At Risk

“I am in Virginia and I have read through the LCD and billing guidelines for Palmetto GBA several times regarding coverage for routine foot care. It is very specific about when CPT 11720 and CPT 11721 will be covered, but it is not specific about CPT 11055, CPT 11056 and CPT 11057. My interpretation is that for coverage of CPT 11055-CPT 11057, there must be a systemic condition with class findings and if there are no systemic conditions that would qualify for coverage, modifier -GY should be used and -GA if an ABN is on file. I am wondering if CPT 11055-CPT 11057 are also covered with primary diagnosis code of L85.1 with appropriate secondary diagnosis similar to how CPT 11720 and CPT 11721 are covered for mycotic nails with primary diagnosis of B35.1 with appropriate secondary diagnosis. Are callus codes (CPT 11055-CPT 11057) covered with the primary diagnosis of L85.1 (or similar) and a secondary diagnosis of infection, pain, or difficulty walking? Or are they only covered with systemic conditions and class findings?

“Diabetic pt came in for “At Risk,” Routine foot care. This patient is coded with E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene.

“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?”

For the “At Risk,” Routine Foot Care patient, can a mycotic toenail be debrided, and a corn/callus be trimmed on the same toe?

“I saw an established patient who returned to the office for At Risk,” Routine Foot Care. The patient also had a new complaint of heel pain. I obtained X-rays the foot and gave a steroid injection in the heel. Can I bill for the Routine Foot Care and those treatments as well?”

“How are we supposed to bill CPT 11057 to Medicare to get paid? For the typical patient, we currently use the ICD-10-CM codes E11.42, E11.51, L84, R26.2. We bill this as its own claim. We put the podiatrist as the referring physician. We do not use any modifiers and we previously used the Q8 Modifier when appropriate, but it was denied. What does the proper 1500 form look like for CPT 11057?”

“I saw an established patient who returned to the office for “At Risk,” Routine Foot Care. The patient also had a new complaint of heel pain. I obtained X-rays of the foot and gave a steroid injection into the heel. Can I bill for the “At Risk,” Routine Foot Care and those additional treatments as well?”

What is the Active Care Requirement regarding “At Risk, Routine Foot Care?

“I have a patient who honestly only has three mycotic/dystrophic toenails. This elderly gentleman, with Medicare, returns to the office every 90 days for routine foot care (RFC). According to Medicare guidelines, he does qualify for RFC with his physical examine findings. My question is can I bill CPT 11720 for the debridement of the three dystrophic nails and then CPT 11719 for the trimming of the other seven non-dystrophic toenails?”