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From: Ron Werter, DPM


I do not take issue with Dr. Busman's comments about bundling. I do take issue with his surgery...a toe exostectomy taken to the OR and the patient sedated and having a painful recovery period? Does he also take a patient to the OR and sedate them for a P&A. What’s wrong with just a digital block for an exostectomy or even an arthroplasty? We can debate whether the digital exostectomy should be done in the office as podiatrists have been doing them for the past 50 years, but to sedate a patient for that is just wrong. 


Ron Werter, DPM, NY, NY

Other messages in this thread:



From Ron Werter, DPM


If the insurance company is asking for charts before they pay you, you’re probably seeing the backlash from the insurance company dealing with a few of your colleagues playing games with their billing. I assume that you’re an ethical practitioner but maybe some of your fellow podiatrists are pushing things a bit far.  


I was recently asked by a new patient to look at the requested chart notes from a new podiatrist her father had gone to for only routine care. The other DPM had charged out-of-network for a 4th level initial visit, CPT 99204, a vascular exam, CPT 93923, a deep ulcer debridement, CPT 11043, and one additional service. The chart notes for all this were on 1/2 page and didn’t even amount to a 2nd level IOV. He didn’t do any of the additional services he billed for. Maybe the insurance companies are finally getting smart. And yes, it does affect all of us. 


Ron Werter, DPM, NY, NY



From: Paul Busman, DPM, RN


I had previously scheduled a visit to my PCP in April but yesterday I received a phone call informing that they were rescheduling all appointments that didn't require actual hands-on assessment as telemedicine visits. I was planning on calling them about that anyway. I think that the way they did it was the way to go. The fewer patients that set foot into the office, the better.


They followed up with a message on my insurance's message service giving me details on how to set up the visit on my home computer. 


Paul Busman, DPM, RN, Frederick, MD



From: David E. Samuel, DPM


I have been unable to find where we do not have to use video for telemedicine with CMS. This link is dated March 17, 2020 and clearly says we need both audio AND video. Do you have anything that was posted after that date? No video would certainly be easier for those of us less tech savvy or without video capabilities.  


David E. Samuel, DPM, Springfield, PA



From: Allen Jacobs, DPM


I believe Dr. Lehrman may be incorrect regarding telemedicine coding. The need for video (visual) capability has been waived during the current COVID-19 pandemic. A telephone interview and documentation is all that is currently required.


Allen Jacobs, DPM, St. Louis, MO



From: Alan L. Bass, DPM, CPC


In response to Dr. Markinson’s comments on the coding answers for this question, let me begin by stating one unequivocal fact. Billing and coding is not the same as practice. There is always the unknown on why certain claims are denied. What we actually perform and document sometimes are not the same as what we will actually get paid for.


I was a student of Dr. Markinson’s at NYCPM and have the highest respect for his work in podiatry and dermatopathology, but billing and coding is not simple and straightforward. Since obtaining my credentials as a CPC, I have a new appreciation of what insurance companies look for when auditing...


Editor's note: Dr. Bass' extended-length letter can be read here. 



From: Name Withheld


I agree that unbundling is inappropriate. However, staging procedures is a result of insurance companies not paying for separate identifiably different procedures. For example, I recently performed an exostectomy for a patient with adjacent toe osteophytes causing interdigital pressure wounds. When we called the Horizon of Alabama insurance company for pre-authorization, we were informed the second procedure on a separate toe would not be paid at all and the first procedure had a 90-day global period. 


I notified the patient that he would be responsible for payment for the second procedure, so he scheduled it for after the 90 day-period. Regrettably, he will have to take an additional day off from work. Similar rules apply for multiple matrixectomies on different digits, different feet, Novitas insurance. Patients are informed that they can stage it or pay for it. Guess which option is chosen?


Name Withheld



From: Bryan C. Markinson, DPM


Let me start by saying that I appreciate the inputs of our APMA-endorsed DPM (only discussing the DPMs here) coding “experts,” as well as those DPMs who offer advice as consultants from private billing or practice management companies. They provide invaluable advice and information. However, way too often, I come away with the impression that the advice they are offering is their opinion, and more often than not, I come away thinking that they really aren’t sure of their answer.


