10/30/2020

RFC Bundling Denials-BCBS

We have been having a problem when billing BCBS Medicare Advantage for codes 11056 and codes 11721 for a visit on the same date. The same is true for 11720 and 11055 or 11057. The patients fit the requirements for medicare to cover the codes and both would be covered if billed directly to medicare. BCBS pays for one procedure (usually 11056) and not the other (11721) saying they are “mutually exclusive”. We have called BCBS and told them this is not following medicare guidelines and they say they will reprocess it but then they eventually reject it for the same reasons. Any suggestions?

We have been having a problem when billing BCBS Medicare Advantage for codes 11056 and codes 11721 for a visit on the same date. The same is true for 11720 and 11055 or 11057. The patients fit the requirements for medicare to cover the codes and both would be covered if billed directly to medicare. BCBS pays for one procedure (usually 11056) and not the other (11721) saying they are “mutually exclusive”. We have called BCBS and told them this is not following medicare guidelines and they say they will reprocess it but then they eventually reject it for the same reasons. Any suggestions?

Unfortunately, this is not new.  These are common denials with many payers not just BCBS.  Basically, FFS Medicare is taking you at your word because you're appending a 59 Modifier.  This states that it is a separately identifiable procedure and not on the same toe/s.  The Medicare advantage plans do not have to do that and they will often deny as bundled.

Notably, CMS says you can bill CPT code 11055 (Paring or cutting of benign hyperkeratotic lesion) with code 11720 (Debridement of nail[s] by any method; 1 to 5) as long as the two procedures are performed on different toes. The two codes are bundled, but you can use modifier 59 as evidence of the distinct procedure.

This means that if you are paring a callus on the right great toe near the nail area (11055), you can report 11720 with a modifier 59 if you are debriding the right second and third toes. But if you are paring a corn/callus of the right great toe near the nail area and also debriding that great toe nail, you can only report the column-one code [11055].

Calling to have it reprocessed will not result in having the claim paid as It will be sent back and denied the same way. The claim must be appealed with documentation proving the validity of 59 modifier.