Fidelis Medicaid will not pay for 11719 (Q7, Q8, or Q9) with hazardous conditions diagnosis such as E11.51 or I73.89. Our Fidelis rep tells us to bill as G0127. My understanding is G0127 refers to debridement of dystrophic nails and 11719 refers to trimming non dystrophic nails. Would it not be fraudulent to bill trimming of non dystrophic as G0127? Should trimming of non dystrophic nails in a patient with class findings and harardous conditions not be a covered service for a medicaid HMO?
CPT® 11719 - Trimming of nondystrophic nails, any number
G0127 - Trimming of dystrophic nails, any number
CPT® 11720 - Debridement of nail(s) by any method(s); one to five
CPT® 11721 - Debridement of nail(s) by any method(s); six or more
If nondystrophic toenails are trimmed, CPT 11719 should be submitted. If nondystrophic toenails are trimmed, it is not appropriate to submit G0127 and doing so could cause problems on retrospective review of a claim.
HIPAA requires that all payers follow the most current code sets. A payer should not be telling you to code incorrectly. Here is the reference for that:
“The CPT code set, together with the U.S. Department of Health and Human Services’ Healthcare Common Procedure Coding System, has been adopted as the nation’s standard medical data code set. HIPAA requires that health plans use the most recent version of the medical data code set.”
The above information answers the coding aspect of your question. You also asked about coverage of a service by a specific payer. Different payers have different coverage guidelines for routine foot care. They are all not necessarily the same. Most are the same but it cannot be assumed that all are the same. Therefore, the only way to know for sure what the coverage guidelines are for this payer is to ask the payer.
Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2023 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor
Lehrman Consulting, LLC