“Is the debridement of a plantar keratosis (CPT 11055) at the first metatarsal head considered bundled with nail debridement (CPT 11720)?”
With the exception of Noridian Healthcare Solutions, every other Medicare Administrative Carrier (MAC) considers the billing of CPT codes 11055 and 11720 to be a classic example of “at risk,” routine care. Noridian differs from the other MACs from the standpoint that they allow CPT codes 11055, 11056 and 11057 to not only be performed and billed for “at risk,” routine foot care, but also for the trimming/paring of symptomatic hyperkeratotic lesions.
On a specific date of service, assuming that the patient has a covered systemic disease and class findings, a hyperkeratotic lesion (ICD-10-CM code L84 – Corns and callosities) and mycotic toenails (ICD-10-CM code B35.1 – Onychomycosis) can be treated appropriately on a given date of service.
The two CPT codes in question are the following:
CPT 11055 – Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
CPT 11720 – Debridement of nail(s) by any method(s); 1 to 5
When the NCCI edits are accessed, CPT 11055 is the Column 1 Code to CPT code 11720, the Column 2 Code and therefore CPT code 11720 is not separately reimbursable unless it can be appended appropriately by the 59 modifier to indicate a Distinct Procedural Service. How can we be sure that these two CPT codes can both be billed when performed on the same date of service? There is an article that provides direction. It is the following: MLN Fact Sheet Proper, Use of Modifiers 59 & –X{EPSU}: MLN1783722, March, 2022, specifically “Example: Column 1 Code/Column 2 Code – 11055/11720.”
The following is from the example: “CPT codes 11720 and 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 code 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. “
Based upon the fact that 5 or fewer toenails were debrided and the hyperkeratotic lesion was located at the first metatarsal head, it would be correct to bill CPT codes 11055 and 11720. The 59 modifier should be appended to CPT code 11720 to correctly unbundle the two CPT codes and to demonstrate that CPT code 11720 is indeed a distinct procedural service.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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