Podiatry Coding & Billing Alert

Reader Questions:

Mend This Distinct Procedure Modifier Mess

Published on Fri Mar 17, 2023

Question: Our podiatrist performed an office/outpatient evaluation and management (E/M) service with a nail biopsy. We billed E/M-25, which was paid, and 11755-59, which was not. What did we do wrong?

AAPC Forum Participant

Answer: Assuming your documentation supports that the podiatrist did, in fact, perform a significant and separate E/M along with the biopsy at the encounter, your correct use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the appropriate level of E/M is why you got paid for the E/M service.

But appending modifier 59 (Distinct procedural service) to 11755 (Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure)) in this situation is unnecessary if the nail biopsy was the only procedure your podiatrist performed during the visit. The modifier would only be needed if your provider had performed a second procedure at the encounter, and if the use of a modifier was necessary to avoid any bundling problems when the procedures were performed on the same date of service. The fact the podiatrist performed an E/M on the same date of service does not justify a modifier on the procedure code in this instance — that is the function of the 25 modifier on the E/M.

However, your payer may want to see another kind of modifier on the 11755. Very likely, the payer would like to see an anatomical modifier place on the nail biopsy code. Given that the podiatrist would have performed the biopsy on one of the patient’s toenails, you would choose from HCPCS Level II modifiers T1-TA to indicate on which toe the provider performed the nail biopsy.

Remember: Modifier 59 should only be used as a modifier of last resort and not if another modifier is more appropriate. If the reason is to unbundle a bundled code set that includes two procedure codes and not an E/M and procedure, you will still need to document the reason why you need to unbundle the procedures based on criteria laid out by the payer and CPT^®modifier guidelines.