“The NCCI edits talk about having calluses on toes 2-5 that are proximal to the distal interphalangeal joint (DIPJ). However, what about the hallux? We have diabetic patients with class findings that meet the criteria to debride hallux toenails. Occasionally, these patients also have a callus at the medial interphalangeal joint (IPJ). Payment is being denied on appeal due to the rule about not being a separate toe or proximal to the DIPJ. However, the hallux does not have two joints – just the IPJ. Is the IPJ thus considered the most distal joint? And debriding calluses either plantar to the IPJ or medial to the IPJ is included in the code?”
This is a terrific scenario to post and one that must raise the same questions by many podiatrists across the country. The best source of information for the appropriate use of the 59 modifier is CMS’ Medicare Learning Network aka MLN, specifically MLN1783722 March 2022, “Proper Use of Modifiers 59 & –X{EPSU}.”
Within this article/publication, the “Definition of Modifiers 59, XE, XP, XS, and XU” are thoroughly explained. It then moves onto “Appropriate & Inappropriate Use of These Modifiers.” Beneath this topic the following is stated:
“From an NCCI program perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ. We created NCCI edits to prevent the inappropriate billing of lesions and sites that aren’t considered separate and distinct. The treatment of contiguous structures in the same organ or anatomic region doesn’t generally constitute treatment of different anatomic sites. For example:
• Treatment of the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying the distal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site.” The article then goes one step further and provides “Examples of Appropriate & Inappropriate Use.”
“Example 4: Column 1 Code/Column 2 Code – 11055/11720
• CPT Code – 11055 – Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
• CPT Code – 11720 – Debridement of nail(s) by any method(s); 1 to 5 Don’t report CPT codes 11720 and 11055 together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. Don’t use modifiers 59 or –X{EPSU} if you debride a nail on the same toe on which you pare a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint. You may report modifier 59 or –XS with code 11720 if you debride 1 to 5 nails and you pare a hyperkeratotic lesion on a toe other than 1 with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which you debride a nail.”
This example with the article does not make reference to nor does it mention a situation that certainly exists on the great toe. There is only one joint, the interphalangeal joint or the IPJ. Is it considered a distal interphalangeal joint? Is it considered a proximal interphalangeal joint? If a hyperkeratotic lesion is “pared” on the great toe and the same toe has the toenail debrided, both services should be reimbursed. The CMS article that defines and demonstrates the appropriate use of the 59 modifier or the “X” modifier subset does NOT make reference to the great toe. Based upon the above post, the health insurance industry takes it upon themselves to simply reject the “paring” of the callus on the great toe when the toenail is debrided, as well. What can be done? I would SO access this article and use it as my source of information to appeal the denial of payment.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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