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11056 Palmetto Claims

  1. Default 11056 Palmetto Claims
    Medical Coding Books
    Is anyone else having trouble with billing the debridement codes for Palmetto NC claims?


    Thanks!
    Stephanie

  2. Default
    CODES: 11055-11057
    I read something on this stating medicare will only reimburse for this if it is medically necessary which usually means the dx must fall in the catigory of what they determine would be a dx in which this procedure would be covered. Which in reading sounds very limited. You must first have a dx of either 700, 701.1, or 757.39. Then you must have a second dx of either 686.9, or 729.5. On every claim which if this is the case and it is medically necessary the phys. Must document this so you can code properly. In this case if you want to get paid. Good luck.

  3. Default
    I am having a problem with 11055-57 denying for medical necessity. We have dx 701.1 but still denies. Also having a problem with 11721 and 11055-57 bundling. Does anyone have any answers?

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by nccodingchick View Post
    Is anyone else having trouble with billing the debridement codes for Palmetto NC claims?


    Thanks!
    Stephanie
    This is covered only for certain diagnosis, Can you provide more on the documentation as well as the denial reason from Palmetto?

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Location
    Honolulu, HI
    Posts
    20
    Default
    Quote Originally Posted by Jana Lee View Post
    I am having a problem with 11055-57 denying for medical necessity. We have dx 701.1 but still denies. Also having a problem with 11721 and 11055-57 bundling. Does anyone have any answers?
    was that supposed to be mod-57 or mod-59??? if you are using 57, that is part of the problem. you didn't mention use of a Q-mod either, does your patient have a qualifying disease or disorder to warrant med nec??

  6. Default Denials
    Have you gone to the Palmetto website to check the local coverage determinations for the MN dx'es? From there you would go to check the NCCI edits to see if the procedures you are querying bundle, whether they can be unbundled, and then over to the MUE's to see how often they can be billed.

  7. #7
    Location
    Detroit Chapter
    Posts
    76
    Smile
    I billed for a podiatry clinic for three years. Provided the patient had these dx's i would bill the following:
    11056-11057 - 250.6x or any supporting dx with a Q7 Q8 or Q9 modifier. however Medicre does require the box 15 to be filled out when using the Q modifiers

    11720-11721 - 110.1, 729.5

    I was able to bill these together with a modifier -59. I never had trouble unless the provider did not dictate something and in that case as all coders know " if its not dictated it didnt happen"!!!

    Hope that helps

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