Callus debridement with class findings

The short answer to your question is that CPT 11055-11057 are not covered more than once every 60 days in NGS. They could be crippled with pain, NGS does not care. Charge the patient! Cash is king!

Explanation: Your Medicare contractor NGS, lumps CPT codes 11055-11057 together and explains their limitation within the routine foot care services LCD. Regardless of how painful they are, they are still by most Medicare contractors, considered to be routine and thus not covered, subject to two exceptions:

The patient must have specific systemic diagnoses, listed in the LCD:

AND

The patient having vascular findings or neuropathic findings.

The rationale here is that both must be present, thus creating a potential danger to the patient.

Only under these two exceptions, NGS Medicare and most other Medicare contractors will cover this once every 60 days. To play it safe most providers re- appoint their patients once every 9 weeks.

When I was in practice I had several patients who wanted to be seen every 4 to 5 weeks. They were told it was not covered that frequently and they signed an ABN. Some patients did not care if we billed Medicare on those non-covered dates, others wanted us to (particulalry those whose secondary did cover them).

For the latter group we billed NGS with the appropriate 1105X code and amended it with GA. Our fees were commensurate with Medicare's fee minus a cash paying d/c.

For those patients who did not have the vascular or neurological findings, we also would bill to Medicare if they wanted us to, and for those, we amended the 1105X with GY. That is these patients were NEVER covered.

Since Medicare is not a single universal payor, there are possible variations on this.

Most DPMs who practice in So California know that 11055-11057 are reimbursable for patients with painful hyperkeratosis under a separate LCD. As far as I know for Fee for Service Medicare, this is the one exception.

As for Medicare Advantage plans, Medicaid plans and private plans, their policies may differ from plan to plan even within the same contractor.

One thing to look for when researching plans other than Medicare Fee For Service, is to look at the other carriers and see what their policies state. If they reference that theyfollow Medicare Fee For Service (In Dr. Morelli's area of the country) then that policy is what must needs to be adhered to.