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03/22/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Taking X-Rays on Patients with Ingrown Nails
From: Ivar E. Roth DPM, MPH
I have reviewed cases just like this. Here’s how these unscrupulous doctors justify taking x-rays for ingrown nails. They claim that when they push down on the nail and there was pain, they had had to rule out a subungual spur. Clever? I call it a rip-off, but this is done all the time by some of our esteemed brethren.
Ivar E. Roth DPM, MPH, Newport Beach, CA, ifabs@earthlink.net
Other messages in this thread:
07/04/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Reimbursement Parity from Insurance Companies (Harold Glickman, DPM)
From: Ira Baum, DPM
Accomplishing reimbursement parity from insurance companies through EBM is a dream. In fairness to Dr. Glickman, I did not read or hear the broadcast of Meet the Masters. But I do know that insurance companies, at this time, are profit-driven with limited government regulations. Things may change under Obamacare, but that remains to be seen.
Therefore, there are limited options podiatry has to obtain reimbursement parity. 1. Effectively modify the “supply and demand” equation. 2. Change the medical degree so that insurance companies cannot financially discriminate against a medical specialty. 3. Compel the insurance companies to pay “equal pay for equal service”, through the courts (I think it was successful in Maryland and unsuccessful in Connecticut).
Methodology: 1. Reduce the number of podiatric students and graduates, or educate them on the importance of demographics impact on reimbursement. 2. Force insurance companies to discriminate on an anatomical area, not by degree. Let’s see how MDs and DOs would react.
Ira Baum, DPM, Miami, FL, ibaumdpm@bellsouth.net
06/28/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Another Set of Foot Orthotics (Paul Keselman, DPM)
From: Simon Young, DPM
Contact the insurance carrier and get the devices pre-authorized. Usually, patients are allowed a new pair every 3 years. I agree that the patient should be seen and evaluated. Patients should not dictate their course of treatment; the practitioner should.
Simon Young, DPM, NY, NY, simonyoung@juno.com
06/08/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: FloChec & 93922 (Eric Kaplan, DPM, Richard Rettig, DPM)
From: Richard A. Simmons, DPM The query asks about using this equipment and billing CPT 93922 even though it does not perform ABI testing. From what their literature states “infrared light is transmitted into the digits” and a “sensor measures reflected light which correlates with blood flow.” If I am not mistaken, this is the definition for photoplethysmography. For Medicare patients, photoelectric plethysmography for 93922 is “not covered per CMS Manual System, Pub 100-3, Medicare National Coverage Determinations, Chapter 1, Section 20.14 as these methods have not yet reached a level of development such as to allow their routine use in the evaluation of suspected peripheral vascular disease.” Even so, performing the ABI test would be simple enough: attach the sensor to the digit (index finger for Brachial pressure reading or second toe for ankle pressure reading); inflate the cuff until a flat line is observed; slowly deflate cuff; when a waveform becomes apparent record that pressure reading from the sphygmomanometer. The photocell method can be a very useful screening tool for PAD and may increase accuracy in performing the ABI as a component of the E&M visit code. Richard A. Simmons, DPM, Rockledge, FL, RASDPM32955@gmail.com
05/14/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Humana Records Request (Pete Smith, DPM)
From: Philbert Kuo, DPM
The Humana reps bring their own scanner...no copying required. I pulled the requested charts and let them at it. They were in and out fairly quickly.
Philbert Kuo, DPM, Chesapeake, VA, philbear@pol.net
05/10/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Clinical Summaries: Place of Service (Michael Brody, DPM)
From: Alan Bass, DPM
To expand on what Dr. Brody posted, you are required to provide a clinical summary or continuity of care document (CCD) within 3 business days for greater than 51% of patients who receive an E&M service. In regards to meaningful use criteria as a whole, you only need to collect the data on a majority of your patients. If you treat a small percentage of your patients outside of your main practice location(s), those patients may be excluded from capturing meaningful use criteria.
