09/27/2018    Name Withheld

Fraudulent Billing of CPT 11305, 11306 and 11307

I am an RN with 25 years of O.R. experience
working with orthopedic and podiatric surgeons
and I work part time for a DPM. I’m also a
certified coder and fully understand proper
billing practices. I make a majority of my
income as an outside consultant for many
insurance companies when there is suspected
fraud. The past two years have been keeping me
busy reviewing literally thousands of claims for
procedure codes CPT 11305, 11306 and 11307
billed by DPMs.

I have reviewed thousands of these claims with a
committee which includes two DPMs and a
dermatologist. Over the past two years, we did
not review a single claim sent by a DPM where
the code was justified. These codes are for a
shave of a lesion and they are being used
incorrectly. The code is to shave remove a
lesion such as a nevus or suspected lesion and
should require local injectable anesthesia and a
specimen for biopsy.

This code is NOT a procedure that should be
billed every 61 days, etc., and a procedure that
should NOT be billed for keratotic lesions,
IPKs, porokeratoses or calluses. You can get as
creative as you’d like but it’s called fraud.
Unless you are using an injectable local
anesthetic, and shaving a lesion to remove the
lesion and send for biopsy, you are likely
dancing on thin ice. Trimming a keratotic lesion
or “shaving” an IPK should be billed as a CPT
11055/11056/11057.

Getting creative to get paid for a high paying
code is fraudulent and the insurers are
scrutinizing these claims. One large company is
so fed up with the abuse, they are considering
having to have these codes pre-authorized. If
you’re simply trimming keratotic lesions or IPKs
and billing these codes, I urge you to stop,
unless you’d like to be like two DPMs who now
each owe over $300,000 back to the insurer with
significant other consequences.

Name Withheld

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