06/28/2022
Part One-Healthfirst Denial for CPT 11730, Part Two- 224 Day Frequency for Nail Avulsion
Healthfirst-Denial for CPT 11730-Member Can’t Come in Within 224 Days for a Second Procedure if Using Same Modifier CAN YOU PLEASE CLARIFY 2 THINGS: 1)If a member with Healthfirst presents (Within 224 days) with an infected ingrown toenail on the SAME toe, that previously had an Avulsion (11730) , performing the same procedure on the same digit will result in a denial. According to this frequency limitation, by the Managed Care Plan, if a provider proceeds with this treatment the claim will automatically be denied. I understand that APPEALING with supporting documentation is appropriate but I disagree that it is ONLY solution. I question this because it puts the provider at a disadvantage. It can take weeks, if not months, to resolve such an issue - through the Managed Care Plan's appeal process. AS WE ALL KNOW - APPEALING, A DENIED CLAIM, IS NO GARUNTEE OF SUCCESS (PAYMENT). However, would it not be prudent for the Provider to request Pre- Authorization or Pre-Determination from HealthFirst? THIS WOULD PREVENT THE RISK OF PERFORMING A PROCEDURE AND NOT GETTIN REIMBURSED. ALSO, SHOULD THE PROCEDURE GET DENIED, AT LEAST THE PROVIDER CAN USE THE DOCUMENTATION SUBMITTED FOR THE PRE-AUTHORIZATION AS A BASIS FOR AN APPEAL. Appealing, on the basis of Medical Necessity, for a frequency limitation, where it is the SAME procedure performed at the SAME anatomic location, can be challenging. In such a scenario, an appeal will work best if the repeat procedure is for a separately identifiable diagnosis. For example: A patient has a partial nail avulsion (11730) on the Left big toe, due to an infected ingrown nail, but returns within the 224 day global period due to trauma to the same toe and nail. Avulsion of the nail plate (11730) may be required on the same toe, in order to treat the trauma. 2) Is this 224 day frequency limitation provider specific? For example, if a Medicare patient has Routine Foot Care performed by Podiatrist (A) and then goes to a different Podiatrist (B) within the 60 day global period, for Routine Foot Care, the claim would get denied for Podiatrist (B) based on parameters.
In regard to the first question, attempting to get authorization within the 224-day global period for a subsequent avulsion on the same digit will not provide an easier way to get reimbursed for the minor procedure over a medical necessity appeal. When a claim is submitted for CPT 11730, if the patient is still within the arbitrary global period from Health First, it will trigger a denial. Even if a provider calls customer service and states that services were pre-certified by the managed care plan, getting the pre-certification does not constitute a guarantee of payment nor would they even issue one. It will not overturn the frequency denial, which will still have to be appealed with supporting documentation to justify medical necessity of being performed within 224 days of the last covered procedure. You may inform the patients of these issues and have them either pay for the procedure or argue it with their insurance company.
To the second part of the question, this limitation is not provider specific, and like the RFC example provided within the inquiry, the subsequent avulsion would be denied if it was performed (and paid) by a different podiatrist within the 224 said frequency period.
Please refer to the 2 links below (Novitas and NGS):
Our local article (NGS), does not specify the frequency , however the Novitas and FCSO policies specify the frequency (32 weeks-224 days ), In addition, Healthfirst does not have a policy that is available their website that specifies frequency utilization guidelines.
Novitas details the following-“A medically reasonable and necessary repeat avulsion or excision of the same nail within 32 weeks of a previous avulsion, or excision, of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated”
First Coast Service Options: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57666&ver=18&keyword=&keywordType=starts&areaId=all&docType=6,3,5,1,F,P&contractOption=all&hcpcsOption=code&hcpcsStartCode=11730&hcpcsEndCode=11730&sortBy=title&bc=1