Issues Billing “At Risk,” Routine Foot Care: Challenges Billing CPT 11057

“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?”

The most important question that needs to be asked when a claim is denied is WHY was it denied?
At face value, it appears that the ICD-10-CM codes that were linked to CPT 11057, E11.42, E11.51, L84 are correct. R26.2, Difficulty with ambulation is not needed. Assuming that the patient had 2 Class B Findings, it was appropriate to append the Q8 modifier to CPT 11057.

Here are some potential issues:

1. 1. When the claim was denied, an EOB is received. On the EOB it is indicated WHY the claim or the line on the claim was denied with a denial code. I certainly would be looking at this.
2. 2. Since this is an “At Risk,” Routine Foot Care patient with an asterisk systemic disease that indicates the “Active Care Requirement” which means that the patient needs to have seen the physician that is treating the systemic disease (ie. Diabetes Mellitus) within 6 months prior to the date the podiatric service was provided. The physician treating the diabetes should be the referring physician and his/her information (ie. name, NPI, date last seen for the systemic disease should be placed in Box 17).
3. 3. Is it possible that the patient also had toenails debrided and/or trimmed on the same date of service and the treatment of the toenails was submitted on a separate claim? If this was the case and the claim for the toenails was received first, despite the fact that the date of service for both claims was the same, it is possible that the system paid for the CPT 11721/CPT 11720/CPT 11719/G0127 claim and rejected the CPT 11057 claim.
4. 4. The Medicare number for the patient on the claim form was incorrect.

Here is a link to access the instructions on how to fill out the CMS 1500 Form:

Instructions on how to fill out the CMS 1500 Form
https://www.lacare.org › default › files › universal PDF

This is my opinion.

Michael G. Warshaw, DPM, CPC

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