July 12, 2021

Last week, APMA wrote to CMS urging the National Correct Coding Initiative (NCCI) to update its policy on modifier 59 use.

In 2014, CMS made a change to NCCI policy for use of modifier 59 when callus paring and nail debridement are performed on the same toe. While APMA previously contested this change, and CMS did make a partial modification in 2018, that modification did not fully address our concerns.

Prior to 2014, CMS appropriately allowed payment for both paring of calluses (CPT ® 11055–11057) and debridement of a toenail (CPT ® 11720/11721) when performed on the same toe if the pared callus was unrelated to and not contiguous with the debrided nail and the callus paring and nail debridement were distinct, unrelated procedures. Then in 2014, CMS changed the policy to: “CPT codes 11720 and 11055 should not be reported together for services performed on the same toe. Modifier 59 should not be used if a nail is debrided on the same toe on which a hyperkeratotic lesion is pared.”

APMA disputed this policy, specifying that use of modifier 59 with callus paring and nail debridement should be acceptable if the procedures were conducted on lesions that were anatomically separate from one another, even if on the same digit, as unrelated and non-contiguous pathology.

After several communications and meetings between APMA and CMS, CMS made changes effective January 1, 2018, which allowed use of the 59 modifier if “one to five nails are debrided and a hyperkeratotic lesion is pared on a toe other than one with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided.”

As APMA members know too well, the 2018 change only addressed part of the problem. The policy that remains (only allowing callus paring and nail debridement on the same toe if the callus is proximal to the distal interphalangeal joint) inappropriately bundles two unrelated services performed at separate anatomic sites—services with no overlap in time, work, risk, instrumentation, or cost that are performed on unrelated, non-contiguous lesions in separate anatomic locations. Therefore, APMA is once again requesting that CMS revise its policy and revert to the pre-2014 policy as originally requested.

APMA will continue to update members on these advocacy efforts. In the meantime, for more information and APMA advocacy and resources, visit the At-Risk Foot Care and -59 Modifier Tool Kit.