Primary Care Coding Alert

Watch out for scenarios where Medicare is denying payments for preoperative tests, too.

If you have been recently facing Medicare denials when your FP is performing routine foot care or debridement of nails, don’t fret. You may not be alone. Likewise, you may also have company if you have been recently facing Medicare denials for preoperative tests that your FP ordered. Recent information from National Government Services (NGS), a Medicare administrative contractor (MAC), discusses these problems and what you need to do if you encounter them.

Scenarios: Your FP performed debridement of 5 nails for a Medicare patient. You reported 11720 (Debridement of nail[s] by any method[s]; 1 to 5). You face a denial to your claim. In another situation, you report 11719 (Trimming of nondystrophic nails, any number) for routine foot care that your FP performed for another Medicare patient. You got a denial for this claim, too.

In yet another situation, you face a denial for some preoperative tests (like a chest x-ray or an EKG) that your FP ordered. These tests were not routine preoperative tests but tests that your FP ordered due to medical necessity.

So, what are you doing wrong? According to NGS, you may not be doing anything wrong; the fault may lie with your MAC.

The problem: NGS has identified the following production issues that are causing erroneous denials of these types of claims.

Routine Foot Care and Debridement of Nails

• Some claims for routine foot care and debridement of nails have processed incorrectly since the transition to ICD-10 editing. NGS is adding some diagnoses as payable for these services and correcting edits, which resulted in incorrect denials. The additional diagnoses will be included in the LCD.
• NGS has also identified submitted claims where some services that did not meet coverage criteria have been allowed in error.

Noncovered Services

• Some claims for preoperative tests (e.g., EKGs, chest X-rays) have been denied in error due to an editing issue.

What you need to do: NGS will be adjusting the denied claims for routine foot care and debridement of nails to pay correctly. No provider action is required. Also, claims for preoperative tests that have been denied incorrectly will be reprocessed by NGS. No provider action is required. If you submit your claims to a MAC other than NGS and are having the same problems, please check with your MAC to see if any action is needed on your part to correct the situation or if your MAC will make the necessary adjustments on its own.

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