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11/21/2018
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Jessica M. Wade
In response to Dr. Long's query regarding injection coding for Morton's neuroma, the current CPT code is 64455. This was updated from the CPT 64450 in the CPT manuals and NCCI several years ago. When billed with the "G" ICD-10 codes (G57.61 or G57.62), the 64455 is valid and billable in conjunction with the proper "J" code(s). As Dr. Borreggine stated, the 20550 and 20551 are the proper injection codes for plantar fasciitis.
Jessica M. Wade, Practice Manager, Blue Ridge Footcare & Surgery, PLC
Other messages in this thread:
11/03/2023
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: David Secord, DPM
The discussion of the use of absolute alcohol injections for neuromas leads to some of this:
And some of this: along with this was the initial advocacy for using code 64640 when doing a 4% absolute alcohol injection series for treatment of neuroma with 7 injections...
Editor's note: Dr. Secord's extended-length letter can be read here.
11/03/2023
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A
From: Jeffrey Kass, DPM
I too, like the Texas Codingline subscriber, have found much success with these injections, however, not as much success with their reimbursement. Colleagues should be aware that some insurance companies will deny payment for CPT code 64632, stating they consider this treatment experimental and investigational. Therefore, I would have this code pre-authorized so that you don’t end up getting screwed by Mr. Insurance Company.
Jeffrey Kass, DPM, Forest Hills, NY
07/27/2023
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1 B
From: Ivar E. Roth DPM, MPH
I read this post asking how to potentially bill for adjusting a backed out screw for a hammertoe just weeks after surgery. The doctor wanted to take the patient back to the operating room to “adjust the screw”. I really think something is wrong here. Taking the patient back to the operating room to adjust a simple twist of a screwdriver with a superficial percutaneous incision? This is a huge waste of insurance dollars spent when the doctor can simply do this in the office with local to the toe. Common sense should prevail.
Also, why would the doctor even want to charge for this? This should be a simple courtesy procedure since it is so close to the surgical intervention. Billing patients and insurance companies for this kind of situation, in my opinion, does not bode well from a PR point of view. Looks greedy. Why should the patient be presented with another bill for a nothing burger situation? What do my colleagues think?
Ivar E. Roth DPM, MPH, Newport Beach, CA
07/27/2023
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1 A
From: Allen Jacobs, DPM
Regarding the question on proper coding for the re-insertion of a loose and fixation device, my concern would not be the proper code. The real question would be why did the fixation device loosen? The author states there was no infection but those such infections can be quite subtle. If there is no infection, why would you think that the device would hold a second time when it failed to maintain purchase initially? I’d give it a little bit of thought before I'd introduce the same implant.
Allen Jacobs, DPM, St. Louis, MO
03/30/2023
RESPONSES/COMMENTS (CODINGLINE CORNER) -PART 1A
From: John Moglia, DPM
I learned the hard way that CPT 11750 will be reimbursed only once per lifetime for an individual toe. This does not take into consideration that a different nail border on the same toe can become symptomatic years later. Is it then appropriate to bill CPT 11730 as an alternative after an appeal has failed?
John Moglia, DPM, Berkeley Heights, NJ
03/30/2023
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: Jeffrey Kass, DPM
I don’t know the process whereby CPT codes and LCDs get changed. But, I would like to chime in on this 11750 LCD code change.
1. Is there or is there not an announcement of a code change or LCD change where there is a way to write in and express opinions pro or con the change?
2. Why isn’t the profession, as a whole, more involved in collectively doing something about this?
3. I would think – podiatrists are the number one users of this code, with dermatologists coming in second.
4. The unfairness of the CPT code LCD is that a patient can...
Editor's note: Dr. Kass' extended-length letter can be read here.
01/02/2023
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: Name Withheld
I was one of the few to have this issue first. I made APMA aware of it, as the negotiation has stalled to a crawl between Aetna and APMA. I did suggest APMA get to threatening the health plan with exposure and recommending legal action, class actions, etc. The appeal letter is not the answer. Yes, I win every time, but I have to appeal over and over again. I suggest the following: APMA members should submit their good notes with the EOMBs to APMA. Flood them with this and demand they use your dues money to lawyer up, pay billing experts, and fight them.
Furthermore, we should all write letters to the U.S. Department of Labor asking them to take sanctions and fines for such abuse! Maybe we should start telling our patients to switch plans to avoid us from charging them what the health plan rejects. APMA and AMA should demand a cost of living increase of 5 percent from this health plan and others. We are being taken advantage of.
