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Medicare/Palmetto stating "too many/frequency" for 11042 that was billed 2x.

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bgage85:
I am new to podiatry billing and my provider did a debridement on a patient and billed 11042 with a LT and RT for wound care. I saw somewhere else on this forum that LT and RT should not be used, but that post was rather old. Is this still the case? Do I add up the centimeters and bill the 11042 and then do the add on code 11045 if it goes over the allotted 20 for the 11042?

I am in TN and this is for Palmetto GBA since they recently moved it from Cahaba.

Any help is appreciated. Thank you in advance!

bgage85:
Correction to my above post....I am now seeing that the add-on code for additional area over the first 20 sq cm is 11047 NOT 11045. I am also seeing that I think I know the answer to this already and that I should only be billing 11042 once unless the total area was over 20 sq cm. if someone just wants to confirm this for me that would be great. Thanks so much!

kristin:
Selection of ulcer debridement codes are determined by three factors:
1. Method of debridement
2. Depth of debridement
3. Total square centimeters of area(s) debrided.

So if the doctor debrided 20 square centimeters of tissue down to the subcu level, using a scalpel, you would bill 11042, regardless of how many ulcers there were. If he did more than 20 sq. cm's at the subcu level, you would also bill the add-on code 11045(next 20 square cms or part thereof). The 11047 is the add-on code for debridement into bone, not subcu tissue.

Here are the codes/add-on codes:
11042/11045-Subcu tissue
11043/11046-Muscle
11044/11047-Bone

Things to remember:
1. 11042-11047 never get LT/RT modifiers
2. The add-on codes never get 59 modifiers or X-modifiers
3. If the total area debrided goes over 40 square centimeters, you use the add-on codes with the appropriate amount of units. Say 42 square centimeters were debrided, it would look like this:
11042-1 unit
11045-2 units

While it is rare a podiatrist will have that many square centimeters debrided, if their scope of practice in their state extends to legs and not just feet/ankles, it can happen.

Since you are new to podiatry billing, the two biggest pieces of advice I can give you are to thoroughly review your MAC's LCD's on Routine Foot Care, Wound Care, and anything else that relates to the feet, and to purchase the Optum Coding Companion for Podiatry. It is the bible for podiatry, and every podiatrist or podiatry biller/coder should have one.

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