CPT Code included in the allowance.....Assistance Please!

[PippiT]

I am so confused. the following two CPT codes have always been billed together:

11721, Q8, XS
11055, Q8

They have also always been paid. Recently the 11721 is not being paid and it states that it is included in the allowance for 11055. Customer service cannot tell me why this is so all of a sudden. The same DX codes are being billed on previous claims that paid and I am completely lost as to how or why this is happening. I cannot find an NCCI edit or anything to back up the claim they are not separately payable. Any ideas? Thank you!!

[kristin]

Medicare does have a rule in place that if a 11721 is done with 11055-11057, that the 11721 will deny as bundled into the 11055-11057...but ONLY if the corns/callouses debrided are on a TOE(s) that also had a nail debridement. The thing is, it all depends on whether your MAC follows the NCD or their own LCD. It could be that your MAC has decided to follow the NCD, or made their LCD stricter.

[PippiT]

Medicare does have a rule in place that if a 11721 is done with 11055-11057, that the 11721 will deny as bundled into the 11055-11057...but ONLY if the corns/callouses debrided are on a TOE(s) that also had a nail debridement. The thing is, it all depends on whether your MAC follows the NCD or their own LCD. It could be that your MAC has decided to follow the NCD, or made their LCD stricter.

This is actually for BCBS and if they changed it they did in the last 3 months. I can't get through to a CSR, last week was a long hold time that I didn't have time for and this week even when I call at 8am they cannot take my call because there are too many calls. lol.

I do have a similar one for UHC that also just started not paying both so if I could get the CD they are using that would help.

Thank you!