Name Withheld
01/02/2023
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A
From: Harold Koehler, DPM
We are also getting denied on those codes with basically every non-Medicare plan. Appeals are a waste of time. On top of it, they pay the lesser paying code instead of the higher paying code. Insurance companies are basically a legal means of extortion. It would be nice to see them punished financially for their purposeful denial of legitimate claims to bolster their profits. A class action suit would be the best way to go if this was possible.
Harold Koehler, DPM, Auburn Hills, MI
12/22/2022
RESPONSES/COMMENTS (CODINGLINE CORNER) -PART 1A
From: Connie Lee Bills, DPM
I have never collected more than the fee schedule allowed for the code, so if the co-pay is larger, I don’t collect the entire co-pay. I’m not an expert but I wouldn’t collect more when you know you’ll need to refund.
Connie Lee Bills, DPM, Mount Pleasant, MI
12/22/2022
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: George Jacobson, DPM
I think the discussion is over-generalizing. It depends on the contracts. If the patient's contract says that the podiatry co-pay is $40, then in my opinion, if the allowed amount is less than $40, the patient still contractually pays $40. The co-payments are agreed upon by the patient when they sign the contract. They know what to expect. Their premiums are based on how much their deductible, co-pays, co-insurance, and maximum out-of-pocket they will be.
If I have a $250 co-payment for every visit to the ER, I pay $250, even if they tell me to go home and call a podiatrist for the ingrown toenail. The higher co-payments above the approved amount are how the insurance companies pay nothing and have shifted costs to the patients. But again, the patient knew these costs before signing the contract. We also knew this when we accepted a very low reimbursement plan, where the co-payment may be the only payment. The answer to this question depends on the contracts and should be asked of a healthcare attorney.
George Jacobson, DPM, Hollywood, FL
03/14/2022
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: Jeffrey Kass, DPM
I’d like to thank Drs. Prikaszczikow and Freedman (Dr. King as well) for their honest response to my posting. They mention that “several years ago”, APMA recognized this bundling problem, and that over the past “several years” had discussions with medical directors from Anthem, Aetna, and other payers”.
I think the frustration on my part, as well as many of my colleagues, is we all recognize a problem existed for “several years”, and the sad truth is it still exists! After reading the response given, it is clear “podiatric leadership” has indeed “challenged the issue”. The problem is correction of the abusive bundling rule created by NCCI (not Medicare) which unfortunately still exists. I thank those who put their time in for the cause but have to wonder why what appears to be a simple problem has to take “several years” to be fixed. Elon Musk can fly people to space, build electric cars, dig tunnels underground, and have trains hover on electromagnetic rails, and we can’t change a bundling edit that is illogical? Something’s wrong!
Jeffrey Kass, DPM, Forest Hills, NY
03/14/2022
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A
From: Paul Kesselman, DPM
As Drs. Freedman, King, and Prikaszcikow have already elaborated, APMA has done much to mitigate the initial rulings on the NCCI edits applicable to nail debridement and paring of hyperkeratosis. These leaders have done an admirable job of reviewing what APMA has accomplished and continues to work on, in an attempt to resolve the NCCI edits which Dr. Kass correctly asserted are unfair.
Dr. Kass' accusations that APMA leadership has been inattentive is clearly wrong while attacking the very people who have been successful at resolving much of this issue. Had he been an APMA member, he would have received the communications all APMA members received to keep them up-to-date on this issue as well as others.
The volunteer leadership and members of each and every APMA and NYSPMA committee which I have participated in over the past twenty years work very hard. They often sacrifice office hours, face arduous travel schedules while also sacrificing personal family time. They do this all for the betterment of our profession without any remuneration. It would be nice if these individuals were provided with a simple thank you instead of the unkind comments recently offered.
Paul Kesselman, DPM, Oceanside, NY
03/11/2022
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A
From: Michael King, DPM
Jeff, I think the APMA leadership can answer that better than I can; however, I know there is an ongoing dialogue regarding your query. Yes, we feel it is ridiculous for skin issues/lesions to be lumped into nail debridements when on the DIPJ, or distal to the PIPJ. I know APMA has been in an ongoing debate over this and has made some headway. Needless to say, when some payers have the opportunity to bundle such things as "debridement" into one bucket, they do so. I can tell you, the coding committee members of the APMA are not in favor of such bundling.
