“We have billed CPT 11730 for all 10 nails using the appropriate toe modifiers. Anthem Blue Cross paid for five of the toes but is denying the other five. The denial comes back with CO-222 (Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific.) Please advise.”
There are a couple of issues here:
The first issue is that when you are billing for more than one partial or total toenail avulsion, the following CPT codes are to be used followed by the appropriate to modifier:
CPT 11730: Avulsion of nail plate, partial or complete, simple; single
CPT 11732 Avulsion of nail plate, partial or complete, simple; each additional nail plate (list separately in addition to code for primary procedure)
The second issue is based upon the number of times that CPT codes 11730 and 11732 can be billed on a single patient on a designated date of service. Medicare has this all specified within the Medically Unlikely Edits or MUEs. For CPT code 11730 the number is 1. For CPT code 11732 the number is 4. If this was a Medicare patient, if appropriately coded, five (5) toenail avulsions can be performed and billed for on a designated date of service.
Based upon the fact that 10 toenail avulsions were billed on the patient in the above post on the same date of service and the reason for denial was: CO-222 (Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific.), I suspect that Anthem Blue Cross Blue Shield is following the same protocol.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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