“My business partner and I have different opinions regarding this issue and I’m having trouble finding a succinct and primary source document. When performing nail care and callus care for a high-risk patient, can you bill for both when the callus is located on the tip of the toe? It is my understanding that the skin is a separate structure than the nail and thus they are separate diagnoses and CPT codes, but my business partner states he heard a lecture that stated not to charge for calluses that occur on the same toe as a nail that is trimmed or debrided. This seems to be an LCD-dependent decision as I have not been able to locate anything in CMS policy that states either way. Can someone point us in the right direction with primary source reference?”
With respect to billing for both performing nail care and callus care for an “At Risk,” Routine Foot Care patient when the callus is on the tip of the toe and the same toe has the toenail debrided, the best sources of definitive information are the following:
1. From The CMS Publication: “59 Modifier Article”
Modifiers XE, XS, XP, XU were effective January 1, 2015. These modifiers were developed to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible. (Modifier 59 should only be utilized if no other more specific modifier is appropriate.) Although NCCI may eventually require use of these modifiers rather than modifier 59 with certain edits, providers were able to begin using them for claims with dates of service on or after January 1, 2015. The modifiers are defined as follows:
• XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
• XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”
• XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”
• XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”
EXAMPLE OF MODIFIER 59 USAGE:
• 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.
• Column 1 Code / Column 2 Code – CPT 11055/CPT 11720
• CPT 11055 – Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus) CPT 11720 – Debridement of nail(s) by any method(s); 1 to 5
2. MLN Fact Sheet Proper Use of Modifiers 59 & –X{EPSU}: MLN1783722 March 2022 – Example: Column 1 Code/Column 2 Code – CPT 11055/CPT 11720
CPT 11720 and CPT 11055 should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. Modifier 59 should not be used if a nail is debrided on the same toe on which a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint is pared. Modifier 59 may be reported with CPT 11720 if one to five nails are debrided and a hyperkeratotic lesion is pared on a toe other than one with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided.
It should also be noted that the above does not apply to the great toe since only an IPJ is present. Additionally, only CPT code 11720 is at issue. G0127 and 11719 are not affected.
It is important to note that the above sources of information are not LCD dependent but are directly from CMS.
This is not my opinion. These are the rules.
Michael G. Warshaw, DPM, CPC
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