Michael King, DPM, Nashville, TN
03/10/2022
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: Steven Selby Blanken, DPM
Aetna Medicare advantage plans as well as standard Aetna is not recognizing the modifier -59 code when it's placed next to 1-172-041-1721 paired with 11055–11057. We have to appeal these every time even though we see the patient four times a year. We are paid every time. This is a CCI coding edit error on their software which is intentional and, in my opinion, illegal. You should make copies of all these rejections; black out the patient information and send all of them to APMA's legal team and demand action and sanctions for their abusive way of coding clean claims. Demand interest and demand that they get thrown off their plans. Also tell the patients they need to complain or they will owe you the money that should’ve been paid by their health plan.
A similar situation happened with Anthem, and APMA (with the help of some of its members) were able to get them to correct and change their wrongful policy. It is now our turn to get Aetna to see it in the correct way.
Steven Selby Blanken, DPM, Silver Spring, MD
03/10/2022
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A
From: Jeffrey Kass, DPM
Dr. King answered Dr. Lane’s query by informing him, “The location of the lesion could be a factor as well if billing for these codes and the nail care codes as distal lesions have been lumped in with nail debridements.” Can anyone please explain to the PM News readers why a corn on a toe is inclusive in debridement of a nail on the same digit? Why has podiatric leadership not challenged and corrected this abusive rule created by Medicare?
Keratotic lesions and dystrophic toenails are completely separate and distinct medical issues, carrying their own separate risks particularly in the at-risk population. If the doctor assumes liability for these patients, he should definitively be rewarded by compensation when treating these patients. What am I missing?
Jeffrey Kass, DPM, Forest Hills, NY
09/28/2021
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: Jay Berenter, DPM
Tony, first of all, let me assure you my original post was not directed at you personally. I am one of the many who appreciate your dedication to our profession. As Vice President of Synergy Orthopedic Medical Group, the largest private practice orthopedic group in San Diego, I am reminded daily by our billing staff of the assault on our fees and allowable charges. This problem transcends the world of podiatry and spills over to all of our surgical colleagues be it orthopedic, general surgery, etc.
My goal was simply to generate discussion on this topic and perhaps to have our leadership at the state and national level actually begin to confront this problem through legislative efforts to make the needed changes so that we are compensated fairly. All too often, and unfortunately I include myself in this category, we roll over for the insurance companies and accept Medicare cuts and ridiculous exclusions that do not accurately reflect the scope and difficulty of our work.
It is time for us to redouble our efforts, alongside our orthopedic colleagues and others, to prevent any further reduction in surgical compensation. And again, I find it interesting that no one in leadership has chimed in on this thread. And to be clear, I appreciate their hard work as well and say this as a challenge to stand up and count me in if my help is needed on this front.
Jay Berenter, DPM, San Diego, CA
09/28/2021
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A
From: Steve Leonard, DPM
I want to thank Name Withheld for clearly identifying the source of this injustice, i.e. the federal government. Last time I checked, nowhere in the U.S. Constitution is the power to regulate healthcare granted to the federal government. Therefore, this authority falls to the individual states.
Removal of a joint implant is a separate and additional procedure to the fusion. It requires additional work, time, and risk of the surgeon. To say otherwise is delusional thinking and a great example of “gaslighting” by our federal bureaucracy.
Steve Leonard, DPM, Spring Hill, FL
09/27/2021
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1C
From: Name Withheld
I’ve read the back and forth regarding the inclusion of implant or hardware removal during a surgical procedure. Some complained about Dr. Poggio, as if he wrote the rules. The facts are that CMS has a document which is NCCI policy. Even though this is a government policy, most if not all commercial carriers follow this policy. And this policy is for ALL specialties including podiatry, orthopedics, spine, etc.
The exact policy reads: “There are CPT codes (20670 and 20680) for removal of internal fixation devices (e.g., pin, rod). These codes are not separately reportable if removal is performed as a necessary integral component of another procedure. For example, if a revision of an...
Editor's note: Name Withheld's extended-length letter can be read here.
09/27/2021
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: Paul Kesselman, DPM
I understand the frustration of those who feel that perhaps the coding gurus have undervalued our services. Having been in the trenches for more than 35 years, I experienced medical practice before the bean counters brought us to where we are today. There are times where the answers are correct, but those responding may not like the answers any better than those reading them. I know Tony, and I am sure he would agree with that perspective. From the coding perspective, removing the implant is part of the fusion procedure. I am sure Dr. Poggio did not mean to infer there isn’t more work involved here.
Dr. Poggio did provide a correct answer, but perhaps there is a better correct answer. Submit the claim for the fusion as one normally would and receive payment for a clean automatically processed claim. Cash in hand, upon payment, submit an appeal with the -22 modifier, indicating you did more work than usually expected during a fusion. Submit this with the operative report. Perhaps that will yield something more from the payer. Perhaps not.
