Hello,

In my office we are having with Humana and United health care insurances paying for nail and callous care on same visit for patients that aren't new with no new podiatry diagnosis.  We use codes like 11055 for callouses, 11720 for nail care.  We add 59 modifier to callous code and we get denial for callous code treatment.  Other insurances besides these two accept the callous code with 59 modifier if I do nails and callouses on same visit and pay for both codes.  

I am in state of WV if that makes difference.  Insurances pay for same code different amounts in different regions of country.  

My question though is, I've heard of other offices in my area using 59 modifier on 11720 AND 11055 both for these insurances.  They are getting paid for both codes if they do it that way instead of just one 59 modifier instead of two.  Does anyone else do this?  59 is for second procedure I thought.  

  • Comments (5)
  • To my knowledge, they don't ask where the corn/callus is or which nails on a claim form, merely the number involved.  If you're specifying those kind of details, you're providing more information than is necessary and hurting yourself in the process.  If you have calluses sub 2nd, 5th mets of both feet, with or without an HD of the 5th toe, there's no way to indicate the location on a claim. There's never a need to indicate which nails ore mycotic/dystrophic on a claim form.  Of course, those details do need to be in your progress note, but not on a claim submission.

  •  The whole problem is that podiatrists must read their carrier's website regarding posts and examples on how to bill. 

    The Novatis website said that if a corn is on the same toe that a toenail is debrided one should not use the 59 modifier.

    This was example #4 given by this carrier's website on how to correctly bill medicare. One must follow the carriers advice. 

    I feel Medicare's interpretation is unfair because if there was no mycotic toenail debridment on the right 5th toe then one could correctly bill 11721 Q8 59 for "less work" (only 9 toenails are debrided instead of 10 mycotic toenails). The moment that that 10th toenail gets debrided on a toe with a corn then a podiatrist cannot use that 59 modifier. 

    My question is:

    If one cannot bill 11721 Q8 59 can they instead bill 11720 Q8 59 instead since the first 5 toenails debrided were on the other foot. 

  • CCI edits:  11055 is on the first line with Q8; 11721 on the second line with 59 and Q8 or pain codes.

     

  • If a patient with I79.8 has 10 mycotic nails and a corn on the right 5th toe how would this be billed?

     

    My opinion is one cannot bill 11721 59  Q8 and 11055 Q8

    Medicare feels that any lesion on the toe ( even if at the interphalangeal joint ) is the same anatomic site as the toenail. 

    Is it acceptable to bill:

    1.   11720 Q8 59   and 11055 Q8

     

    ( because 5 of the mycotic toenails were on toes right 1, 2, 3, 4, 5 without the callous the 59 modifier could be used) 

     

     

     

    Or must one bill:

    2. 11055 Q8 without billing for any mycotic toenail debridement? 

  • Try using XS instead of 59. Also some EMR programs require each line to be sent as a separate invoice (you still need the modifier)