APMA Advocacy Leads to -59 Modifier Change

As a result of APMA’s advocacy efforts, the National Correct Coding Initiative (NCCI) updated Chapter I of the NCCI Policy Manual for Medicare Services in Section E.1.d.(3), Example #2, to reflect a prior determination by CMS specifying that use of Modifier 59 or X[ESPU] is acceptable if the procedures described by CPT® 11720 and 11055 are conducted on lesions that are anatomically separate from one another—even if on the same digit.

Effective January 1, 2021, the NCCI Policy Manual Chapter I now includes an example that reads as follows:

Example 2: The Column One/Column Two code edit with Column One CPT code 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion) and Column Two CPT code 11720 (Debridement of nail(s) by any method(s); one to five) should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. Modifiers 59 or –X{EPSU} should not be used if a nail is debrided on the same toe on which a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint is pared. Modifiers 59 or –XS may be reported with code 11720 if 1 to 5 nails are debrided and a hyperkeratotic lesion is pared on a toe other than 1 with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided.

This victory ensures the NCCI Policy Manual language is consistent throughout and accurately reflects CMS policy.

APMA’s 59 Modifier Workgroup was formed last year to address this discrepancy and develop a Routine Foot Care and -59 modifier toolkit. The toolkit includes educational materials and resources to help members when Medicare Advantage plans, Medicaid Managed Care Organizations, or other commercial plans deny covered nail care (CPT® 11720/11721) when callus care (CPT 11055-11057) is provided on the same date.

The workgroup is pleased with this victory and will now work toward the coverage of nail debridement without any restrictions related to callus paring or cutting.

For more information visit www.apma.org/59toolkit.