July 20, 2021

APMA recently wrote to Anthem, Centene, and Humana to address members’ concerns with these carriers denying properly coded at-risk foot care claims. After hearing from APMA, Anthem has agreed to revise its policy and follow current National Correct Coding Initiative (NCCI) policy. The change goes into effect at the end of the month and is enterprise-wide. APMA is scheduling a meeting the last week in July to gather more information about this policy change.

In the meantime, APMA will continue to push Centene and Humana to make similar changes to their policies.

The primary issue arises when a podiatric physician attempts to code both trimming and/or debriding of toenails (e.g., G0127, CPT 11719, 11720, 11721) and paring or cutting of benign hyperkeratotic lesions (e.g., corn or callus) (e.g., CPT 11055, 11056, 11057). According to APMA member podiatrists, these carriers are denying payment of CPT 11719, 11720, 11721, and G0127 based on both the nail procedures and callus procedures having been performed at the same encounter, regardless of the physician’s proper use of the NCCI modifiers 59 or X [ESPU], and regardless of the location of the hyperkeratotic lesions pared.

For more information about APMA’s advocacy efforts and for resources, visit www.apma.org/59toolkit.

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