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Service Specific Audit
Procedure Code 11721
Data Analysis shows the AR Consortium with a standard deviation in Carrier to Nation ratio greater than 3.0 in allowed services per beneficiary for procedure code 11721. In addition, the data indicates providers are billing
debridement codes (11720, 11721) when actually performing routine foot care, billing Evaluation and Management code with Modifier 25 on the same date of service as debridement when no separate identifiable service was documented, no documentation for the
extent of debridement, and billing modifier 59 and another procedure code on the same date of service as debridement, with no documentation to support a distinct procedural service.
Based on medical review findings and data analysis a prepay medical review audit is being established on procedure code 11721.
Requirement to comply with request for additional documentation:
- Documentation for Date of Service billed records would be expected to support the documentation requirements in the policy (AC-03-003) to include clinical evidence of mycosis, affected toes, manner and extent nails were debrided, description of
qualifying symptoms.
- For debridement of nails (caused by a systemic condition), claim documentation must include:
Diagnosis code of covered indication; systemic condition diagnosis code; class finding modifier of Q7, Q8, or Q9; and name of MD/DO who is actively treating the patient’s condition and date patient last saw this physician. (within 6 mo. before or 30 days
after the procedure).
Reference: AR LCD AC-03-003: DEBRIDEMENT OF TOENAILS |
