Medical billing is rife with nuances, and proper modifiers can help distinguish one patients’ case from another. Modifiers determined by the Center for Medicare and Medicaid Services (CMS) act as a system that distinguishes different types of cases, and whether or not they are covered by Medicare. One such modifier is the GY modifier used in medical billing, including podiatry billing.

So, what is GY modifier and what does it mean? The GY modifier is used in medical billing to indicate that the service is statutorily excluded by Medicare. In this article, we explain the difference between GA, GY, GZ modifiers, and how to use it properly in podiatry coding.

Understanding Billing Modifiers

Billing modifiers provide information to the payer, whether it’s the patient using out-of-pocket expenses or the health insurance company providing support. A billing modifier is used to clarify how a service is being processed and billed differently from standard procedure.

For instance, a modifier is used to clarify which of the tests in a bundled code were not performed. In this case, we are talking about the modifiers that identify how items and services that are statutorily excluded or do not meet any definition of Medicare policies and codes are specifically handled.

What Are G Modifiers?

G modifiers are a specific set of modifiers used to indicate that a service or item is not covered by Medicare. The most common modifiers include GA, GX, GY, and GZ.

Here’s how they differ from each other:

GA Modifier: Waiver of Liability Statement Issued As Required by Payer Policy. 

The GA modifier is used when you report a mandatory advance beneficiary notice of noncoverage (ABN) for an item or service. This means the patient knows the item or service doesn’t meet the definition of any Medicare or Medicaid policies, and will therefore not be covered.

In other words, the GA modifier is used when physicians want to indicate that they expect Medicare to deny a claim as not reasonable or necessary. While billers don’t have to submit a copy of the ABN, a file must be kept on-hand for easy access and verification.

GZ Modifier: Notice of Liability Not Issued, Not Required Under Payer Policy 

The GZ modifier is used when doctors want to specify that they expect Medicare to deny an item or service as unreasonable or not necessary. Compared to the GA modifier, this is used to note that they don’t have an ABN signed by the beneficiary.

GX Modifier: Notice of Liability Issued, Voluntary Under Payer Policy 

The GX modifier is used if an item or service is statutorily excluded or is not a Medicare benefit. The GX modifier is used instead of the GY modifier if an ABN is provided.

GY Modifier: How Is It Different?

The GY modifier is similar to the GZ modifier in that it is used to specify that the supply or service is not supported by any definition of Medicare accepted policies. The difference between the GY and the GZ modifier is the issuing of an ABN.

The GY modifier helps with auto-denial claims and is typically used when a patient has secondary insurance that can cover the service. Note that the issuance of an ABN is not required to use the GY modifier; the bill may be submitted even if a voluntary ABN was not signed by the beneficiary.

What does “statutorily excluded” mean? 

Medicare benefit only applies to items or services that are legally defined as essential services. Certain services and items, such as hearing aids, corrective dental items like braces, and temporary prosthetic devices, do not meet the definition of services and goods included in the Medicare benefit.

Podiatry Services: What Is Covered and What Isn’t

What podiatry services aren’t covered by Medicare?

As a rule of thumb, routine foot care and grooming services are not considered to be part of the Medicare benefit. Listed below are some podiatry services not covered by Medicare and Medicaid services:

1) Flat foot treatment

Services, including diagnosis and physical therapy, as well as corrective devices used towards the care of flat foot is not included in the definition of any Medicare covered service.

2) Routine foot care

Routine foot care visits that are considered grooming and not surgical or corrective in nature are not covered by Medicare. This includes the removal and treatment of corns and calluses, as well as the cutting, clipping, and debriding of nails.

Hygienic care and preventative maintenance also do not meet the definition of essential care, and are thus not considered medical services. Cases involving ingrown nails are evaluated individually; if a podiatrist determines toenail clipping as hazardous without the help of a medical professional, it might be covered by Medicare.

Patients with diabetic sensory neuropathy experiencing loss of protective sensation (LOPS) may be able to redeem Medicare benefits provided that the patient has a documented diagnosis of diabetic sensory neuropathy, as well as LOPS. The policy covers treatment and examination no more than once every six months, given that the patient has not seen a podiatrist for any other reason within this time period.

Other such exemptions concerning foot care are determined on a case-by-case basis. For instance, the treatment of mycotic nails is covered under certain specifications.

Mycotic nail treatment for ambulatory patients and non-ambulatory patients without a systemic condition are covered as long as the podiatrist provides clinical evidence of toenail mycosis and that the patient has declared limited mobility, pain, or a secondary infection due to the condition.

