Wiki CPT 11055 Denial

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WHAUN

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Nampa, ID
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Question! Patient is 59 and has a commercial Blue Cross plan - no diabetes, PVD, etc. New pt came into the office for a corn and hammertoes on LT 4th and 5th toes - her corn is on the LT 4th toe. I billed the 11055 w/ L84 as the primary diagnosis and of course, insurance denied as not a covered benefit, which is not a surprise. However, my question is since the provider documented that the corn is being caused by the bone of the hammertoe rubbing on her adjacent toe, are we allowed to bill w/ the hammertoe diagnosis as the primary diagnosis? Or pain as primary? Or did I bill correctly w/ the L84 as primary and she gets to pay the bill?
My rationale was: L84 is the current condition she's seeking treatment for which is caused by the M20.42 - so the L84 goes first, right?!

Any input is helpful! Thanks!!
 
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I would report the L84 primary; that is the condition being treated. Have you appealed the denial with the explanation given above and medical records to support it?
 
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Does BCBS have a policy regarding these services that advises how they want the codes ordered? That's the first thing I'd look for. If you can't find one, take it to your provider rep - if you know who that is - and ask if they require the underlying condition to be coded first. The service reps answering the phones these days don't have any idea. If you are not able to contact your provider rep, I'd resort to an appeal with a detailed explanation and request that they advise of the policy they're using to uphold the denial if they continue to deny.

Years ago, I worked Anthem A/R for the practice where I was employed and Anthem (our local BCBS plan) required us to report the cancer code primary, anemia code secondary for any patient getting treated for chemo-induced anemia. Coding guidelines stated to code the anemia primary but Anthem wasn't having it. It was also an unpublished requirement so I didn't find out until I got a service rep on the line who was willing to share this information.
 
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It denied as "this service or procedure is not a covered benefit" - due to the use of L84 as the primary dx.
UPDATE** I submitted an inquiry to the plan and the rep was helpful enough to tell me I could submit a corrected claim using the hammertoe as the primary. So that's what I did...we shall see!
 
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I have never seen a payer cover this when the hammertoe is also treated at the same toe. The corn/callus is caused by the hammertoe rubbing. Exceptions can be diabetics and PVD as you mentioned but still not when the hammertoe is treated (28285). Of course, they will say you can submit a corrected claim with a different dx but it's still going to be denied in my opinion. In looking at the AAOS GSD for 28285, it states, "excision of skin lesion (eg, 11420-11426)" is included. Even though 11055 is not specifically stated, it's essentially the same thing.

You would need to look up the coverage policy for the Anthem plan of this particular patient. For example here is a link to BCBSND and you can see it is not covered in the situation you described: https://www.bcbsnd.com/providers/policies-precertification/medical-policy/f/foot-care-services
 
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You may have to check with the payer but they usually follow medicare guidelines. Code it with L84 as primary and a pain code as secondary. Per our local Medicare LCD, that will allow it to be covered. Don't attach the bunion at all.
 
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