Medical Billing Forum

Billing => Facility Billing => : djk April 04, 2014, 04:46:49 PM

: Billing 11721 with 11055 or 11056
: djk April 04, 2014, 04:46:49 PM
Medicare is bundling these codes and shouldn't be.  Any suggestions on how they should be billed.
: Re: Billing 11721 with 11055 or 11056
: Merry April 04, 2014, 07:46:06 PM
I am not a coder but since these are podiatric codes,  Medicare only pays under certain circumstances.. Relating to certain diagnoses such as diabetes, peripheral neuropathy etc. I would check the guidelines on your MAC site. 
: Re: Billing 11721 with 11055 or 11056
: kristin April 04, 2014, 08:04:06 PM
I bill for six podiatrists in four different MAC's, and each of those MAC's will only pay if each code has a 59 modifier on it. This is in addition to have proper dx's, Q modifiers if needed, and LDS if needed.
: Re: Billing 11721 with 11055 or 11056
: djk April 07, 2014, 10:57:30 AM
I have tried to bill with the Modifer 59 and it was denied for invalid modifier.
: Re: Billing 11721 with 11055 or 11056
: Michele April 07, 2014, 11:58:58 AM
It's really hard to tell without all of the info in front of us.  We don't know dx's, dx pointers for each code, and any modifiers billed.
: Re: Billing 11721 with 11055 or 11056
: djk April 07, 2014, 12:15:52 PM
Ok, I bill for 11721. DX 110.1, 729.5 and 440.20 with the modifier 59
then for the same visit with 11055 DX- 729.5, 701.1
: Re: Billing 11721 with 11055 or 11056
: kristin April 07, 2014, 12:52:33 PM
Were those the only two line items on the claim? Was the patient in a 10 or 90 day global period for another procedure? Who is your MAC?  I can say this...if this was one of my claims, for any of the MACS I bill for, and there were no other line items with other diagnoses(say, a DM dx, for instance), and the patient was not in a global, I would bill 11721 just as you have, and the 11055 the same, but also with a 59 modifier. Are you saying you have already tried that, and it denied for wrong modifier on the 11055?
: Re: Billing 11721 with 11055 or 11056
: djk April 07, 2014, 12:58:48 PM
Yes, i have tried it with the 59 modifier and yes these are the only 2 lines on the claim, no other dx.. This is a Medicare claim for NY
: Re: Billing 11721 with 11055 or 11056
: dekenn April 07, 2014, 01:26:26 PM
I believe 11055 is considered routine foot care and is only covered when the patient has a sytemic disease. CPT 11721 is covered with the DX 110.1 (mycotic nails) and 729.5 (pain), only if the patient is ambulatory. 11055 would not be covered just with the diagnosis pain, without the systemic disease and the qualifying modifiers (Q codes)
: Re: Billing 11721 with 11055 or 11056
: kristin April 07, 2014, 02:27:16 PM
The NY MAC is one I do not bill for, and they could have a different LCD...in which case I would review it, and see what their requirements are for 11055. For all the MAC's I work with, how you billed it is perfectly fine. NY must be stricter with RFC.
: Re: Billing 11721 with 11055 or 11056
: djk April 07, 2014, 04:20:21 PM
Yes, it is harder, LOL... I have tried to find on the NGS website the LCD codes for the 11055/11721 but no luck. There are some articles that touch on the subject but not completely.. I guess it's just trial and error..
: Re: Billing 11721 with 11055 or 11056
: kristin April 07, 2014, 05:07:49 PM
This is what you need:

http://www.ngsmedicare.com/ngs/portal/ngsmedicare/a45934/!ut/p/a1/tVLLkoIwEPwVPXi0MgJROaKLlA98QFkKFytCxKgExZS1_v0moLUe1sdlc0pnupNM96AQLVHIyYUlRLCMk4PCYXMFY_3L6mEDwMcY-jZ4LddvaWA0JCFQhIHfLQmuCdC3mn7PcUCfjLVS_3fZGBp3_ZNlwUv9BKMFClF4JhcaZdmeUYWiAyX5L_Rspz8ZFwUujmKLAp6cUxqziORSxQXlogYPZzWIsgvNSUIrMRU0Txkv7KhByThUjtmBRddKJJU0rwExsKkb6oWjFMX0zBJeoIjFKCA4Jq24DQamsoMmMbUGxIQ2N42Njs128cfRpIOCKclFpfPaUdXym0QKR95kUhKemx7IP7SePjLUkK_uWHTd1Wxue5L9kIBEjwlIeEtA7h77_NygwQdDqOVu101UAmJbZ3yToeUtFllku9MptOQAqLS_BVr-0wQsStvuxjvmqAf9mWs4dttsgC2HGdCCROqq0sHbPjgrv7bomM7ne89p7-gab_xpmlrWdFwP11cdB6lVrf4AkPGDlQ!!/dl5/d5/L3dHQSEvUUtRZy9nQSEh/?clearcookie=&savecookie=&REGION=&LOB=Part%20B

