“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?”
When a patient has a specific systemic disease (metabolic, vascular, or neurologic disease), and that patient requires the services of a physician (DPM, MD, DO), Medicare will pay for routine foot care. In general, routine foot care services will be paid by Medicare if the patient’s systemic disease has resulted in the patient having severe circulatory embarrassment or areas of diminished sensation in their leg or foot. Medicare commonly refers to these patients as “AT RISK” patients.
When a patient qualifies for “At Risk,” routine foot care and the patient has a qualified, covered systemic disease per CMS and/or the LCD of the Medicare Administrative Carrier of the state where the care is being provided, the patient can have the toenails debrided or trimmed depending upon the type of toenail(s) diagnosis(es) and the paring or cutting of corns and/or calluses.
With respect to the toenails, there are four CPT/HCPCS Level II codes that can be billed based upon the diagnosis of the toenails in question.
CPT 11720 Debridement of nail(s) by any method(s); 1 to 5 (ICD-10-CM code B35.1)
CPT 11721 Debridement of nail(s) by any method(s); 6 or more (ICD-10-CM code B35.1)
G0127 Trimming of dystrophic nails, any number (ICD-10-CM code L60.3)
CPT 11719 Trimming of nondystrophic nails, any number; A nondystrophic nail is essentially a “normal” toenail. (ICD-10-CM code L60.9).
When using the above CPT codes, the correct ICD-10-CM codes and the appropriate Q modifier in addition to the primary diagnosis being the qualifying systemic disease, you can bill CPT 11720 for the debridement of the three nails if they are mycotic and then CPT 11719 for the trimming of the other seven non-dystrophic toenails.
The correct coding scenario would be the following:
CPT 11719 – Q_
CPT 11720 – 59, Q_
The 59 modifier would need to be appended to CPT code 11720 based upon the fact that it is the Column 2 code to CPT code 11719, the Column 1 code within the CCI edits.
Unfortunately, dystrophic and nondystrophic/normal toenails cannot be billed together based upon the key phrase within their descriptions/definitions, “any number.”
This is my opinion.
Michael G. Warshaw
DPM, CPC
Read Comments