Orthopedic Coding Alert

Question: I bill for an orthopedic surgeon who specializes in the foot and ankle. How do you get Medicare to pay for nail trims (11720 and 11721)?

Brenda Heinmiller, Accounts Receivable

Answer: Great question, especially since Medicare has had two separate billing rulings on this subject within the past couple of years. The first change was effective Dec. 1, 1997, and it said that modifier Q1 (mycosis of toe nail) would no longer be accepted with codes 11720 and 11721. Then effective Jan. 1, 1998, M0101 (trimming of nails) became a deleted Medicare Level III CPT code.

Codes 11719 (trimming), 11720 (debridement), 11721 (trimming or debridement on six or more toes) can be paid, but the diagnosis is the key for payment. Medicare will only pay for services that are medically necessary with the presence of markedly thickened toenail(s). The correct diagnosis codes in this situation would be: 110.1 (onychomycosis), 681.11 (paronychia, resulting in soft tissue infection) and/or 719.77 (difficulty in walking because of pain).

Documentation must be on file and easily obtainable to clearly verify these conditions. The lack of documentation will result in claim denials by Medicare. Medicare requires additional information on the claim form, such as the name of the referring physician, the date the patient was last seen by the referring physician, and the class findings (modifiers Q7, Q8, Q9). All are required for reporting codes 11719, 11720 and 11721. The class findings have these descriptions:

Q7 - One class A finding of systemic condition

Q8 - Two class B findings of systemic condition

Q9 - One class B and two class C findings of systemic condition(s)