Podiatry Coding & Billing Alert

Question: I billed a claim using the codes 11040 and 11042-59-RT. The insurance paid for 11042-59-RT, but denied 11040 because of bundling edits. Insurance reps said I should bill 11040 with modifier 59, and 11042 with modifier RT, but I'm still confused. What exactly do debridement codes 11040-11044 describe?

Alabama Subscriber

Answer: CPTs 11040-11044 describe debridement of relatively localized areas with or without their contiguous underlying structures. They are considered payable if the doctor removed two ulcers  on the same foot or separate foot on the same date of service.

While you use 11040-11044 to treat skin ulcers, they do not refer to ulcer size. Instead, they refer to levels of  actual tissue debridement of noncontiguous skin, and other deeper tissue structures (based on tissue type, for example, partial skin, full thickness skin, or subcutaneous tissue).

Tip: Medicare allows payment for a total of four independent tissue debridements on a given day of service, whether the debridement was performed on one or both feet, per date of service. Any number more than that for one or both feet per date of service will result in a denial. These modifiers can help you describe the specific digit(s) involved:

• Modifier TA -- Left foot, great toe
• Modifier T1 -- Left foot, second digit
• Modifier T2 -- Left foot, third digit
• Modifier T3 -- Left foot, fourth digit
• Modifier T4 -- Left foot, fifth digit
• Modifier T5 -- Right foot, great toe
• Modifier T6 -- Right foot, second digit
• Modifier T7 -- Right foot, third digit
• Modifier T8 -- Right foot, fourth digit
• Modifier T9 -- Right foot, fifth digit
• Modifier LT -- Left
• Modifier RT -- Right
• Modifier 59 -- Distinct procedural service

Important: You should take note of the ICD-9 codes you're reporting along with the procedure codes. Ulcerations can be located on the ankle (707.13), heel or midfoot (707.14), toe (707.15), or other area of the foot.

Example: A podiatrist debrides skin and subcutaneous tissue on the patient's right heel. She also debrides skin, partial thickness on the patients right hallux. In this case, you would use the following codes: 11042-RT 707.14 11040-T5-59 707.15