06/03/2021

Correct Diagnoses for CPT 11055 & 11102

What is the correct Diagnosis code for 11055 and 11102? The diagnosis code i always use Fidelis started denying we tried using Dx B35.1/ B35.3

There are multiple options for medically necessary diagnosis codes for either of the CPT codes listed below. Since Fidelis does not have its own medical policies on coverage for procedures and these are not subject to authorization requirements, it would be reasonable to imply that the Medicare coding guidelines should be applied for billing Fidelis patients. Neither diagnosis code (B35.1 or B35.3 would be medically necessary for either the biopsy or the removal of corns & calluses:

• CPT 11102 should be billed only if the patient has a neoplasm (benign or malignant), or some type or dermatology related diagnosis that would warrant the biopsy, such as pyogenic granuloma, dermatitis, xerosis, or a similar condition (note that NGS does not have a LCD policy or article on this minor procedure to provide guidance).

• CPT 11055 should follow Medicare guidelines where only if the patient has a systemic condition (such as diabetes) that prevents them from safely doing routine foot care at a home setting would it be covered by a podiatrist per the LCD for New York State.