Alan Bass, DPM, Manalapan, NJ, abassdpm@optonline.net
04/19/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Removal of Screw (Kathy Jagger, Office of Mark Goldberg, DPM)
From: Charles Morelli, DPM
I have certainly asked my share of coding questions of this forum, and have been helped each time. I want to suggest to Ms. Jagger and all others in need of this type of service that they utilize AMPA's coding resource center (apmacodingrc.org/index1.asp). It's inexpensive and your answers are realized immediately. This is the wave of the future, and in a short period of time, I can assure you that there will no longer be ICD-9 (soon to be ICD-10) and CPT books anymore. I have no vested interest in this site.
Charles Morelli, DPM, Mamaroneck, NY, podiodoc@gmail.com
04/18/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Code for Adjusting a Brace (Allen Sater, DPM)
From: Michael Hames, DPM
The Don Joy Velocity brace does not have a PDAC for L1971. Although the patient did buy this brace online, I would caution providers to check the braces they dispense with the Medicare DME site for accurate coding to limit liability in regards to an audit. The site for this is dmepdac.com/dmecsapp/do/search
Michael Hames, DPM, Florence, AL, hamesfootclinic@yahoo.com
04/17/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Code for Adjusting a Brace (Alan Sater, DPM)
From: Ron Werter DPM
A while back, I was asked as a favor by a neighbor to speak to their house guest who was waiting for her fractured 5th metatarsal to heal. It seems that the guest had gone to a local podiatrist who was going to dispense a CAM walker. The patient/guest, who had no insurance for many years, had declined the CAM walker. Instead, the guest had gone on the Internet and bought one herself because it was cheaper. But she bought the wrong size. I advised her to go back to the local podiatrist and follow his advice and treatment, and have the podiatrist fit and dispense a CAM walker properly. She was a bit dubious about my advice, but she did ask me if I would buy the CAM walker that didn't fit her from her at the inflated Internet price!
Ron Werter, DPM, NY, NY, hawkeyedpm@aol.com
04/16/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Code for Adjusting a Brace (Allen Sater, DPM)
From: David E. Gurvis, DPM
I would tell the patient that if I get and fit an ankle brace, and make an adjustment, it is covered in my original fee. If I were to make an adjustment to a brace bought online and something goes wrong (breakage?), I cannot be responsible. I have them sign a waiver to that effect. I then estimate the amount of work involved in the adjustment, and tell them how much it is going to cost CASH. Otherwise, I cannot do the adjustment. The adjustment is ala carte and not covered in the office visit.
David E. Gurvis, DPM, Avon, IN, deg1@comcast.net
04/14/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Getting Exempt or Penalized from eRx (Tony Poggio, DPM)
From: David Taylor, DPM
We successfully opted out of the eRx "program". The vast majority of our Medicare patients are diabetic, returning for established problems that do not require an E and M code necessary to to satisfy the eRx requirement. In addition, Allscripts charges $20 per doctor per month to use their app on a smart phone (It is free for a desktop computer). Check the Medicare website and you will find the information. Once you find the form, you can submit it electronically.
David Taylor, DPM, Flint, MI, dttaylor_19@yahoo.com
04/09/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: NCS Testing Bilaterally (Tony Poggio, DPM)
From: Elliot Udell, DPM
For years, I was against doing NCV testing in my office. If I had a patient whom I felt needed further neurological testing, I used to refer them to neurologists to have a complete neuromuscular examination. I lacked confidence in the various mobile testing services that approached me at podiatry conventions and bombarded me with letters and phone calls. This all changed when I was treating a woman with incalcitrant heel pain. Nothing was eliminating her symptoms, and she was adamant about not going for a neurological exam which involved the insertion of electrically charged needles into her muscles.
I ordered an NCV test performed by a professional service run by a neurologist. The report came back indicating that she has a serious radiculopathy. I then referred her to an orthopedic back specialist who read the report and followed up with an MRI. He discovered a stress fracture of her lower spinal column, which was pressing on nerves that innervated the calcaneous. She had immediate spinal surgery. Today she is doing much better and her heel problem is gone. Is NCV testing the gold standard of neurological exams? No. Does it have a place in our work-up of patients with peripheral neurological problems? Yes.
