​Enhanced Claim Editor Program: Reporting of nail trimming, nail debridement, and lesion trimming

April 6, 2021

​AmeriHealth has a variety of programs in place dedicated to ensuring claims are billed accurately and in accordance with industry standard coding principles. In order to verify all providers are adhering to AmeriHealth claim payment policies and the industry standard source guidelines as of February 1, 2021, the AmeriHealth Enhanced Claim Editor Program includes Coding Validation performed by a team of Registered Nurses and Certified Professional Coders that will review select professional and outpatient facility claims in conjunction with patient claim history. 

Area of focus: Proper reporting of nail trimming, nail debridement, and lesion trimming and appropriate modifier usage

CPT® codes 11720 – 11721 and 11055 – 11057 should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. The National Correct Coding Initiative (NCCI) edit between debridement of nail(s) and paring or cutting of a benign hyperkeratotic lesion may be bypassed with Modifier 59 or XS only if the trimming of the lesion is performed on a site other than a distal interphalangeal location on a debrided toe or a separate site of the foot such as the heel.

Similarly, use of modifiers to bypass the NCCI edit between CPT code 11719, trimming of nondystrophic nails, and 11720, nail debridement of one to five nails, is only appropriate if the trimming and the debridement of the nails are performed on different nails or if the two procedures are performed at separate patient encounters.

Documentation in the medical record must support the use of the modifier to bypass the NCCI edits between these code pairs. With the implementation of coding validation, claim lines found to be submitted with inappropriate coding may be denied.

Identifying claims that went through the Coding Validator process

If your claim was affected by one of the Coding Validation reviews, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E819X. Should your claim line contain an E819X code/message, it means it was affected by the Coding Validation review. You can also find the E819X codes/messages on the Claim Status Inquiry Detail screen on the NaviNet® web portal (NaviNet Open) and on the PEAR portal.* To view, hover your mouse over the service line and select View Additional Detail. If you see an E819X code/message the further detail in the Rationale and Description section will state Per Coding Validation review. Only E8XXX codes/messages are part of the Enhanced Claim Editor Program. All other codes/messages are unrelated to the enhanced claim editor.

Request for Coding Validator claim review

While you may use NaviNet Open* or the PEAR portal to view detailed information on a Coding Validator E819X denial, clinical information is needed in order to dispute the denial. Please ensure that all applicable medical records, notes, and tests are submitted along with a cover letter explaining the reason for the dispute.

To facilitate a review, submit the documents listed above via:

Claim Coding Validation
1901 Market Street
Philadelphia, PA 19103​

*If your organization has transitioned to use PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal, you can use the Claim Search transaction to view this information. Additional information and self-service training materials are available in the PEAR Help Center.

For more information

For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ).

Note: The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, please send an email to ahclaimeditquestions@amerihealth.com.

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