Many healthcare providers face frequent claim denials due to coding errors. Ask any medical biller about their daily challenges, and you will likely hear about CPT coding complexities. These codes serve as the standardized language that healthcare providers use to report medical procedures to insurance companies and government payers.
CPT code 11055 is one of the most frequently used dermatology and podiatry codes. However, many billers struggle to bill it correctly. That’s why our billing experts have compiled this CPT code 11055 guide. It covers everything healthcare providers and billing specialists need to know about 11055. So, let’s start.
CPT Code 11055 – Description
CPT code 11055 represents the “paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion.” In simple terms, this means removing a single corn or callus using a scalpel, curette, or similar sharp instrument. This procedure is usually performed to remove excess or thickened skin that has built up on the feet due to persistent pressure or friction.
The main objective? Relief. Patients usually go for this treatment when these lesions become painful and cause discomfort. However, it is important to note here that 11055 is only used to remove a single lesion. If multiple lesions need to be excised, healthcare providers must use other CPT codes, like 11056 (for 2-4 lesions) and 11057 ( for 4+ lesions).
Plus, remember that this code must not be used for wart removal or for addressing potentially malignant lesions. These conditions are billed using their own separate CPT codes.
Scenarios Where CPT Code 11055 is Applicable
To better understand how and when to use CPT code 11055, let’s look at some real-world scenarios where it can be used.
Podiatric Care
The most common application of CPT 11055 is in podiatric medicine, where providers frequently treat corns and calluses on the feet. The calluses are formed on the pressure points, such as the bottom of the feet or toes. Reasons for such lesions can be:
- Shoes that don’t fit properly (too tight or too loose)
- Foot abnormalities affecting weight distribution
- Structural deformities like hammertoes, bunions, or fallen arches
- Occupational factors requiring prolonged standing or repetitive motions
Dermatology Applications
While less common in dermatology, this code may apply when treating:
- Calluses on the hands (often occupation-related)
- Pressure-related thickening on other body areas subject to friction
- Hyperkeratotic lesions related to psoriasis or other skin conditions (when debridement is needed)
Applicable Modifiers for CPT Code 11055
Modifiers provide additional information about the circumstances of a procedure. The following table outlines some modifiers that can be used with CPT code 11055:
| Modifier | Description | When to Apply |
|---|---|---|
| RT | Right side | For lesions on the right foot |
| LT | Left side | For lesions on the left foot |
| Q8 | Two Class B findings | Medicare patients with two Class B findings (e.g., skin discoloration, redness of skin ) |
| Q9 | One Class B finding and two Class C findings | Medicare patients with mixed findings (e.g., edema, paresthesia, or burning) |
CPT Code 11055 – Billing & Reimbursement Guidelines
Successful billing for CPT 11055 requires attention to detail and awareness of the following payer requirements.
Medicare Coverage Circumstances and Criteria
Medicare has particularly stringent requirements for covering CPT code 11055. For Medicare beneficiaries, this procedure typically qualifies for coverage only when:
- The patient has a documented systemic condition (diabetes, peripheral vascular disease, etc.) that compromises circulation to the lower extremities.
- The patient is actively under physician care (MD or DO) for this condition.
- The supervising physician has evaluated the patient within six months of the procedure date.
Plus, to justify the medical necessity and the medical record, you must demonstrate at least one of the following conditions:
- Pain severe enough to limit mobility or routine activities
- Signs of inflammation, skin breakdown, or infection at the lesion site
- Failed conservative treatments (padding, over-the-counter products, etc.)
Medicare Documentation Requirements
For proper reimbursement and preventing claim denials, submit the necessary documents with your claim. The records must include:
- Specific location, size, and appearance of the lesion
- Specific systemic conditions affecting foot health
- Method used for removal (scalpel, curette, etc.)
- Description of tissue removed and post-procedure appearance
- Photos, when possible (especially for unusual presentations)
- Include the name and NPI of the attending physician
Reporting Units
A common error that many billers make is the use of incorrect reporting units. To correctly bill a claim for CPT code 11055, always bill 11055 with a unit of 1 to indicate treatment of a single lesion.
For multiple lesions, use the appropriate code instead:
- 11056 for treating 2-4 lesions
- 11057 for treating 4+ lesions
Diagnosis Code Pairing
Correct diagnosis is also essential for the successful reimbursement of 11055 claims. According to Medicare guidelines, the following ICD-10 codes may qualify as a medical necessity, given that you can prove the requirement.
- L84: Corns and callosities
- E11.40: Type 2 diabetes mellitus with diabetic neuropathy, unspecified
- I70.203: Unspecified atherosclerosis of native arteries of extremities, bilateral legs
- E10.51: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
Wrapping Up
CPT code 11055 represents a relatively simple procedure of paring or cutting a single benign hyperkeratotic lesion. While it appears straightforward, proper coding, documentation, and billing for this procedure require a thorough understanding of medical necessity criteria, appropriate modifier usage, and payer-specific guidelines.
However, medical billing and coding are complex processes that require expertise. Contact our expert billing consultants if you consistently encounter billing errors and claim denials. We provide premium podiatry billing services that can boost your revenue collection.