3) Orthopedic Devices

Corrective and supportive devices including but not limited to orthopedic shoes are typically not covered, unless it is a part of a leg brace and its cost is lumped in with the total cost of the leg brace. This includes orthopedic devices prescribed for diabetic patients; too many patients falsely believe that they are entitled to free footwear because of diabetes.

4) Preventative Maintenance

Only essential services are covered by Medicare services, which means podiatry services that are preventative in nature will not be covered.

What podiatry services are covered by Medicare?

Alternatively, certain podiatry services and items that are deemed reasonable and necessary can be covered by Medicare. This typically includes chronic ailments including bunion deformities. Conditions like heel or toe spurs can also be covered by Medicare.

Other diseases and deformities that are eligible for Medicare coverage include:

• Hammertoes
• Plantar Fasciitis
• Stress Fractures
• Peripheral Neuropathy
• Morton’s Neuroma

Podiatry patients should be aware that Medicare part B pays 80% of the Medicare-approved amount for covered foot care. They only pay 20% of the bill including the annual deductible. Clinics must clarify payment details to patients to avoid surprise bills in the future.

Communicating With Patients Regarding Non-Covered Services and Items

Educating patients is the first step to avoiding tension and confusion when their bill finally arrives. This is especially true for elderly and diabetic patients who have routine foot care as part of their regular care.

An easy way to educate patients is by providing this information upfront during their initial exam. Explaining why their item or service doesn’t meet the definition will give the patient a more concrete understanding of the situation. We suggest following up with an advance beneficiary notice if the patient agrees to move forward with the foot care, as proof that the patient understands that their service or product isn’t deemed necessary or essential, and thus will not be covered by Medicare.

In our experience, patients have difficulty adjusting to information especially if their old podiatrist clinic was unclear. At Hippocratic Solutions, our billing experts will patiently explain these and clarify any issues with your patients, both old and new.

Other ways to educate patients include creating useful content they can read online, asking them to sign an ABN, and providing posters around the clinic for easy access.

Why Work With Hippocratic Solutions

Hippocratic Solutions is a specialized podiatry billing company. Our billings and coders are well-versed in podiatry-specific billing codes, which greatly enhances our efficiency by reducing human error. Our team regularly keeps up with the codes, modifiers, and other podiatry-specific billing policies established by the Center for Medicare and Medicaid Services (CMS). This means our team is up-to-date with new policies surrounding all things podiatry billing.

On top of that, our billers aim to represent your clinic in the best way possible. When we encounter patients with issues, we rectify problems amicably and provide compassionate but straightforward reasoning behind denied claims.

As a result, your podiatry clinic has reliable cash flow and an even better reputation with your patients.

It’s not every day that you have to think about visiting a podiatrist for a special problem with your feet. But every now and then, you might end up with a serious foot issue that can significantly impact your daily life.

Whether it’s an ingrown toenail, a bunion, athlete’s foot, or something else, issues with your feet can make the simple act of walking around a struggle. With that said – what would you have to pay to visit a podiatrist?

So how much does the average podiatrist visit cost, with or without health insurance? Like any doctor visit, there are a number of important factors that determine the cost of every specific podiatrist visit.

Some of these factors are your location, the expertise of your podiatrist, the purpose of the visit (whether consultation, treatment, or surgery), and the length of the appointment.

On average, a short consultation with a podiatrist should cost anywhere from $60 to $400.

Understanding Podiatrist Cost

A visit to a podiatrist means getting specialty care that general practitioner doctors can’t do on their own. This means that patients should be expecting slightly higher costs with a podiatrist visit than the average visit to their family doctor or pediatrician. Podiatrists specialize in care for the lower extremities, specifically the feet and the ankle. Common conditions related to these areas include:

• Unwanted odor
• Ingrown toe nails
• Athlete’s foot
• Toenail fungus
• Sports injuries
• Ankle or foot pain
• Hammer toe
• Calluses
• Warts
• Bunions
• Flat feet

To understand how much your podiatrist visit might cost, it is important to get a good idea of what treatment you are seeking. What is wrong with your foot or ankle, and what kind of treatment would you need to help your condition?

The cost of a podiatrist visit varies on a case-by-case basis. A practice’s rates are generally consistent, and health insurance should cover at least some of the payment, depending on your condition. If you are visiting a podiatrist without any insurance, you will have to pay more out of pocket to cover the whole cost.

The consultation with the podiatrist makes up the first part of your bill. As stated above, the consultation rate of your podiatrist will depend on your location and the expertise of the doctor (cities and more experienced doctors will generally charge more). On average, patients can expect consultation costs to range from $60 to $400.

