11/29/2023 Yelena Dreyzina
Bundling Of Codes
Recently, there was a problem with Aetna Advantage
Medicare plans refusing to pay for codes CPT
11720(1) and CPT 11055(6) together. I believe it
was resolved. However, we now started seeing the
same issue with EmblemHealth/HIP plans. This
started in October 2023. The denial code: F86.
F86: This service is part of the procedure that
has already been billed. Submit records showing
this is a separately payable service.
Recently, there was a case where patient had a
nail procedure (CPT 11730) and a diabetic ulcer
debridement (CPT 97597) on another foot. The CPT
97597 code was not paid with the denial code F88.
F88: This service is part of a procedure that has
already been billed. Separate payment will not be
made.
Yelena Dreyzina, Office Manager, Bronx, NY
Response: And the story continues. Medicare
Advantage plans just refuse to follow the rules
and regulations as stated by traditional Medicare
when it comes to “at risk” routine foot care. As
long as the patient has a covered systemic disease
and class findings and it is supported by the
documentation within the medical record for the
date of service in question, CPT 11055/CPT 11056
and CPT 11720/CPT 11721 should be both reimbursed
when performed together on the same date of
service. Aetna Medicare Advantage plans appear to
be reimbursing for this code set after pressure
was applied by the APMA.
The correct coding scenario is:
CPT 11055/11056 – Q_
CPT 11720/11721 – 59, Q_
So along comes Emblem Health/HIP plans and they
are refusing to pay CPT 11055/11056 and CPT
11720/11721 when they are both performed and
billed for on the same date of service. The reason
for denial is: This service is part of the
procedure that has already been billed. Submit
records showing this is a separately payable
service. First of all, the assumption that this is
a Medicare Advantage plan and they are supposed to
follow the rules and regulations of traditional
Medicare which clearly reimburses when these two
CPT procedure code sets are properly billed
together. Additionally, the 59 modifier is
appended to the CPT 11720/11721 code set to
indicate a distinct procedural service. Wouldn’t
you expect this to demonstrate to the health
insurance carrier that the two code sets that were
billed are separately payable services. I would so
appeal this!
If that is not enough, here comes another issue. A
nail avulsion was performed, and CPT 11730 was
billed. CPT 11730 is defined as the following:
Avulsion of nail plate, partial or complete,
simple; single. In addition, a diabetic ulcer was
debrided, and CPT 97597 was billed. CPT 97597 is
defined as the following: Debridement (e.g., high
pressure waterjet w/wo suction, sharp selective
debridement with scissors, scalpel & forceps),
open wound, (e.g., fibrin, devitalized epidermis
and/or dermis, exudates, debris, biofilm),
including topical application(s), wound
assessment, use of a whirlpool, when performed and
instruction(s) for ongoing care, per session,
total wound(s) surface area; first 20 sq. cm or
less. When this CPT code set was billed to the
health insurance carrier, CPT 97597 was rejected
with the following reason for denial: This service
is part of a procedure that has already been
billed. Separate payment will not be made. The
assumption is that both CPT codes were linked to
the appropriate ICD-10-CM codes and that the
billing scenario was correct.
When the NCCI edits are accessed, CPT 11730 is the
Column 1 code to CPT 97597 the Column 2 code. In
order for these 2 CPT codes to be billed and
reimbursed on the same date of service, the
billing scenario needs to be the following:
CPT 11730 – T_
CPT 97597 – 59
Once again, the 59 modifier is appended to CPT
97597 to indicate a distinct procedural service.
If CPT 97597 is clearly a distinct procedural
service, how can you justify that CPT 97597 is
part of a procedure that has already been billed?
You can’t. I would so appeal this scenario too!
Michael G. Warshaw, DPM, CPC, Lady Lake, FL
