiki Again--billing issues with 11056 and 11721

[ollielooya]

I've been asked by a team-mate if I would submit an inquiry to the forum for help on a recurring coding issue. I'm NOT a podiatry coder yet know this is the place to come for help. She has furnished this information to me: Is there anyone out here who would be available for her to contact you?

Washington State Medicare patientt (Noridian). I cannot get these two codes paid together:

11056 and 11721 or

11055 and 11721

billing as follows:

11055 757.39 729.5

11721-59 110.1 719.7

Medicare is denying the 11055 (or 11056) as not medically necessary. I tried to rebill the 11055 with 703.8, also denied. 11721 is paying. According to the LCD these codes should pay with these dx, without a Q modifier or PCP info

 

[espressoguy]

I've been asked by a team-mate if I would submit an inquiry to the forum for help on a recurring coding issue. I'm NOT a podiatry coder yet know this is the place to come for help. She has furnished this information to me: Is there anyone out here who would be available for her to contact you?

Washington State Medicare patientt (Noridian). I cannot get these two codes paid together:

11056 and 11721 or

11055 and 11721

billing as follows:

11055 757.39 729.5

11721-59 110.1 719.7

Medicare is denying the 11055 (or 11056) as not medically necessary. I tried to rebill the 11055 with 703.8, also denied. 11721 is paying. According to the LCD these codes should pay with these dx, without a Q modifier or PCP info

There are 2 LCD's governing CPT 11055/56. Your above coding meets LCD 24374, however LCD 24356 says that the only dx that meet medical necessity are 110.1, 700, 703.8, and 703.9

You'll note that dx 757.39 is not mentioned at all for LCD 24356.

Once I discovered that I had to satisfy 2 LCD's, I had no trouble getting these claims paid.

 

[lchilliard]

Yes- there are two active LCD's that address the 11055-57 codes. Each one represents 2 different scenarios. One LCD is for routine foot care-LCD#24356. This is the one you alluded to in which a patient qualifies due to a specific systemic disease process and most times requires a Q modifier and PCP info. The other LCD #24374 is for patients who qualify due to a pathological event which has nothing to do with routine footcare.
This is the LCD it looks like you are trying to use. In this LCD, in a perfect world the combination of 11055 with an icd-9 of 757.39 listed first and pain 729.5 listed second should be payable. If you are getting denied you could either call your CAC representive for Noridian to point out this is not getting paid. You could call medicare yourself and tell them according to LCD 24374 that combo should be payable and their software program is not recognizing this. The faster solution would be to look at the icd-9 code 701.1 to see if that addresses what your Dr. is actually doing. 701.1 is acquired keratoderma, hyperkeratosis- the code you are trying to use states Congenital keratoderma and does not state hyperkeratosis in its definition. I would take these 2 codes ( 701.1 and 757.39) to your Dr. and get a clarification of what he is actually paring or cutting. Chances are the 701.1 definition code fits better what your Dr. is actually paring and that I know is payable along with 729.5 in second position. Of course this is assuming that the lesions are indeed painful.
I must reiterate- do not change the codes yourself but bring an icd-9 code book ( hopefully recent) to your Dr's attention and have him clarify. If he states it is definitely what 757.39 defines than you will have to make phone calls- Modifiers would go on the nail codes (11720-11721)
Hope this helps-
Lee Hilliard RN, CPC, CPC-H
Puyallup,WA

 

[ollielooya]

Thank you both for the great responses, Lee, I sent you a private message.

And I see Espressoguy that you are from our neck of the woods, as we're in Everett. Would like to contact you directly if you wouldn't mind?

 

[micheller0630]

Hi, I noticed that you were having a problem getting your 11055-57 and 11721 paid. I am not sure about WA LCD but Texas allows for them to be paid together under certain LCD GL. When I combine mine in the same day I utilize it this way.
11721 110.1 250.60 (59) )Q7-Q9 MOD (or any diabetic code or DX on LCD as secondary) otherwise considered Routine
11055-57 250.60 ,357.2 or (443.9 standalone...) mod or any DX on LCD W/ same Q7-Q9
with this goes the last time the pt saw their PCP that is treating their diabetic condition. The patient has to have a systemic condition for this clm not to be considered RFC which of course is not covered.

Hope this helps.