Podiatry Coding & Billing Alert

Question: Our podiatrist attended to a new Medicare diabetic patient in the office for appx. 30 min. After a detailed exam and history, he ordered nail debridement (7), avulsion and some paring of 3 corns for vascular impairment. Can we bill an E/M for this encounter? Which modifiers should I use for these multiple procedures and in what order?

New Jersey Subscriber

Answer: Yes. You can report the E/M service as your description does not suggest that the patient had come expressly for the procedures. As the E/M visit resulted in the later decision to perform the procedures, the visit is billable. You should report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…) based on your notes. Attach 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 demonstrate that the procedures were not pre-planned. 

For the debridement, you should report 11721 (Debridement of nail[s] by any method[s]; 6 or more) and you can code 11730 (Avulsion of nail plate, partial or complete, simple;single) for the avulsion. Attach a suitable modifier from TA-T9 depending on the toe the procedure was performed. For the paring/cutting of corns, you should report 11056 (Paring or cutting of benign hyperkeratotic lesion [e.g., corn or callus]; 2 to 4 lesions). 

As Medicare does not pay for routine care such as debridement or corn removal (11056 and 11721), you are required to report a modifier from Q7-Q9 to show the coverage is based on the presence of a qualifying systemic condition. In your case attach modifier Q8 (Two [2] Class B findings) to 11056 and 11721. Additionally, as per CCI edit code 11721 is included in codes 11056 and 11730. Attach modifier 51 (Multiple procedures) for multiple toes and modifier 59 (Distinct procedural service) for debridement. Within all the above procedure codes, 11730 has highest RVU. Hence, you should bill as follows:

• 99203-25
• 11730-TA
• 11056-51, Q8
• 11721 -59, Q8

“You should only bill 11730 if anesthetic was used unless there is severe neuropathy and the report of 11721 and 11056 should only be reported if the podiatrist himself did the cutting and trimming,” cautions Arnold Beresh, DPM, CPC, Peninsula Foot and Ankle Specialists PLC in Hampton, Va.

There is no need of using modifier 59 with code 11730, since it is not included in any other procedure codes.