Wiki Mutually inclusive for routine foot DM care

[twalls]

Hello fellow podiatry coders! Wondering if you can offer some assistance. I am having difficulty with this scenario. Dr. see the pt dx look like E11.42, E11.51, L84, dystrophic 6 nails and elongated nails 4 nails, L60.3 & Q84.5 and Q8 lets say.
11719-Q8- DX E11.42,E11.51, Q84.5
11721-59,Q8- DX E11.42, E11.51, L60.3
11056-Q8- DX E11.42, E11.51, L84

Medicare and Medicare Advantage plans are picking to pay one or the other of the debridement or trimming and denying the other, saying it's mutually inclusive. So do I just pick one code and bill only for all ten toes and avoid this lunacy?? Because I clearly can NOT get paid what was done! DX codes are all confirmed per LDC. I am at a loss. Any input would be greatly appreciated!

Thank you!
Tammy

 

[podcoder70]

I have seen this happen from time to time. The scenario you have presented should be billed 11056 and 11721 (if the nails were debrided in length and thickness), G0127 (if the nails were just trimmed). You cannot bill 11721 AND 11719 together. If the doctor debrided 5 nails and trimmed 5 nails then you would bill 11720 and 11719 (non dystrophic) or G0127 (dystrophic).

11721 is for debridement of 6 or more nails, 11720 is for 1 to 5 nails. I believe your claim is being denied because the 11721 is stand alone and cannot be billed with 11719 nor G0127.

Some of the Medicare Advantage plans are not following Medicare rules and have a subset of their own rules. You will need to check their guide. For example, some do not want the Q modifier. Others do not cover the G0127 code.

Hopefully this helps.

 

[twalls]

I have seen this happen from time to time. The scenario you have presented should be billed 11056 and 11721 (if the nails were debrided in length and thickness), G0127 (if the nails were just trimmed). You cannot bill 11721 AND 11719 together. If the doctor debrided 5 nails and trimmed 5 nails then you would bill 11720 and 11719 (non dystrophic) or G0127 (dystrophic).

11721 is for debridement of 6 or more nails, 11720 is for 1 to 5 nails. I believe your claim is being denied because the 11721 is stand alone and cannot be billed with 11719 nor G0127.

Some of the Medicare Advantage plans are not following Medicare rules and have a subset of their own rules. You will need to check their guide. For example, some do not want the Q modifier. Others do not cover the G0127 code.

Hopefully this helps.

It does! Thank you so much!