Recently, one such designated expert answered a query regarding billing for a prudent exam on a diabetic patient (referred by the PCP) who turns out to have no complaints, and a normal exam. The doctor asks if he can get paid with the diagnosis of diabetes alone. My initial gut reaction to this question was that...


Editor's note: Dr. Markinson's extended-length letter can be read here.



From:  Name Withheld


Dr. Kaniadakis is 100% correct. Unbundling is not possibly fraud, it IS fraud. I’ve written here before regarding billing issues. I am an RN and review orthopedic and podiatric claims for several insurance companies. So I’m well aware of those who unbundle. I’m not sure that these providers understand that most insurers follow Medicare rules and there is the Medicare fraud act, which specifically mentions unbundling.  


Unbundling to try to beat the insurance company is fraud. Period. Staging procedures over several weeks for reimbursement is simply unethical and places the patient under added risk for anesthesia complications, etc. Providers are always looking for ways to beat the system and it’s something I do not advise. You will eventually get caught. 


Insurers are targeting fraud more than ever, and at the top of the list is unbundling. So if you’re performing a bunionectomy with an osteotomy and are unbundling it to a bunionectomy with one code and an osteotomy with another code and a capsulotomy with another code and a synovectomy with another code for something else, you have committed fraud. There is one code to use for all of the above. Those who are doing this are well aware of what they are doing, but aren’t well aware of the consequences including sanctions, pay back, penalties, exclusion from the carrier, and even legal action. If you don’t like the insurance rules, unethical billing or practices isn’t the answer. The answer is play by the rules or opt out of the insurance. 


Name Withheld



From: Estelle Albright, DPM


I find it interesting that complex foot surgeries are bundled into a flat fee... and supplies, meds, and so forth are all included. My oral surgeon charges for each and every part of the procedure, and the endodontist does the same---and insurance pays these fees. And, my dentist charges full fee for each tooth when multiple teeth are done in one session--insurance also pays for this. So, why are our fees discounted to half for the 2nd procedure, 25% for the 3rd procedure, etc.?


Estelle Albright, DPM, Indianapolis, IN



From: Steven J. Kaniadakis, DPM


Unbundling could be illegal. Healthcare fraud is essentially the case when you attempted to make more money than otherwise entitled to receive. Just by sending the "unbundled" codes in the mail could be a crime. This is true, even if the third party did not pay for the charges. 


Do not get into a factual dispute about what is "included" or "not included in the global", that is, what might well be the better "global code" or bundled code "package". Find the true legal issue. Did you ultimately make more money than otherwise entitled to? Find what the third party would have paid for the (better) bundled code. 


Also, DPMs should understand that global "period" is not the same as a global "code". A particular global code, from what I understand, is a bundled code or package of other AMA CPT codes and may include other billable codes, supplies, procedures, and E&M codes. Any DPM getting notifications concerning bundling related matters should immediately seek out a self-audit of all the office's billing and coding business practices. 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



From: Paul A. Galluzzo, DPM


In my 38 years of doing surgery, there's one thing I learned early on. The more work you do on the same day, regardless of how many incisions you make, the less you will be paid. You can appeal all you want, send documentation, use modifiers which is a joke, wait forever for a response, and you'll get the same result. No additional payment. You'd be better off staging your procedures on different days. Now the insurance companies would have to pay more for your patient's treatment. Like everyone else, I really dislike working for free! 


Paul A. Galluzzo, DPM, Rockford, IL



From: Benjamin Cullen, DPM


Regarding the comment by Dr. Borreggine, I disagree. The definition for CPT code 28122 makes no mention of plurality. If more than one tarsal or metatarsal bone requires an exostectomy (e.g., 1st metatarsal base and cuboid), then multiple units could be billed. However, if each of these osteophytes were accessed through the same incision (e.g., 1st met base, medial cuneiform), then only one unit would be appropriate.


Benjamin Cullen, DPM, San Diego, CA



From: Marc Katz, DPM


The correct code is CPT 64632. This is specific to the common digital nerve.  CPT 64640 applies to nerves other than interdigital nerves. Here is the description: "CPT 64632, Under Destruction by Neurolytic Agent (e.g., Chemical, Thermal, Electrical or Radiofrequency)."