And a quick review shows that your dx of 701.1 is not covered...but you aren't getting a dx denial, which is odd.
: Re: Billing 11721 with 11055 or 11056
: djk April 07, 2014, 05:10:23 PM
This doctor only works in our clinic one day a week, so I called her office and they told me that they bill 701.1 and get paid for it, so that is why I placed this on the forum if any one else was having difficutly with this code..thanks for the attachments
: Re: Billing 11721 with 11055 or 11056
: Michele April 08, 2014, 05:52:29 PM
I think you are missing the appropriate Q modifier.  See this article:  http://c.ymcdn.com/sites/www.wocn.org/resource/dynamic/forums/20130225_124324_31289.pdf

I bill those codes to the NY MAC.  If they have a covered dx and the appropriate modifiers they are reimbursable.

The concern I have is that you cannot simply add modifiers or change coding to "get them paid".  It is important that the coding is done by someone who has access to the chart and is qualified to code.  Just want to make sure you aren't just coding for them to get the reimbursement.  The documentation in the chart must match the billing.
: Re: Billing 11721 with 11055 or 11056
: HeidiK April 08, 2014, 06:05:21 PM
Hello!

One issue to consider is how Medicare is able to identify medical necessity.  The coverage determinations state how debridement is only allowed as a separate service is if there is clinical evidence to support the need.  That simply means if they have never had a claim filed for a mold or yeast culture for the patient, the system will continue to reject the debridement no matter which diagnosis code is used.

The LCD I reviewed did not show 701.1 as an allowed diagnosis code for 11720 or 11721, but I wasn't sure by your last post if this was the code you referrred to in your last post.

http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=27487&ContrId=161&ver=45&ContrVer=2&DocType=Active&bc=AgIAAAAAAAAAAA%3d%3d&

I went to cms.gov and searched "debridement of nails" and a number of links came up which may also help...

http://cms.gov/site-search/search-results.html?q=debridement%20of%20nails

I haven't done podiatry billing in some time however, I do remember needing to use the foot and toe modifiers (TA - T9) in order for claims to process correctly as well.

Hope this helps!
: Re: Billing 11721 with 11055 or 11056
: jennifer8055 April 22, 2014, 01:07:22 PM
i bill for 5 podiatrists in tennessee and this was the rule of thumb i was given when i started podiatry - for diabetic nail care...11055 (1 callus)/11056 (2-5 callus)removal of corns or callus; 11719 trimming of nails; 11720 (<5 nails)/11721 (>6 nails) debridement of fungal nails....certain combinations require certain modifiers (i.e. 51 or 59).  if the patient is diabetic, you need the appropriate Q7, Q8 or Q9 modifier on it as well.  here's the combinations i use depending on what patient had done.....

11055/11056 Q7,Q8,Q9
11719 51 - Q7, Q8,Q9

11055/11056 Q7,Q8,Q9
11720/11721 59 Q7,Q8,Q9

11720 59 Q7,Q8,Q9
11719 Q7,Q8,Q9

YOU CAN NOT BILL 11721 W/11719 -- no modifiers will allow this
YOU CAN NOT BILL 11720 W/11721 -- not allowed same "procedure" different #

diagnosis codes:

11055/11056    700 (corn/callus)
11720/11721    110.1 (onychomycosis)
11719              703.8 (onychauxis)

those dx codes must be accompanied by either 681.10, 681.11, 719.7 or 729.5 and a systemic condition code of 249.00-249.01, 249.10-249.11, 249.20-249.21, 249.30-249.31, 249.40-249.41, 249.50-249.51, 249.60-249.61, 249.70-249.71, 249.80-249.81, 249.90-249.91, 250.00-250.03, 250.10-250.13, 250.20-250.23, 250.30-250.33, 250.40-250.43, 250.50-250.53, 250.60-250.63, 250.70-250.73, 250.80-250.83, 250.90-250.93; 440.20-440.9, 443.1 & 782.0, 443.0, 443.9, 451.0, 451.11, 451.19, 451.2, 451.81

if i bill a patient w/all three nail care codes - here's how i do it and they're paid 99.9% of the time:
EXAMPLE ONLY:
11056 Q8
11720 59 Q8
11719 59 Q8

dx's of:
110.1
703.8
700
250.60


hope this helps  8)

: Re: Billing 11721 with 11055 or 11056
: jennifer8055 April 22, 2014, 01:09:07 PM
oops....forgot ----- don't forget referring/primary care doctor name on claim along w/patient's date last seen too
: Re: Billing 11721 with 11055 or 11056
: djk May 02, 2014, 01:17:06 PM
thanks that does help, I have also add for pain, Medicare wont pay on either code unless 729.5 is second diagnosis.  The really odd part is that Medicare is paying on some claims and not others and they are all billed exactly the same way with the same diagnosis, so i have to do written appeals on each one  yikkees LOL thanks for your help
: Re: Billing 11721 with 11055 or 11056
: jennifer8055 May 23, 2014, 05:36:36 PM
it is VERY weird on medicare sometimes w/the pain dx of 729.5.  on our software system there's only space for 4 dx codes -- if patient is having all three procedures done, i can't add 729.5 to the 250.60, 110.1, 703.8, 700 because there simply isn't room.  some claims medicare pays it without the pain dx and sometimes they send a request for records......it's very strange.  i wonder if it just depends on who the processor is.....if there are still actual "claim processors"....

