Wiki CPT 11055-11057 Med Adv denials

[Heatherc7]

Hello,

As of 1/1/2023, Providence Med Advantage plans have a new foot care policy (see attached.) All of our CPT 11055-11057 are being denied as not covered patient responsibility. I called the health plan and was told that can't be billed with L84 as the primary Dx. The secondary Dx is E11.40. They state they're following Medicare guidelines see: https://www.cms.gov/medicare-covera...e.aspx?articleid=57957&ver=40&bc=CAAAAAAAAAAA. After reviewing the LCD for Routine FC, it appears we are meeting Medicare guidelines.

Now, I'm being told to appeal. I believe this is a lot of effort to go through, especially since we are following Medicare guidelines.

To add, this is not being billed with an office visit. It's being billed with CPT 11721, however, modifier XS is being added to CPT 11721, and that code is being paid. CPT 11055-11057, always paid with these Dx's and code combination in the past.

Any helpful advise, would be welcome.

 

[podcoder70]

Heather, you are not alone in this scenario. Providence Med Adv is 100% wrong to deny these claims. They are not following Medicare guidelines. Many of the Medicare Advantage plans are denying claims with 59/xs modifier and are specifically targeting routine foot care. It is happening to other specialties as well. Currently, the only recourse is to appeal with a copy of the encounter note and the medicare guidelines and/or a letter showing exactly where they have gone wrong. They are testing our documentation. Side note, the APMA is very aware of this and wants us to present to them samples of notes that have proper documentation. The APMA is actively fighting this situation with each and every carrier.
Retract the HPI from the note and send it to healthpolicy.hpp@apma.org they are using these encounter notes to show the payers that Podiatrists DO know what they are doing.