APMA News - November/December 2020 - 28

Reimbursement

59 Modifier Challenges and Guidance:
Appeal, Appeal, Appeal!

Several state components alerted APMA in 2014 to a major
carrier adjudication of routine foot care claims where procedure codes appended with the 59 modifier were being denied
inappropriately. The predominant payer abusers were several
of the major Medicare Advantage Organizations (MAO). APMA
Health Policy and Practice (HPP) department staff and APMA
leadership investigated these concerns immediately. This situation has persisted despite APMA's efforts to resolve it.
Members have reported to APMA that they are experiencing denials when CPT® 11720, 11721 (nail debridement)
is submitted with services for CPT® codes 11055, 11056,
11057 (corns and callus debridement for diabetic patient). In many cases, claims were and continue to be denied
with " unsupported use of modifier " or " procedure included
in another code " listed as an explanation. These services
were being adversely determined/adjudicated when in fact,
the carrier requested no supporting information when making its initial determination.

APMA's Action Plan
APMA HPP staff, Health Policy and Practice Committee
members, consultants, and attorneys organized a plan to obtain examples of these types of denials from member podiatrists, validate correct coding, and investigate further prior to
formally challenging the carrier or carriers. APMA assembled
resources and allocated funding for this initiative. The effort
included, but was not limited to, funding of resources to as28 APMA News November/December 2020

sist with legislative contacts and health policy and practice
consultants.
Using these resources, APMA was able to obtain the participation of a significant CMS representative. APMA scheduled
conference calls with the primary carrier in question. HPP
staff and the committee met with representatives responsible
for policy development and principals of the carrier at its corporate headquarters.
APMA's initial take-away from the meeting was guardedly
optimistic. We were led to believe that corrective actions on
the part of the carrier would lead to a favorable and equitable
resolution. However, after numerous interactions, it became
apparent that the carrier was going to continue with inappropriate edits. The carrier justified its actions by claiming that
podiatrists and other providers generally did not appeal, and
those who did appeal were not significant in number.
APMA has urged members to vigorously appeal inappropriate denials to help refute this justification. However,
APMA members have reported that more carriers are adversely adjudicating routine foot care claims by inappropriately denying procedure codes appended with the 59 modifier. In June, the committee responded to this growing
concern by organizing the Modifier 59 Workgroup to evaluate the issue, develop more member resources, and continue outreach to carriers.
As APMA has gained a better understanding of the
carriers' perspective, it has become apparent that other

APMA News - November/December 2020

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