Nail and Lesion Debridement During the Same Visit

Question:

A patient presents to the office who meets Medicare’s definition for medical necessity for routine foot care. Nails are noted to be elongated and thickened, and hyperkeratotic lesions are noted to be on the right plantar heel and right foot second metatarsal head. The podiatrist debrides all ten nails and trims two lesion sites. Is it appropriate to use modifier 59 to unbundle 11721 and 11056?

Answer:

Yes. In the scenario you describe, both services are reportable under both CPT definitions of codes 11721 and 11056 and CMS NCCI edits and narrative guidelines.

From a CPT standpoint, your question describes two different services; debridement of nails and trimming of skin lesions.

The most recent change to the NCCI guideline was published in 2018, and remains in effect in 2019. It states:

NCCI has a procedure to procedure edit with column one CPT code 11055 (paring or cutting of benign hyperkeratotic lesion…) and column two CPT code 11720 (debridement of nail(s) by any method; 1 to 5). Modifier 59 shall not be used to bypass the edit if these two procedures are performed on the same distal phalanxincluding the skin overlying the distal interphalangeal joint.Source: NCCI 2019, Chapter 3, Section E

Your question includes similar procedures, but for a greater number of sites (11056 is used for paring or cutting of 2-4 benign hyperkeratotic lesions, while 11055 is for a single lesion and 11721 is used for debridement of 6 or more nails, while 11720 is used for 1-5 nails).

Under the NCCI guideline, the determining factor is whether the hyperkeratotic lesion is located on the same distal phalanx, including the skin over the distal interphalangeal joint. When that situation exists, it is not appropriate to use modifier 59 to bypass the NCCI edit between codes 11720 and 11055, (or 11721 and 11056).

In your scenario, the lesions are at the plantar heel and at the second metatarsal head; based on their locations, separate reporting would be allowed, and the Column 2 code, 11721, could be reported with modifier 59.

*This response is based on the best information available as of 08/22/19.