From: Michael E. Graham, DPM
There has been so much controversy on the use of sinus tarsi implants, and one of the greatest is how to bill for the procedure. Orthopedic surgeons routinely bill the procedure as a subtalar fusion and have no issue with it. I agree that this is wrong. There is an argument to make on the use of CPT 28585 as it describes the procedure being performed, BUT the AMA and APMA have stated that this is not an accepted code. My company has stopped advocating that code once that clarification was made, even though we did have support from some insurance carriers who agreed it was a correct code.
I have spent considerable time, money, and effort to get a real code for this procedure and the best we can get right now is 0335T. That is the only “approved” code to bill for the insertion of a sinus tarsi implant – period! We need to pull together as a profession to publish more research and to keep pushing the insurance carriers to cover this procedure. Don’t sit on the sidelines and complain or commit insurance fraud. Patients will pay for the procedure - they pay billions for plastic surgery and dental care. My opinion is that foot alignment is more important to the body than a slightly crooked tooth. We need your help to fight this battle.
Disclosure: Dr. Graham is Founder & CEO of GRAMedica |
Michael E. Graham, DPM, Macomb, MI
RE: Fraudulent Billing of CPT 11305, 11306 and 11307
From: Name Withheld
I am an RN with 25 years of O.R. experience working with orthopedic and podiatric surgeons, and I work part time for a DPM. I’m also a certified coder and fully understand proper billing practices. I make a majority of my income as an outside consultant for many insurance companies when there is suspected fraud. The past two years have been keeping me busy reviewing literally thousands of claims for procedure codes CPT 11305, 11306, and 11307 billed by DPMs.
I have reviewed thousands of these claims with a committee which includes two DPMs and a dermatologist. Over the past two years, we did not review a single claim sent by a DPM where the code was justified. These codes are for a...
Editor's note: This extended-length letter can be read here.
RE: NGS Reviews Nail Debridement Billed with E/M Services with -25 Modifier
From: Ken Malkin DPM
This was the quote from an NGS notification which is a basterdized version of the -25 modifier: "Modifier -25 should be utilized when documentation supports a medically necessary significant, separately identifiable E/M service was performed on the same day as a minor procedure. An E/M service billed on the same day as nail debridement is not eligible for reimbursement unless the medical record clearly supports the need for treatment of an unrelated problem." The notification then talks about routine foot care and LOPS to further confuse matters.
This is the REAL CPT definition: "CPT modifier -25 is used when, on the day a procedure or service was performed, the patient’s condition required a significant, separately identifiable evaluation and management (E&M) service above and beyond the other service provided or beyond the usual pre-operative and post-operative care associated with the procedure that was performed."
Do not allow NGS to use their own definition which overly restricts the -25 modifier. Appeal any adverse decisions on this basis.