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
03/30/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Taking X-Rays on Patients with Ingrown Nails (Tony Poggio, DPM)
From: Barry Mullen, DPM
Subungual exostoses are not rare, though not every pincer nail can be ascribed to one. So, how does one differentiate and become suspicious of their presence when a patient presents with a painful ingrown toenail? The key is the exact location of the patient's maximum pain relative to the nail folds. One must be very specific how one palpates the toenail in order to distinguish between the two. Ingrown toenails are usually maximally painful to palpation along the disto-medial/lateral nail folds, while subungual exostosis pain is generally centrally located just proximal to the distal nail fold.
The exception occurs when an underlying subungual exostosis or bone tumor is eccentrically located (discovered via D/P x-ray). If a symptomatic pincer nail's maximum palpable pain is centrally located, a D/P and isolated hallux lateral x-ray image is most certainly warranted to rule out the suspected underlying osseous pathology because its presence totally changes the treatment course.
Osteochondromas are much more frequent in children and have cartilage caps, so their visualization on x-ray can be missed, or grossly underestimated, though much less so with the newer, higher resolution digital x-ray machines.
Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com
03/29/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Taking X-Rays on Patients with Ingrown Nails (Tony Poggio, DPM)
From: Howard Lepolstat, DPM
It seems to me that a subungual exostosis is a sufficiently frequent occurrence that the patient deserves to have an x-ray taken to rule out the possibility. The question is when. The first time the ingrown nail occurs, providing it is not terribly severe, I think it is appropriate to simply remove the offending nail spicule. At a recurrence and prior to attempting a "permanent" solution, would seem to be a reasonable time to take that x-ray.
If there is no spur at that time, and barring the possibility that multiple, severe, recurrence does not cause a spur, it is not likely that it will develop in the future. Therefore, x-rays for ingrown nails seem to me to be absolutely appropriate to take once before any attempt at permanent correction. Once patients know that they do or don't have that bone issue, they can relate it to any DPM they see.
Howard Lepolstat, DPM (Retired), Sun City West, AZ, TeachrComp@aol.com
03/28/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Taking X-Rays on Patients with Ingrown Nails (Tony Poggio, DPM)
From: Barry Mullen, DPM
The key concept in Dr. Poggio's reply is "medical necessity." Healthcare providers must be able to justify the performance of any given service from both medically necessary and appropriate standards. This is a key component within medical compliance regulatory guidelines that we're all held accountable to and by which third-party carriers decide benefits upon.
In addition, X-ray exposure is not completely innocuous. It has inherent, associated risks, albeit somewhat limited with pedal collimators; but, one does have a medical responsibility to limit x-ray exposure for only those circumstances where its outcome affects one's medical decision-making.
GROSS over-utilization of any service eventually leads to...
Editor's note: Dr. Mullen's extended-length letter can be read here.
03/27/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Taking X-Rays on Patients with Ingrown Nails (Ivar E. Roth DPM, MPH)
From: Michael M. Rosenblatt, DPM
Dr. Roth is against x-raying all ingrown nails and feels it's a rip-off of patients. In many cases, that is true. However, there are some patients who have greatly incurvated nails where at the distal aspect there is a strong possibility of a bony exostosis. Most ingrown nails are only incurvated at the medial and/or lateral sides, but some actually appear to be pointed upwards dorsally. Those may actually demonstrate pain on squeezing the toe downwards.
These situations receive extra-pressure from the footgear. Appropriate treatment of this situation may require treating the bony exostosis in order to allow the nail plate to flatten out. If you believe your patient has this situation, x-rays are appropriate. That should be documented in your chart notes. You would certainly not x-ray all ingrown nails. I suppose it is up to you if you choose not to bill for a negative film. But my point is that it is sometimes appropriate to x-ray a patient who has a complaint of ingrown nail(s).
Michael M. Rosenblatt, DPM, San Jose, CA, Rosey1@prodigy.net
03/26/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Taking X-Rays on Patients with Ingrown Nails (Name Withheld)
From: Robert K Hall, DPM
While x-raying every acute ingrown nail is over-utilization, occasionally a patient presents with chronic recurrent infected ingrown nails, for which excision (11730) and proper C & S/antibiosis have been unsuccessful. Here, an x-ray to rule out osteomyelitis may be appropriate.
