Wiki Billing CPT 11055 to Medicare

Hackettstown, NJ
Best answers
Hello All,

Our derm is billing 11055 paring of corns/calluses to Medicare and it is being denied. The LCD is a bit confusing for NY. Am I reading this correctly? MUST the patient have an underlying condition with approved diagnosis code(s) from Group 1 OR have some form of neuropathy condition as per the Group 4 diagnosis codes? Our patient has SLE Systemic Lupus Erythematosus and presented to the doctor with other dermatological conditions including painful corn/callus on right foot. We billed with L84 and M79.674 for pain in right toe(s) but Medicare is denying for medical necessity specifically citing the LCD. Can anyone provide any insight? Thank you!
While i'm not familiar with your specific LCD, (I'm in Iowa) I can tell you that after the updated 2016 LCD for 11055 came out, it seems 95% of these services are not covered. L84 will never be a payable primary DX. The only way this code is payable is if the pt has a systemic condition, which must be listed first in addition to qualifying for a Q code modifier. The date last seen of the PCP must also be on the claim, and they must have seen that provider 6 months prior or 30 days after the dos.

Our claims typically look like this:

*date last seen needs to be in "extended info" in the podiatry/PT section of the ailment or on your claim.
are the Q-code modifiers (Q7, Q8, Q9) applicable only to the podiatry practice profee billing for cpt 11055? or is this pertinent to technical component billing if this is done in the hospital outpt clinic / department (HOD) as well? what DX would be required to support? and what documentation would need to be present in the HOD setting?