Marc Katz, DPM, Tampa, FL



From: Barry Mullen, DPM


I respectfully disagree with Dr. Zlotoff's coding reply for a plantar plate repair. He opined for either using a flexor tendon repair code with the osteotomy code, or an unlisted code. In actually, when a CPR is correctly performed, one preserves the long flexor tendon. It is carefully retracted away from the plantar plate prior to the plate's incision. Therefore, that code is inappropriate. I'm unsure about my colleague's experiences using unlisted codes, but remuneration takes forever and only after multiple appeals. No thanks! I avoid them if a suitable code exists that reflects the work I perform. 


So, when we think of the pedal pathology and the surgical repair, don't almost ALL plantar plate tears ultimately lead to...


Editor's note: Dr. Mullen's extended-length letter can be read here.



RE: Continued Noridian CPT 11055 Denials (Richard Papperman, MBA)

From: Philip Larkins, DPM


The response to this post misses the point. The point of the poster is to say that, somehow, magically, Noridian Medicare was able to stop paying for qualified foot care as of October 1, 2015. Coincidentally, that was the switchover date to ICD-10. Somehow, what was covered by Medicare the day before, is now no longer covered. Of course, my tongue is in my cheek. This is a mistake by Noridian, and evidently they have no desire to fix it properly. The code to use for 700, is now L84, but Noridian does not seem to grasp this concept. I have now sent all my denials to an ALJ and I intend to waste their time with these nonsense appeals. Maybe someone else can shed light on this.


Philip Larkins, DPM, San Diego, CA



From: Robert Scott Steinberg, DPM


Dr. Young's post is to the point. We as individuals cannot change the way we are treated, but our state and national associations could, if they put in as much energy into this as they put into their now blurred "Vision." It is NOT routine when we are performing RFC on an at-risk patient. This is not rocket science. 


Robert S. Steinberg, DPM, Schaumberg, IL



From: George Jacobson, DPM


I needed a few extra credits, so I just finished reading "A Practical Update to Comprehensive Screening in the High-Risk Diabetic Foot" Podiatry Management's February 2015 edition. Although we all know how to assess our patients and know the benefits to society from "At-Risk-Foot-Care", one should review this article for its statistics which we sometimes forget. The lifetime risk of developing a diabetic foot ulcer is as high as 25% and precedes 84% of all non-traumatic LE amputations and deaths. The annual recurrence rates for diabetic foot ulcers are reportedly as high as 34%, 61% and 70% at 1, 3, and 5 years, respectively. WE have a good chance of preventing this with our patients' compliance. 


The prevention of these horrific consequences are why we do "At-Risk-Foot-Care" and prescribe "Therapeutic Shoes" (which I unfortunately...


Editor's note: Dr. Jacobson's extended-length letter can be read here



From: Bryan C. Markinson, DPM


Dr. Jane Koch asks, "How do I code for an "excision of soft tissue mass, foot" when the path report states it is a capillary hemangioma?" The response by Dr. Zlotoff was: Consider using one of these codes, based on anatomic location, depth of mass:

CPT 28043 - excision tumor, foot, subcutaneous tissue

CPT 28045 - deep, subfascial, intramuscular


I would be careful with this. A skin lesion is NOT a soft tissue mass. I have never seen a capillary hemangioma in any other place but the skin. When a hemangioma invades the deep tissues, it is called a cavernous hemangioma and they are usually very complicated excisions if attempted. I am assuming that Dr. Koch removed a skin lesion. The codes suggested are for soft tissue masses, which are not skin and not bone. I would use the appropriate skin biopsy or excision codes if indeed this is the case.


Bryan C. Markinson, DPM, NY, NY



From: David T. Taylor, DPM, Shashank Srivastava, DPM


Collect the money upfront and refund it if Medicare pays the claim. We simply tell the patient the CMS website indicates your deductible is $XXX.XX and that's what we need to collect today. 


David T. Taylor, DPM, Flint, MI 


I would not call Medicare or the PCP. Do not make this more complicated than it is. The patient owes you the money - period. Just bill her and explain that the PCP likely did not file the claim and she should be owed a credit by the PCP. She owes you the money and there is no need for you to call the PCP or Medicare and make it more complicated. She can deal with the PCP on her own and get a refund.


Shashank Srivastava, DPM, Rockville, MD

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