Robert K Hall, DPM, Ft Lauderdale, FL, robertkhalldpm@bellsouth.net
Please correct me, but is this discussion also inclusive of painful onychocryptosis with paronychia? Does this also include neuropathic patients with significant nail deformity with or without paronychia? I was taught to take radiographs to rule out possible osteomyelitis or other osseous pathology in these patients. Other local pathology and/or systemic co-morbidities may be present. Radiographic evaluation in these cases is indicated.
Although fortunately having no personal experience with this possibility, how do we defend NOT doing simple radiographic evaluation should legal ramifications follow a poor result, undiagnosed bone pathologies, etc.?
Neil H Hecht, DPM, Tarzana, CA, drhecht@sbcglobal.net
03/24/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Taking X-Rays on Patients with Ingrown Nails (Ivar Roth, DPM)
From: Elliot Udell, DPM
Dr. Roth raises a valid objection to podiatrists taking x-rays in the evaluation and treatment of an uncomplicated ingrown toenail. In our practice, x-rays are only taken when a patient presents with symptoms which may be caused by osseous pathology. Let me play devil's advocate for the purpose of adding to this discussion.
I have my teeth cleaned professionally. Once a year, the dentist will take a series of x-rays. This past year, he discovered the beginning of an abcess. After two opinions by endodontists, I underwent a root canal in order to save the tooth, even though it was asymptomatic at the time the initial views were taken. The question is whether we as podiatrists should be conducting comprehensive foot evaluations on all of our patients and should this also include a basic set of foot x-rays?
Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com
03/23/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Taking X-Rays on Patients with Ingrown Nails
From: Jon Purdy, DPM, Neil A Burrell, DPM
In this day and age of tort law let off its leash, I don’t think anyone could fault a practitioner for taking an x-ray of a toe that has purulent drainage present for months. How many of us have taken out painful subungual spurs? They exist; so how are they diagnosed? In the art of medicine, there are very few of us that could throw stones at others in one area and not have them thrown back at us in others. Chronic nail infections and tented nails deserve a closer look. Taking x-rays on the majority of these is most likely out of line, but I would not be willing to incur a practitioner’s liability by drawing a line for them.
Jon Purdy, DPM, New Iberia, LA, jpurdy@mindspring.com
Twenty-two years ago, I was running late getting back to the office, so my nurse took an x-ray of the patient's toe to buy some time. The patient was the son of a plaintiffs' attorney. The x-ray showed an enchondroma which we successfully removed. I have not taken an x-ray for an ingrown since then. This was the first and only time. That young patient is now a local plaintiffs' attorney. I see his parents out in public all the time. They never fail to thank me for taking such good care of their son 22 years ago.
Neil A Burrell, DPM, Beaumont, TX, nburrell@gt.rr.com
03/08/2012
RESPONSES / COMMENTS (CODINGLINE)
RE: Wound Treatment Coding Question (Kevin Brattain, DPM)
From: Don R Blum, DPM, JD
I contend that whether you are treating an ulceration that is caused by pressure or because of the diabetes would not make a difference. One could have an ulceration caused by pressure, the delay in healing, or complication in the healing could be because of diabetes or vascular condition. The concern by not relating the diabetes to the wound/ulceration could affect your treatment plan. If you decide you want to use Dermigraft or Apilgraf, you need a qualifier in additon to "ulcer"/"wound." If you decide you want to use hyperbaric, the differential from pressure to vascular-related or to diabetic-related could cause a denial in coverage.
In my opinion, if you are just doing "debridement", whether excisional or if it falls under "wound care", then coverage would not be an issue. After all, patients with no issue of vascular or diabetes can get ulcerations, such as decubitus, from pressure.
Don R Blum, DPM, JD, Dallas, TX, donrblum@sbcglobal.net
12/20/2011
RESPONSES / COMMENTS (CODINGLINE)
RE: Diabetic Shoe Frequency (Paul Kinberg, DPM)
From: Ilona Barlam, DPM
Unfortunately, in my experience, billing A5500 and A5512 even a day before 365 days--was denied by Medicare. So, if a patient were billed A5500 and A5512 on October 1st of 2010, the next pair of diabetic shoes that the same patient can be billed for is October 2nd of 2011.