Submitting the appeal in this manner, after you’ve received the initial payment, is a much better cash flow strategy than submitting the claim manually from the beginning. That only would cause weeks, if not months, of delays in receiving any payments at all.
Paul Kesselman, DPM, Oceanside, NY
09/27/2021
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A
From: Ivar E. Roth DPM, MPH, Gerald Peterson, DPM
In my private practice, revision surgery is one of my specialties. While it is NOT proper to bill removal of an implant as well as a fusion code, the level of expertise and care for revision surgery is recognizable and deserving to be paid more for the extra effort. I bill a -22 modifier to the appropriate code. I charge 25% in addition to my normal fee for revision surgery. It is both fair to the patient and the doctor.
Ivar E. Roth DPM, MPH, Newport Beach, CA
I’m sure Dr. Poggio advocates for us all the time but advocating for charging for implant removal when doing a fusion? C’mon. No, the implant wasn’t there in patients needing a fusion in other cases, but you also didn’t have to do all the WORK of removing the joint either. Some remodeling maybe, but not anywhere near the work involved with starting from scratch. Billing for implant removal is just plain bogus and is over-billing.
Gerald Peterson, DPM, West Linn, OR
09/23/2021
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B
From: Clifford Wolf, DPM
Dr. Poggio's response to the question as to whether you can bill for removal of an implant and a fusion at the same setting is troubling. Of course, they are separate procedures. No one comes with an implant as original equipment, and as such, removal of the implant is not standard when performing a fusion.
I agree with Dr. Berenter. Dr. Poggio, can you (or anyone reading this), forward an insurance denial for this scenario. Let’s see the justification for why the insurance company and their experts would deny this.
Clifford Wolf, DPM, Oceanside, CA
09/23/2021
RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A
From: Tony Poggio, DPM
Dear Jay, sorry that you found fault with my reply. The Codingline forum is excellent because it allows for multiple opinions. Doctors can then make up their own decisions. In this case, all the opinions seemed to essentially agree with me.
What saddens me is that you think I (and others) do not stand up for our profession. We served on the CCPM student council together way back when. I have served as the chair for the CPMA Medicare Committee since 1996 and have gone to bat countless times for us to make sure we get treated fairly and paid properly. Where Medicare goes, others follow.
Many phone calls, emails, teaching articles, seminars, etc. I have done, have been done gratis. Ultimately, presenting what are current billing guidelines and thereby keeping our doctors out of audits, avoiding fines and penalties is also a way to stand up for my colleagues and friends.
Tony Poggio, DPM, Alameda, CA
02/22/2021
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Justin Sussner, DPM
About 10 years ago, my wife was having some upper GI symptoms. Upon a recommendation, we made an appointment with a local GI group. We were told during that call that she would have to prep before the appointment for full colonoscopy and endoscopy. Thinking that it would save time once the doctor interviewed and examined her, and if it was indicated, we followed the instructions.
Upon prepping, and going to the appointment, filling in the paperwork, they attempted to bring us directly to the procedure room. Never seeing a doctor yet! We protested and refused. We were told this was standard procedure, and everyone coming in goes through this. We demanded the doctor consultation first. We found out, after the fact, that they were known as a scoping factory. We never went back there again. Do what is appropriate, nothing more, nothing less.
Justin Sussner, DPM, Suffern, NY
02/12/2021
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Kristin Happel
Dr. Poggio is dead-on with his advice. Starting in 2018, our local BCBS was across the board denying any E/M code submitted with a -25 modifier. I appealed EVERY denial with treatment notes using the Availity portal for BCBS; and every denial was overturned, and payment made for the E/M code. Eventually, once 2020 rolled around, BCBS stopped denying our E/Ms with the -25 modifier, as they must have come to the realization that yes, we ARE billing properly. As Dr. Poggio indicates, make sure the E/M is truly significant and separately identifiable, and appeal, appeal, appeal!
Kristin Happel, Office Manager, Lake Zurich Foot Clinic
11/02/2020
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Jeffrey Kass, DPM
“If you do multiple procedures, then there is a fee reduction for doing multiple surgeries on the same day. If you do them individually, then this would not apply… but that could imply that you are doing so to avoid the multiple procedure reduction. That could be considered abusive billing.” - Tony Poggio, DPM
I opine that the fee reduction imposed by the insurance company for multiple procedures is the abusive practice.
Jeffrey Kass, DPM, Forest Hills, NY
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