Cost Per Podiatrist Treatment

After the consultation, your next costs at the podiatrist will depend on the condition to be treated as well as the kind of procedure to be done. It’s not always about the kind of procedure – your cost will also depend on what is being treated. For example, while callus removal procedures and ingrown toenail removal procedures are both removal treatments, they do not cost the same as different conditions are being removed.

• Ingrown toenail: Ingrown toenails can be extremely difficult to live with, and getting them removed as soon as possible is the best thing a person can do for themselves. The average surgical removal rates for an ingrown toenail ranges anywhere from $250 to $500.
• Callus: Calluses are also a pain to deal with on the foot, but these are simpler to remove and treat. For a podiatrist callus removal treatment, patients can expect an average cost of $90.
• Bunions: Bunions are a deformity that can be found on the outside of the big toe, and to remove them requires a surgical procedure. The surgery for bunion removal costs anywhere from $40,80 to $6357.

Does Insurance Cover Podiatrist Visits?

Routine visits to a podiatrist are typically covered by most healthcare insurance plans, however recent changes in healthcare coverage has led to some frustrating restrictions when it comes to foot care.

Here are some medically necessary situations in which Medicare will cover the podiatry treatment:

• Patients who have foot problems that are related to greater conditions, such as diabetes, vein inflammation, chronic kidney disease, cancer, or others
• Patients who have diabetes and need custom-made shoe inserts or therapeutic shoes
• Patients who have diabetes and have a loss of sensation in their ankles or feet
• Patients who need toenail clippings that are done by a professional as it would be hazardous to their health otherwise

Most professional and trusted podiatrists will work with patients in contacting their insurance company to find out what exactly is covered before undergoing any treatment.

Hippocratic Solutions – Podiatry Billing Services

Billings and other office tasks can hold back the growth of any podiatry clinic, which is why Hippocratic Solutions is here to help. Hippocratic Solutions assists podiatrists all over the country with billing with insurance companies and other office needs.

Contact us today to find out more about how Hippocratic Solutions can help you maximize your podiatry clinic.

Routine foot care is perhaps the most common reason patients visit podiatry clinics. And one treatment that is sometimes done during routine foot care is debridement of nails. Depending on the number of nails involved, this is labeled with the CPT code 11721.

So how do you successfully bill 11721 to Medicare? The most important thing to remember when billing 11721 to Medicare is that Medicare will only cover it if it is medically necessary.

If the patient has a systemic condition resulting in leg or feet desensitization or if they have severe circulatory embarrassment, then they will quickly cover and approve 11721. Without this medical necessity, billing 11721 to Medicare can be more of a headache.

What is 11721?

11721 or Current Procedural Terminology (CPT) code 11721 is a medical procedural code that can be found under Surgical Procedures on the Nails, as defined by the American Medical Association.

Specifically, CPT 11721 refers to the debridement of nails, which is the removal of a toenail bed due to the diseased toenail bed. This can be performed with an electric grinder or with a manual instrument. Patients who are diagnosed with conditions such as onychomycosis are generally recommended for nail debridement.

The 11721 code is used to classify procedures involving debridement of 6 toe nails or more, while the 11720 code is used to classify procedures involving the debridement of 5 toe nails or less.

Known Issues with Billing 11721

Recently, podiatrists have been met with denials from Medicare when billing for the code 11721. Since the implementation of ICD-10 it has become more difficult to have Medicare cover the costs of 11721 procedures. The reason is that 11721 is generally considered medically necessary.

According to Medicare, routine foot care can be payable when the treated patient is suffering from a systemic condition. The systemic condition should lead to desensitization in the feet or legs or result in severe circulatory embarrassment. These class findings must be supported and reported in the medical record of the patient.

It is important that the 11721 procedure is performed on a patient with an existing system condition to have it covered by Medicare. Without this, it can be difficult to bill 11721 successfully.

When coding 11721, it should also be noted that 11721 requires a modifier – these can be Q7, Q8, or Q9. The purpose of these modifiers is to indicate that the patient is properly classified for routine foot care.  When coding 11721, it typically does not require a laterality modifier, as debridement is not coded by location but by depth and size.

Another known issue with billing 11721 is the use of modifier 59 to bypass certain recent changes in the NCCI guidelines. This is determined by the location of the hyperkeratotic lesion, whether it can be found on the same distal phalanx or not. When this is the situation, modifier 59 should not be used to bypass recent edits.

