Query: Appropriateness of Billing CPT 11056 with
I am considering joining a practice. The doctor
has been practicing for over 30 years, and
primarily performs routine care. In discussions
with him, I found that he frequently bills
Medicare CPT 11056 (paring or cutting of benign
hyperkeratotic lesion [e.g., corn or callus]; 2
to 4 lesions) with the code, ICD-9 701.1
(keratoderma, acquired)...and has consistently
been reimbursed, regardless of time between
visits, and regardless of modifiers (never
uses). This seems odd to me (unless there's
something I don't understand).
Obviously, I would like to make sure everything
is being done correctly before I join the
practice. How do I find out if this is
acceptable billing practice?
Name Withheld by Moderator
Codingline Response: To determine whether or not
the doctor you will be joining is billing
correctly you must answer two questions:
1) What is the local Medicare policy regarding
billing CPT 11055 - CPT 11057?
This does vary from state to state. Go to the
Medicare carrier's website for the state in
which this doctor practices, and read the "LCD"
(local coverage determination policy) for these
codes. In New York, for example, CPT 11055 - CPT
11057 are only paid when the patient meets the
high risk criteria for covered "routine foot
care". This might not be the care for the state
in which this doctor practices.
The second question has to do with the
appropriateness of the diagnosis.
2) Should the patients' conditions have been
coded as ICD-9 701.1 (keratoderma, acquired), or
would they have been more appropriately coded as
ICD-9 700 (corns and callosities)?
You should be commended for looking into the
coding practices of a potential employer,
partner, seller. Too many new doctors join
practices without reasonably investigating the
practice they are entering. In some cases, only
afterwards do the new doctors find out that the
senior doctor failed to bill services correctly.
Unfortunately, they sometimes don't learn this
until the doctors in the practice are the
subject of a Medicare audit, or an OIG (Office
of Inspector General) investigation.
Mark Schilansky, DPM