“Medicare sent me a letter about 6 months ago saying I bill CPT 11721 too often compared to CPT 11720 and CPT 11719. However, they consistently deny the combination of CPT 11719 and CPT 11720-59. Not just bundled, but deny both codes, altogether. That then leaves me an outlier with a bunch of CPT 11721 counted and all of the CPT 11719 and CPT 11720 denials left out of the calculations. Appeals are denied (and a waste of time and resources for $11). Their CCI indicator is 1, meaning they can be billed together with 59 or X- modifier on the column 2 code (CPT 11720). Is it fraudulent billing to code only CPT 11720 even though I am debriding 1 to 4 nails and trimming the rest? It also pays more with just CPT 11720 since it is otherwise secondary to a less-than-$11 CPT 11719 code. I hate to turn away these patients who have a true need. Recommendations?”
One of the CPT codes that Medicare will audit frequently is CPT 11721 which is defined as: Debridement of nail(s) by any method(s); 6 or more. Select Medicare Administrative Carriers will state in their LCD for Routine Foot Care and/or Debridement of Nails that CPT 11721 should not be billed or should not be billed with great frequency. This specifically has to do with the “Otherwise Healthy Individual” where the coverage for the debridement of mycotic nails is based upon symptoms as opposed to class findings and a covered systemic disease.
In this scenario, the number one symptom that is selected is pain, specifically pain in the toes, using ICD-10-CM codes M79.674 and M79.675, pain in the toes, right foot, and left foot, respectively. The problem here is how many patients really have more than five painful, mycotic toenails based upon the physician’s physical examination? Not too many. That is why it is an audited CPT code. On the other hand, if the patient is an “At Risk,” Routine Foot Care patient and an untrained person or the patient attempts to debride the mycotic toenails, the patient runs the risk of infection or loss of limb. That is why CPT 11721 would and should be covered for this patient group and why it should not be factored into the total number of times CPT 11721 is billed. These two groups should be separated.
With respect to CPT 11720 which is defined as: Debridement of nail(s) by any method(s); 1 to 5 and CPT 11719 which is defined as: Trimming of non-dystrophic nails, any number, I do not understand why both CPT codes are not being reimbursed when they are billed together on the same patient encounter. I am assuming that both CPT codes are being linked to the proper ICD-10-CM codes (L60.9 and a covered systemic disease for 11719, B35.1 and a covered systemic disease for 11720). I am assuming that both CPT codes are appended by the appropriate Q modifier which is documented in the medical record. Since CPT 11720 is the Column 2 code to CPT 11719 the Column 1 code within the NCCI edits, CPT 11720 should be separately reimbursable when appended by either the 59 or the XS modifier to indicate a” Distinct Procedural Service.” Unless the CMS 1500 Claim Form or the electronic equivalent is not properly filled out, these 2 CPT codes should both be reimbursed. The only other reason that they would not be reimbursed would be if the 2 CPT codes were billed sooner than the designated 61-day period that must pass between “At Risk,” routine foot care encounters.
As far as performing both CPT 11720 and CPT 11719 on the same date of service and only billing for CPT 11720 is concerned, this is highly inappropriate to do so. You bill for what you perform and document in the medical record. Everyone makes mistakes. However, if this becomes an ongoing situation, it certainly would be interpreted as fraudulent.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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