good luck!
: Re: Billing 11721 with 11055 or 11056
: Michele May 23, 2014, 07:13:06 PM
it is VERY weird on medicare sometimes w/the pain dx of 729.5.  on our software system there's only space for 4 dx codes -- if patient is having all three procedures done, i can't add 729.5 to the 250.60, 110.1, 703.8, 700 because there simply isn't room.  some claims medicare pays it without the pain dx and sometimes they send a request for records......it's very strange.  i wonder if it just depends on who the processor is.....if there are still actual "claim processors"....

good luck!

Is your software updated for the new CMS 1500 (rev 02-12)?  If so there should be room for more dx codes.
: Re: Billing 11721 with 11055 or 11056
: djk June 16, 2014, 09:56:05 AM
Software wont allow to map more than 4 dx either i have sent in request for this to be fixed and nothing yet.. yikkes
: Re: Billing 11721 with 11055 or 11056
: Michele June 16, 2014, 10:00:29 AM
Is your software updated to allow for ICD10?  Are you sure it's not just a setting?  Are software has a place to indicate how many dxs we want to print on a claim.
: Re: Billing 11721 with 11055 or 11056
: RichardP June 16, 2014, 02:22:07 PM
Software wont allow ...

Can you tell us the name of your software?
: Re: Billing 11721 with 11055 or 11056
: jennifer8055 August 18, 2014, 03:31:39 PM
We bill on a software called the Sammy systems from ICS Software out of New York.  We still cannot put more than 4 diagnosis codes on the claim, even though we're using the updated (02-12) HCFA claim form and there's spaces for 12 dx codes. 

When I posed the question to our software vendor that we needed to be able to use more than just 4 diagnosis codes, their comment was "it's not a priority right now since ICD-10 was delayed until 2015."  Unless an insurance company sends us something stating we have to be able to use more than 4 dx codes (right now we're having to "split" bill claims w/more than 4 dx codes) our software people said it's just something they will eventually get to.   ::)

I think eventually insurance companies will get tired of seeing split claims come thru from providers and do some type of mandate for everything to be on one claim as much as possible and for us, it seems like we're going to have to wait for that mandate (or October 2015 - whichever comes first) for that to happen.

Jennifer
Mid-South Foot & Ankle Specialists
Cordova, TN
: Re: Billing 11721 with 11055 or 11056
: Michele August 18, 2014, 11:05:19 PM


When I posed the question to our software vendor that we needed to be able to use more than just 4 diagnosis codes, their comment was "it's not a priority right now since ICD-10 was delayed until 2015."  Unless an insurance company sends us something stating we have to be able to use more than 4 dx codes (right now we're having to "split" bill claims w/more than 4 dx codes) our software people said it's just something they will eventually get to.   ::)


Wow!  That would not be ok with me.  The new form was not delayed and the new form has room for 12 dx codes.  The number of dx codes is completely separate from ICD10.  We have several situations that require more than 4 codes and we were very happy to switch to the new form. 

You are kind of in a hard place unless you are considering switching software.
: Re: Billing 11721 with 11055 or 11056
: coxoffice September 23, 2015, 08:21:00 PM
I am trying to use the modifiers you suggested and my billing program says that medicare says there is a bundle error. I'm billing 11719 59 q8 with 250.00 and 703.8 as diagnosis. I've tried it with modifier 51, 99, and still says bundle error. Any suggestions?
: Re: Billing 11721 with 11055 or 11056
: Michele September 24, 2015, 03:05:29 PM
Not enough info.  What other codes are you billing?
: Re: Billing 11721 with 11055 or 11056
: coxoffice September 28, 2015, 03:11:47 PM
billing with 99213-25
: Re: Billing 11721 with 11055 or 11056
: kristin September 28, 2015, 09:16:55 PM
Okay, so you are billing:
99213-25
11719-59-Q8

Is that all you are trying to bill for this claim? If so, one issue is you do not need a 59 modifier on the 11719, and the Q8 doesn't work with your two diagnoses either. I don't know what dx's you are using on the 99213-25, but if they are the same as for the 11719, it will bundle. If they are different dx's, that is a different story. Another issue is the dx's you are using for the 11719...neither of those two come up on any LCD I use for nondystrophic nails, nor are they listed in the Ingenix Podiatry Coding Companion. Which MAC do you use, and have you checked their LCD for RFC coverage rules?
: Re: Billing 11721 with 11055 or 11056
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