Q&A: Using modifier -59 to bypass a procedure-to-procedure edit

September 11, 2020
Medicare Web

Q: A patient presents for two procedures on his right big toe: parring of a benign callus on the tip of the toe and debridement of the toenail. An NCCI procedure-to-procedure (PTP) edit prevents these services from being separately reported. Can we use modifier -59 (distinct procedural service) to unbundle CPT codes 11055 (paring or cutting of benign hyperkeratotic lesion; single lesion) and 11720 (debridement of nail[s] by any method[s]; 1 to 5)?

A: No, modifier -59 should not be used if a nail is debrided on the same toe on which a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint is pared. Treatment of the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying the distal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site; therefore, modifier -59 would not be appropriate.  

Per the 2020 NCCI Manual:

NCCI has a procedure to procedure edit with column one CPT code 11055 (paring or cutting of benign hyperkeratotic lesion…) and column two CPT code 11720 (debridement of nail(s) by any method; 1 to 5). Modifier 59 shall not be used to bypass the edit if these two procedures are performed on the same distal phalanx including the skin overlying the distal interphalangeal joint.

Modifier -59 may be reported with code 11720 if one to five nails are debrided and a hyperkeratotic lesion is pared on a toe other than one with a debrided toenail or if the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided.

Editor’s note: This question was answered by Alicia Shickle, AHFI, CHC, CPCO, CPC, CPMA, CPPM, CRC, during the DecisionHealth webinar, “Avoid Mistakes with Modifiers -25 and -59: As Practices Rebound, Maintain Your Earned Revenue.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Related Topics: 
Ask the Expert