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Key Concepts in Successful Reimbursement of At-Risk Foot Care
Created in partnership with the American Podiatric Medical Association.
Created in partnership with the American Podiatric Medical Association.
This content was created in partnership with the American Podiatric Medical Association, with special thanks to the APMA Coding Committee and Health Policy and Practice Committee Chairs.
Routine foot care (RFC) is usually not a covered service under Medicare and most health plans. However, when the patient has an "at-risk" condition, routine foot care is a valuable and necessary service that most podiatric practices provide. For this article's purpose, we will refer to this instance as "at-risk foot care." Whether your practice is surgically oriented or conservative in nature, this sought-after service provides necessary care to our patient population. For Medicare, "at-risk foot care" is the exception to the exclusion of this service. However, one must clear certain hurdles to realize reimbursement.
Understanding the Steps to Successful At-Risk Foot Care Reimbursement
One such hurdle involves providing nail debridement (CPT 11720/11721) and/or nail trimming (CPT 11719/HCPCS G0127) at the same visit as paring hyperkeratotic lesions (CPT 11055-11057) for the "at-risk" patient. One would obtain payment for providing this combination of services by meeting certain billing requirements. One must understand the use of modifier 59 or the "X" (XE,XS,XP,XU) modifiers. Next, do not forget that in most, but not all, circumstances, the MACs require a Q7, Q8, or Q9 modifier. Billing "at-risk foot care" requires knowledge of one’s regional/state Medicare carrier's local coverage articles (LCAs) and local coverage determinations (LCDs). For this article, we provide the following list of LCAs from the various Medicare Administrative Contractors (MACs) effective at the time of submitting this article. Understand that each policy may have crucial variations in billing and coding that every practitioner and coding specialist should learn. These variations among the MACs are jurisdictional differences.
| Medicare Carriers by MAC (Click to navigate to the websites) |
| Novitas |
| First Coast |
| Palmetto |
| NGS |
| CGS |
| WPS |
| Noridian |
Another requirement to successfully bill for at-risk foot care is the concept of the "date last seen." Did you know that this can vary by contractor? For example, First Coast has a number of “at-risk asterisk conditions" which require the provider to document and submit with the claim, “the name of the MD, DO, or non-physician practitioner (PA or NP) who diagnosed the complicating condition.”1 Whereas, Novitas, owned by the same company as First Coast, only stipulates submitting the date last seen by the MD, DO, or qualified non-physician practitioner (NPP).2 Like Novitas, Palmetto requires that the date the patient was last seen by the attending physician should be billed in block 19 and that the patient is under the “active care of a Doctor of Medicine or Osteopathy or NPP."3 NGS and CGS requires “a doctor of medicine or osteopathy (MD or DO) or qualified non-physician practitioner” be the treating provider.4 WPS and Noridian are the most restrictive, requiring only "an MD or DO."5
How Does the National Correct Coding Initiative (NCCI) Impact This Service’s Coverage?
An issue with the National Correct Coding Initiative (NCCI) recently became visible in the media with respect to foot care CPT codes. The reimbursement issue involves denial of nail debridement codes when payment is made for corn/callus paring. Fortunately, fee-for-service Medicare figured this out and, in our observation, usually pays for both services when coded correctly. We find, most problems arise in the private sector, such as with Medicare Advantage Plans, managed Medicaid, or commercial policies. This is in part due to the National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits involving at-risk foot care codes, and the misunderstanding of these edits.
In NCCI, Column 2 codes are considered "bundled" into Column 1 codes, unless an exception exists allowing unbundling of the Column 2 codes.6 For "at-risk foot care," CPT 11720/11721 are Column 2 codes to the Column 1 codes CPT 11055-11057. There are no NCCI edits with the nail trimming codes, HCPCS G0127 or CPT 11719, and the hyperkeratotic lesion paring CPT 11055-11057 codes.6 To unbundle the Column 2 nail debridement codes, one must use modifier 59 or the XS modifier on the column 2 code. According to NCCI, to unbundle these procedure-to-procedure (PTP) edits, the hyperkeratosis must either be proximal to the distal interphalangeal joint (DIPJ) or occur on a toe not requiring nail debridement at the same date of service.6 Although proper modifier use sounds like an easy solution, there are other factors to consider for this endeavor to be successful.
Documentation is key, especially if one needs to appeal an adverse determination or withstand a pre-payment or post-payment review. This starts with observing the integumentary system, noting all abnormal toenails and hyperkeratoses. One must provide a detailed description of the abnormal toenails noting the thickness, color, texture, and other abnormalities, in addition to the anatomical location. For the hyperkeratotic lesions, a similar description is paramount. It is not sufficient to list which foot and/or toe has the lesion; rather, one must document the precise anatomical location of each hyperkeratosis. This is crucial for the successful use of the 59 or XS modifier. For the specific requirements of documentation details of the nails and hyperkeratosis description and location, see the Local Policy Article specific for your jurisdiction.
How Can Providers Approach Appeals?
To appeal a denial of CPT 11720/11721 when performed at the same visit that billed CPT 11055-11057, it is critical to include supporting documentation and resources that will convince the third-party payer that the services were distinct, separate, and that the secondary procedure does not overlap the usual components of the main service. In other words, both services represent distinct procedural services. To begin this process, one should submit the appeal with a cover letter and the medical records for the service date. The letter should explain in detail why both services are distinct and cite appropriate CMS references to substantiate the position of separate billing for both services rendered. This is often a process of educating the reviewer, showing that these codes are allowed to be unbundled under circumstances specified by NCCI, and why the services provided followed these guidelines. This assumes that the medical records have the required details of the type of nail and corn/callus pathology present, along with the precise location of these abnormalities.
| CMS Policy and NCCI References for Podiatric Physicians |
|
MLN1783722 Use of Modifier 59 and X[S,P,E,U] Example 4, Page 6 |
| NCCI Policy Manual Chapter I, Page 21 |
| NCCI Policy Manual for Medicare Services Chapter 3, Section E, Example 3 |
What You Should Know About An Important Tool
Fortunately for American Podiatric Medical Association (APMA) members, APMA has done most of the work for you. Members have access to the -59 Modifier Toolkit, which one can find at www.apma.org/59toolkit . This toolkit was the product of the APMA -59 Modifier Workgroup, which created resources and references to assist providers with the necessary tools to understand and properly utilize this modifier. In addition to the CMS and NCCI references listed above that are necessary for an appeal, other educational resources for APMA members include:
In Summary
In today's environment of dealing with third-party payers, it is not sufficient to simply provide medical care within the realm of medical necessity and within the confines of policy provisions. Astute providers must arm themselves with proper "ammunition" to dispute adverse outcomes, including denials, and to educate reviewers. What better way is there to do so, than to utilize facts with references that these payers use to deny these services? This is why the APMA developed their -59 Modifier Toolkit. It is the responsibility of the podiatrist to generate detailed documentation, correct coding, and proper claim filing. The "heavy work" of appealing these wrongfully denied claims with the proper references is written within this article, using the APMA-59 Modifier Toolkit. In that spirit, the authors firmly believe that providers deserve to be reimbursed for medically necessary services they provide to their patients.
Dr. Freedman is the Chair of the APMA Coding Committee.
Dr. Prikaszczikow is the Chair of the APMA Health Policy and Practice Committee.
