Author Topic: Billing 11721 with 11055 or 11056  (Read 17029 times)

djk

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Billing 11721 with 11055 or 11056
« on: April 04, 2014, 01:46:49 PM »
Medicare is bundling these codes and shouldn't be.  Any suggestions on how they should be billed.

Merry

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Re: Billing 11721 with 11055 or 11056
« Reply #1 on: April 04, 2014, 04:46:06 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. 

kristin

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Re: Billing 11721 with 11055 or 11056
« Reply #2 on: April 04, 2014, 05:04:06 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.
« Last Edit: April 04, 2014, 05:17:36 PM by kristin »

djk

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Re: Billing 11721 with 11055 or 11056
« Reply #3 on: April 07, 2014, 07:57:30 AM »
I have tried to bill with the Modifer 59 and it was denied for invalid modifier.

Michele

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Re: Billing 11721 with 11055 or 11056
« Reply #4 on: April 07, 2014, 08:58:58 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.
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djk

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Re: Billing 11721 with 11055 or 11056
« Reply #5 on: April 07, 2014, 09:15:52 AM »
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

kristin

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Re: Billing 11721 with 11055 or 11056
« Reply #6 on: April 07, 2014, 09:52:33 AM »
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?

djk

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Re: Billing 11721 with 11055 or 11056
« Reply #7 on: April 07, 2014, 09:58:48 AM »
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

dekenn

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Re: Billing 11721 with 11055 or 11056
« Reply #8 on: April 07, 2014, 10:26:26 AM »
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)

kristin

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Re: Billing 11721 with 11055 or 11056
« Reply #9 on: April 07, 2014, 11:27:16 AM »
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.

djk

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Re: Billing 11721 with 11055 or 11056
« Reply #10 on: April 07, 2014, 01:20:21 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..


djk

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Re: Billing 11721 with 11055 or 11056
« Reply #12 on: April 07, 2014, 02:10:23 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

Michele

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Re: Billing 11721 with 11055 or 11056
« Reply #13 on: April 08, 2014, 02:52:29 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.
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HeidiK

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Re: Billing 11721 with 11055 or 11056
« Reply #14 on: April 08, 2014, 03:05:21 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!
Heidi Kollmorgen, CCS-P
AHIMA Approved ICD-10 Trainer
hdmedicalcoding.com