Wiki Foot Care Coding Issues

[jessicamarquez05]

I just took over Rev Cycle for F&A and Wound offices, I don't have a ton of guidance.
I have quite a few denials for Medicare Plus Blue and other BCBS products for codes 11056 and 11721.

My office does Medicare split billing, the UB usually pays but the HCFA portion denies. They are usually LCD Denials but from what I can tell these dx codes fit into the LCD. I am at a loss. I have to do CE appeals for almost all claims with these codes. The codes have the q9 modifier like they should and also the mod 59 to override bundling.

Here is an example:


anyone insight on this? Is anyone else having these issues?

Thanks,
Jessica

 

[SharonCollachi]

Did everything deny? If both denied, I would think it would be a diagnosis issue (otherwise, one would have paid if it was a modifier issue), but you never know. Do they want the XU modifier instead of the 59 modifier?

Here is a similar question, and it looks like the order of the dx is what is different: https://associationdatabase.com/aws...ticle/181818/_PARENT/layout_details_cpr/false

Do you have a link to your LCD?

 

[jessicamarquez05]

only code 11056 and 11721 denies, everything else on the claim paid. I haven't ever encountered a claim where a XU modifier was used in this office. i can discuss it with my coder.

here is a link to my LCD

https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56232&ver=14&Date=&DocID=A56232&bc=gQAAAAIAAAAA&

 

[SharonCollachi]

Do you have this part covered?: For diagnosis codes designated by an asterisk (*), it is required the patient be under the active care of Doctor of Osteopathy (D.O.) or Doctor of Medicine (M.D.) The active care requirement would be considered met if the claim indicates that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the service. A list of diagnosis codes can be found in Group 1 Paragraph under ICD-10 Codes that Support Medical Necessity.

Diabetes is one of the asterisk codes.

Box 19. The 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) date patient was last seen and the NPI of his/her attending physician when an independent physical or occupational therapist or physician providing routine foot care submits claims.