“I have a Medicare patient that has healed a neuropathic ulcer (L97.522, E11.62) at the plantar base of his 5th metatarsal. He needs paring of the hyperkeratotic tissue, frequently with hemorrhagic changes, every four weeks or he re-ulcerates at this location. Should this be coded as: CPT 11055 using a GY modifier every other visit? Debriding devitalized tissue CPT 97597 or am I evaluating and managing an ulcer CPT 9921X?”
So, there is a diabetic patient that has a healed ulcer at the plantar aspect of the base of the 5th metatarsal on the left foot. There is a hyperkeratotic build up at the site where the ulcer was located that needs to be pared every four weeks to prevent an exacerbation of the ulcer. The hyperkeratotic tissue frequently has hemorrhagic changes. How should this be coded?
Based upon the fact that the site of the ulcer has been classified as HEALED, it would not be appropriate to evaluate and manage the ulcer using an E/M code. If all that is performed approximately every 4 weeks is to pare/debride the hyperkeratotic tissue overlying the base of the 5th metatarsal on the left foot, it would be classified as “Routine Foot Care.” The fact that there are hemorrhagic changes within the hyperkeratotic tissue is a nonfactor. If the patient, being diabetic, meets the criteria for “At Risk,” Routine Foot Care, the paring/debriding of the hyperkeratotic tissue would be covered per Medicare/CMS National Coverage Determination and Medicare Administrative Carrier Local Coverage Determination for Routine Foot Care. The service would be covered every 61 days. The service would be billed using CPT code 11055 which is defined as: Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion. It would be appended by the appropriate Q modifier and linked to the proper ICD-10-CM codes, perhaps E11.42 and L84.
Since the hyperkeratotic lesion needs to be pared/debrided approximately every 30 days, the alternate paring/debriding encounters would not be covered by Medicare and they would be classified as Non-covered Routine Foot Care. The patient would have to pay out of pocket for those encounters that are not reimbursed by Medicare. If the patient insists that the claim be submitted to the Medicare Administrative Carrier despite the fact that it is a non-covered service, there are two options:
- 1. If an ABN is on file: 11055 – GA
- 2. If an ABN is not on file: 11055 – GY
Playing devil’s advocate, The Wagner Diabetic Foot Ulcer Grade Classification System classifies a Grade 0 ulcer as “intact Skin.” So, assuming that the ulcer is healed, the patient returns to have the overlying hyperkeratotic tissue pared/debrided. The hyperkeratotic tissue is pared/debrided and the underlying skin is intact and “normal,” it would be most appropriate to code as described above classifying the encounter as “Routine Foot Care.” However, if the hyperkeratotic tissue is pared/debrided and the underlying skin overlying the base of the 5th metatarsal is intact, but it appears that it is going to break down unless appropriate treatment is performed, I would think that at this encounter it would be appropriate to bill for the evaluation and management of an ulcer using the appropriate level of E/M code and the Routine Foot Care issue would be ignored. I would advise to please not take advantage and over utilize the E/M coding for this scenario.
CPT code 97597 cannot be used unless there is a non-pressure ulcer that extends into the dermis and there is the presence of necrotic tissue at the base of the ulcer that needs to be excisionally debrided out from within.
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