12/09/2020

Healthfirst Denial for CPT 10061 with ICD-10 L03.031/L03.032

Healthfirst has been denying procedure code 10061 with ICD-10 codes L03.031/L03.032 with corresponding toe pain codes saying the procedure is not valid with diagnosis. How can this be rectified? Thank you.

The denial from Health First is valid based on the cellulitis diagnosis reported. Health First plans follow the NGS Medicare LCD policy in terms of medically necessary diagnosis codes. For this minor procedure, there are only three codes that are covered for podiatry:

• L02.611 (Cutaneous abscess of right foot)
• L02.612 (Cutaneous abscess of left foot)
• L98.8 (Other specified disorders of the skin and subcutaneous tissue) 

A corrected claim would need to be submitted with one of these three codes, or the balance would have to be written off since the coding is not medically necessary per the NGS Medicare LCD policy for I&D.