Modifier

“I am in Virginia and I have read through the LCD and billing guidelines for Palmetto GBA several times regarding coverage for routine foot care. It is very specific about when CPT 11720 and CPT 11721 will be covered, but it is not specific about CPT 11055, CPT 11056 and CPT 11057. My interpretation is that for coverage of CPT 11055-CPT 11057, there must be a systemic condition with class findings and if there are no systemic conditions that would qualify for coverage, modifier -GY should be used and -GA if an ABN is on file. I am wondering if CPT 11055-CPT 11057 are also covered with primary diagnosis code of L85.1 with appropriate secondary diagnosis similar to how CPT 11720 and CPT 11721 are covered for mycotic nails with primary diagnosis of B35.1 with appropriate secondary diagnosis. Are callus codes (CPT 11055-CPT 11057) covered with the primary diagnosis of L85.1 (or similar) and a secondary diagnosis of infection, pain, or difficulty walking? Or are they only covered with systemic conditions and class findings?

The Proper Use of the 25 Modifier

“I billed A5500 and A5512 with modifiers -KX, -RT, -LT. L1940 KXRTLT L2330 KXRTLT L2820 KXRTLT I billed these on separate lines. This claim was rejected so we re-billed putting the KX modifier in the 3rd spot and it was still rejected for the same reason. The comment was: 4 – the procedure code is inconsistent with the modifier used or a required modifier is missing Any thoughts on how to tackle this denial?”

“If a Medicare patient is seen in the emergency department and then surgery is performed later that day or night, can the emergency department consult be billed with a modifier -57 along with the surgery? We have been under the impression that, at least in the office, the visit to decide to do the surgery is included in the surgical fee. Are we correct and does this apply to the encounter in the emergency department too?”

“A new patient was seen with heel pain. X-rays were taken at an outside facility, and I independently interpreted these and reviewed the labs. Based on medical decision making, I believe I should be coding CPT 99204. The patient had one new, acute problem (previously undiagnosed) and I independently interpreted tests. To me this is a no brainer, but my office staff argues that they believe it should be CPT 99203. Thoughts?"

“The patient initially had a gastroc recession at the right lower extremity. Our surgeon performed a debridement procedure of the right foot ulceration. It was performed in the clinic, and we planned to code it as CPT 11042. However, the patient is in the 90-day post op period from the initial surgery that was performed 4 weeks ago. Is a modifier necessary to submit for payment? Is it 79?”

How are the FX and FY modifiers used?

What are the appropriate modifiers to use for the billing of CTPs?

Based upon an article that is posted within The American Institute of Healthcare Compliance website, it is important to note that the OIG is Auditing for Abusive Dermatology Claims. The Office of the Inspector General (OIG) is auditing dermatologists for billing an E/M service on the same date of service that a minor surgical procedure (ie. postoperative global period of 0 or 10 days) is performed. Medicare only covers Evaluation & Management (E/M) services on the same day as a minor procedure if a physician/surgeon performs a significant and separately identifiable E/M service that is unrelated to the decision to perform the minor surgical procedure. In order to bypass the CCI edits or the Correct Coding Initiative edits and bill for the E/M service and the minor surgical procedure/CPT code on the same date of service, the 25 modifier needs to be appended to the E/M service.