How to Bill 11721 to Medicare

To successfully bill 11721 to Medicare, the most important part is ensuring that the patient required the procedure as a medical necessity. Patients must have a systemic condition that demands the procedure to be done.

Without the systemic condition resulting in feet or leg desensitization or severe circulatory embarrassment, Medicare only considers the procedure as routine foot care and not eligible for coverage.

Hippocratic Solutions – The Top Specialty Podiatry Billing Provider

Medical billing can be tough, especially specialized billing like podiatry billing. Giving your patients the best care possible means more than just properly treating their conditions, but also properly processing their claims and helping them with their coverage.

At Hippocratic Solutions, we are here to help podiatry clinics get the most out of their medical billing needs and more. Our expert team can help you unravel any headache and problem you might have with your billing, and keep your clinic running smoothly and seamlessly.

Spend more time doing what you trained to do – treating patients – and let us handle the rest. Contact us today at Hippocratic Solutions to learn more.

G0127 and 11720 are two related procedures typically done during routine foot care, involving the trimming and debridement of nails. Patients who need one treatment done typically need the other as well, which leads to podiatrists billing both at the same time.

So can CPT G0127 and 11720 be billed together? Yes, there is nothing preventing a podiatrist from billing them as one. As long as the forms are done properly and error-free, with the conditions and clearly marked out, there should be no problem with billing the two treatments together.

What are G0127 and 11720?

As defined by the American Medical Association, Current Procedural Terminology (CPT) codes G0127 and 11720 are codes for procedures found under Surgical Procedures on the Nails.

Specifically, CPT G0127 refers to the trimming of any number of dystrophic nails. Dystrophic nails are nails that are suffering nail dystrophy, or the discoloration and distortion of the nail’s normal structure. Nail dystrophy is generally as a result of inflammatory or traumatic processes that affect the nail bed, nail matrix, and/or surrounding nail tissues. In adults, nail dystrophy is most often a result of dermatophyte fungal infection.

CPT 11720 refers to nail debridement, or the removal of the toenail bed, in 1-5 toenails (6 toenails or more fall under CPT 11721). The purpose of debridement is to remove excessive material or curvature from a clinically diseased or thickened dystrophic nail. Debridement reduces the bulk and thickness of the nail, allowing it to regrow normally again.

Tips for Billing G0127 and 11720

These procedures can be done at the same time – nail trimming focuses on reducing the length of the nail, while debridement focuses on reducing the bulk or thickness of the nail. So can CPT G0127 and CPT 11720 be billed together?

Yes, but it is important that the billing is properly done and recorded to ensure that it is not denied. When dealing with CPT 11719, 11720, 11721, and G0127, Medicare typically covers the procedures when they are done on “at-risk” patients, or patients who have systemic conditions.

Systemic conditions are defined as a neurological, peripheral vascular, or metabolic disease leading to severe circulatory embarrassment or desensitization in the feet or legs. Systemic conditions can include:

• Buerger’s disease
• Alcoholism
• Malnutrition
• Diabetes mellitus
• Vitamin deficiency
• Peripheral neuropathies of the foot
• Arteriosclerosis obliterans

If no system conditions are present, the patient must have mycotic nails involving severe symptoms and significant pain that prohibits them from trimming their nails safely on their own.

For CPT 11720 and 11721, Medicare coverage is possible in patients who do not have systemic conditions as long as they are proven to have painful dystrophic nails. To ensure that your bill is approved, make sure that there is a documented history and examination proving that the nails are causing severe pain. Q modifiers here are Q7, Q8, and Q9.

The documentation must objectively prove that the nails are limiting the patient’s ambulation or movement; simply writing the patient’s description of the pain is typically not sufficient for approval.

Finally, when billing G0127 and 11720 (or any other related procedures), ensure that the nail care procedures are aligned with nail ICD-9 codes and modifiers. Errors in billing can quickly result in billing denials. On the foot care claim form, clearly align painful conditions and at-risk conditions with their required ICD-9 codes and modifiers.

Have Your Podiatry Billing Done by the Experts at Hippocratic Solutions

You might think that coding for something as simple as routine foot care service would be quick and easy, but even the simplest appointments can lead to tons of trouble when it comes to billing. With various Medicare carriers and each one having their own variations of policy, getting your forms done right can be difficult and frustrating.

Hippocratic Solutions is here to provide the service every top podiatrist needs – professional, specialized service billing and wound care services you can trust and rely on. We specialize in podiatry billing, meaning we understand all the ins and outs specific to billing and more in podiatry.

Contact us today to learn more about why Hippocratic Solutions is the billing service you need.