APMA News - March/April 2018 - 38

Reimbursement

APMA Scores a Partial Win with Big Implications
CMS published a Modifier 59 article in 2014 that stated:
formed nail care. As a result of these efforts, CMS revised the
"Modifier 59 may be reported with code 11720 if one to five
CCI edit to allow for -59 modifier use when nails are debrided
nails are debrided and a hyperkeratotic lesion is pared on a toe
and lesions are pared on the same toe except those lesions "disother than one with a debrided toenail." Due to previous longtal to and including the skin overlying the distal interphalanstanding CCI edits, some providers continued to use the -59
geal joint on the same toe or fi nger." CMS considers those
modifier with codes CPT 11721
lesions to be included in the treator CPT 11720 when they were
ment of the nail, nail bed, and adAPMA's efforts included
paired with 11055, 11056, and
jacent soft tissues. The new policy
11057 even when lesions were
can be found at https://www.cms.
letters and phone calls, and
pared on the same toe with a degov/Medicare/Coding/National
APMA finally earned an inbrided toenail.
CorrectCodInitEd/Downloads/
Over a period of three years,
modiﬁer59.pdf.
person meeting with CMS
APMA made several attempts to
With this change, the -59 modin Baltimore in August 2017.
have this policy changed. APMA's
ifier can still be used when nail deefforts included letters and phone
bridement and callus paring are
calls, and APMA fi nally earned an in-person meeting with
performed on the same toe; however, it will now signify that the
CMS in Baltimore in August 2017. APMA delivered a multilesions pared are not distal to or including the distal interphapronged educational presentation to CMS, including anatomlangeal joint (DIPJ). If the lesion is not distal to or including the
ical visuals of many different lesion locations. CMS representaDIPJ, as outlined in the policy, it qualifies for use of the -59
tives realized that callus debridement services are, in fact,
modifier, therefore including many of the lesion(s) podiatrists
distinct, not related, and often not in close proximity to perdebride, along with associated nail debridements.
Although this change is small and technical, the implications and burden of proof required when audited have changed
immensely. As APMA members know, many "at-risk" patients
who qualify for covered routine foot care have other deformities causing lesions in all different locations on the foot, which
can potentially become infected or ulcerated. APMA presented
data such as a review of the adverse impacts of excluding podiatrists from Medicaid in Arizona and an independent study
from Dukei, to underscore that message for CMS.
APMA recommends that when documenting covered routine foot care, the provider list the location of the lesion(s) that
qualify for the -59 modifier use. Then, if audited, the provider
can demonstrate he or she has used the -59 modifier correctly.
APMA hopes to use this new CCI language to further educate
Medicare Advantage plans to not disregard the use of the -59
modifier and thus reject payment when it is used appropriately. The education APMA provided to CMS resulted in a policy
change necessary to allow our members to continue to provide
this essential care to at-risk patients on a daily basis.
n

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38 APMA News March/April 2018

For questions about any of these issues, contact the
Health Policy and Practice department at healthpolicy.
hpp@apma.org.

i Sloan, F. A., Feinglos, M. N. and Grossman, D. S. , RESEARCH
ARTICLE: Receipt of Care and Reduction of Lower Extremity
Amputations in a Nationally Representative Sample of U.S. Elderly.
Health Services Research, no. doi: 10.1111/j.1475‐6773.2010.01157.x

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf http://www.apma.org/save

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