Ilona Barlam, DPM Seattle, WA, isbinc2006@gmail.com
12/15/2011
RESPONSES / COMMENTS (CODINGLINE)
RE: Removal of Accessory Ossicle (Anna Sanders)
From: Paul Busman DPM, RN
A reasonable person might think that removal of a sesamoid is "close enough" for billing the removal of an accessory ossicle, but reason has nothing to do with how these people think and act. If it's not actually and specifically a sesamoid, I'd hesitate to use a sesamoidectomy code. Exostectomy, if such a code exists, might be closer.
Paul Busman DPM, RN, Clifton Park, NY, paul@busmanwhistles.com
11/17/2011
RESPONSES / COMMENTS (CODINGLINE)
RE: Diabetic Patient Check-Ups (David J. Kaplan, DPM, Harry Goldmith, DPM)
From: Paul Kesselman, DPM
It sounds like Dr. Kaplan has the PQRS system and CPT coding a bit mixed up. One does not appoint a patient for any examination specifically to satisfy a specific PQRS measure. Reimbursement for a specific evaluation is performed based on a compelling medical rationale for a patient work-up or treating a patient on a specific date. LOPS, as was mentioned by Dr. Goldsmith, may be the exception where a patient may not have any compelling symptoms.
In the real world, for example, a patient presents for at-risk foot care and, while in the office, a practitioner performs PQRS measures. There is no separate CPT code for the exam and one reports the PQRS measure codes which the patient qualifies for.
If, on the other hand, the patient presented...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
11/16/2011
RESPONSES / COMMENTS (CODINGLINE)
RE: Diabetic Patient Check-Ups (Daivd J. Kaplan, DPM)
From: Harry Goldsmith, DPM
There are several things that need to be cleared up regarding PQRS. First, PQRS (Physician Quality Reporting System) is a “voluntary” reporting system dealing with preventive care measures. Medicare happens to incentivize doctors (eligible professionals) to report a minimum number of measures during the year (in 2012, it will be 0.5% of total Medicare allowed charges).
There is nothing I am aware of in PQRS that requires annual, semi-annual, quarterly, or more often follow-up exams.
Second, patients are not scheduled to be seen for...
Editor's Note: Dr. Goldsmith's extended-length letter can be read here.
11/15/2011
RESPONSES / COMMENTS (CODINGLINE)
RE: Diabetic Patient Check-ups (Tony Poggio, DPM, Richard A. Simmons, DPM)
From: David J. Kaplan, DPM
The PQRI findings that Medicare are pushing us to comply with suggest that patients require follow-up exams annually, semi-annually, quarterly, or more often depending on the level of disease that they suffer. Therefore, if you think a patient should be seen more frequently, and they meet the criteria set forth by the PQRI measures, schedule them accordingly.
I just had a diabetic come for routine care and noticed a gangrenous lesion on one of her toes. With her diminished vision, she thought it was just a bruise and thought it would go away. Had she waited longer, she would have been right; it would have gone away...as well as her forefoot!
David J. Kaplan, DPM, San Mateo, CA, drdjkdpm@yahoo.com
11/14/2011
RESPONSES / COMMENTS (CODINGLINE)
RE: Diabetic Patient Check-ups (Tony Poggio, DPM)
From: Richard A. Simmons, DPM
According to Dr. Poggio, there is no code for routine diabetic check-up. Even so, on page 19 of medicare.gov/publications/pubs/pdf/10116.pdf is the following quote: “Foot Exam: Medicare Part B covers a foot exam every 6 months for people with diabetic peripheral neuropathy and loss of protective sensations, as long as you haven’t seen a foot care professional for another reason between visits.”
Though there is coverage for this “check-up,” the limitations on the podiatrist are extremely severe; however, Medicare recipients are told it is covered, and podiatrists are supposed to jump through hoops to meet the criteria.
Richard A. Simmons, DPM, Rockledge, FL, RASDPM32955@gmail.com
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