Primary Care Coding Alert

Check carrier frequency limitations for 11720 and 11721

If you can count on a denial for -routine foot care- every time you report CPT 11720 -CPT 11721 for Medicare patients, this article is for you. Many carriers actually cover debridement -- if you know the ropes.
 
Use the information in the article below to help avoid denials and recoup your rightful payment.

1. Identify the Acceptable Procedure and Diagnosis Codes

The following three different procedure codes represent mycotic nail debridement: 

- 11720 -- Debridement of nail(s) by any method(s);  one to five

- 11721 -- Debridement of nail(s) by any method(s); six or more

- G0247 -- Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include the local care of superficial wounds (i.e., superficial to muscle and fascia) and at least the following if present: (1) local care of superficial wounds, (2) debridement of corns and calluses, and (3) trimming and debridement of nails.

Among many carriers- diagnosis requirements for debridement coverage is the presence of a systemic condition causing mycotic nail(s).

For example, you can get paid for mycotic nail debridement when systemic conditions such as metabolic, neurological or peripheral vascular diseases result in severe circulatory problems in the legs and feet, according to an article from Cahaba Government Benefit Administrators, a Part B carrier in Georgia.

Most carriers will also pay without a systemic condition present, such as Blue Cross and Blue Shield of Arkansas. However, this carrier's Local Coverage Determination (LCD) requires clinical evidence of the mycosis plus documentation that the patient has pain or -secondary infection resulting from the thickening and dystrophy of the infected toenail plate.- In addition, ambulatory patients must have documentation of impaired walking.

Helpful: Most LCDs include a list of acceptable ICD-9 codes that will justify debridement of mycotic nails, and usually LCDs require a primary diagnosis of 110.1 (Dermatophytosis of nail) and a secondary diagnosis, such as 729.5 (Pain in limb).

The key is having a reliable method for keeping these carriers- individual debridement requirements straight.

-According to Medicare guidelines, we report 11721 with diagnosis codes 110.1 and 729.5 if the patient has pain,- says Angela Pietrangelo, billing manager with BILLPro Management Systems Inc.

If the patient has no pain, Pietrangelo reports 11721 with 110.1, along with a diagnosis code that represents an accompanying systemic condition. -We also include the date that the patient was last seen by the PCP, which must be within the last six months,- Pietrangelo says. You-ll also need to append modifier Q7 (One class A finding), Q8 (Two class B findings) or Q9 (One class B and two class C findings) to 11721, she says.

Note: To determine which -Q- modifier applies to your patients, see the box -Master Correct -Q-  Modifier Use- in this issue.

2. Check for Frequency of Coverage

Since you would normally use 11720 and 11721 to report mycotic nail debridement, it's helpful to know that LCDs for 11720 and 11721 are fairly similar across the nation. But the biggest difference is the frequency that carriers allow.

For example, -In New Hampshire, we can only bill for this service every 61 days,- says Linda Casella, coder at Exeter Health Resources in Exeter, N.H. Some other states require as much as a five-month gap to consider nail debridement medically necessary.

3. Follow Proper Documentation Requirements

Even if you have the proper diagnoses in line and know that the nail debridement services are covered within the right timeframe, you still need to supply the proper documentation -- and each carrier has its own idea of what that should include.

Most carriers require a description of each nail treated and a description of the debridement procedure to indicate that it was more than routine foot care.

In addition, some carriers, like TrailBlazer Health Enterprises LLC, want a description of the specified condition beyond a mere mention that the particular condition is present. This means there should be a clinical rationale considering the patient's usual activities, TrailBlazer's LCD states.

Best bet: Make sure the physician documents which specific nails are painful and how the painful nails limit the patient's activities -- in the patient's own words, if possible.

Don't miss: If you report to Empire Medicare Services, read your LCD closely for its documentation requirements.

Empire specifically notes that its physicians must include at least a description of the nail's size, thickness and color, plus -the local pathology caused by each affected nail resulting in the need for debridement.-

Empire also specifies that if the physician performs and bills cultures, you must have documentation of the cultures and the need for prolonged oral antifungal therapy in the patient record. Plus, services for debridement of more than five nails in a single day may be subject to special review -- so you-d better have good documentation in the patient's medical record to support medical necessity.

Follow Special Rules for G0247

Important: Your carrier may specify that it prefers G0247 instead of 11720 and 11721 in diabetic neuropathy cases. For example, if a physician treats symptomatic mycotic nails on a patient with diabetic sensory neuropathy, carrier Palmetto GBA says in its LCD that its providers should report G0247. So be sure you make note of whether your carrier prefers CPT or HCPCS codes when reporting this procedure.

Careful: If you must report the G code, you have to follow special guidelines, according to CMS- Routine Foot Care/Mycotic Nail Debridement information. Included in these guidelines are the following pointers:

- Report G0247 only in conjunction with either G0245 or G0246 -- never alone.

- Use G0247 for routine foot care of a patient with diabetic sensory neuropathy resulting in a loss of protective sensation and who does not meet class findings requirements.

- Know that Medicare limits G0245, G0246 and G0247 coverage to when you report 250.60-250.63 (Diabetes with neurological manifestations) and 357.2 (Polyneuropathy in diabetes).

Expect Payment Only Once

In addition, each physician or physician group may only collect payment for G0245 once for each beneficiary. If that beneficiary must see a new physician, that new physician may also receive payment (once) for G0245 as long as six months have passed since the last time the carrier paid G0245 or G0246, regardless of who provided the service.

Similarly, you can only use G0247 every six months and only if no other foot care occurred in that time. 

Note: To read more about foot care, see the Medicare program memorandum at www.cms.hhs.gov/transmittals/downloads/ab02158.pdf.

Ready Your NEMB Forms

Some patients request routine foot care but don't have the diagnoses to justify billing it to insurance carriers. But just because insurance refuses to pay doesn't mean your practice can't provide the service. Some patients may be willing to pay you out of pocket for these services.

If you-re working with a Medicare patient, CMS recommends (although it doesn't require) that the patient sign a Notice of Exclusions from Medicare Benefits form (CMS-20007). You should not use the advance beneficiary notice (ABN) form with patients receiving routine foot care. The ABN is for services Medicare might cover but will probably deny because of lack of medical necessity.

However, Medicare will never cover routine foot care for asymptomatic patients because it is on a specific list of -exclusions- from Medicare benefits. Therefore, theNotice of Exclusion from Medicare Benefits (NEMB) is more appropriate for your patients to sign.

Example: A Medicare patient visits your practice for a nail trimming.

The physician knows that the patient does not qualify for Medicare coverage because the patient does not have a systemic condition or the qualifying symptoms required for this type of routine foot care.

Even though Medicare does not require the NEMB, CMS recommends it as a courtesy. Having the patient sign the NEMB will remind him that Medicare will not cover the procedure and that you can bill him for it.

You can find the NEMB form online at www.cms.hhs.gov/BNI/11_FFSNEMBGeneral.asp.