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09/22/2021
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Jay Berenter, 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.
It is very disappointing when one of our own does not advocate for us getting fair treatment and payment for the hard work we do every day. Until ALL of us stand up to the insurance companies to demand fair compensation for our profession, we will be at the insurance companies’ mercy. It’s time for Dr. Poggio and others like him to actually advocate FOR our profession instead of diminishing our worth.
Jay Berenter, DPM, La Jolla, CA
Other messages in this thread:
12/01/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Steven Kravitz, DPM
The G2211 code became more widely used and prominent during the COVID-19 crisis for podiatrists practicing wound healing. During that time, due to limited access, podiatrists became the most common medical contact for many patients with chronic non-healing wounds, and therefore became the primary source of much of the medical care. This included direct care to the patient as well as serving as the key resource for referral to other specialties.
As that crisis has now passed, it would appear that it is less commonly used because of the increased access to multiple specialties. Podiatrists are no longer serving as much as a key provider coordinating care for the patient. This is an add-on code and not a stand-alone. It's used for E/M services.
Steven Kravitz, DPM, Winston-Salem, NC area
11/09/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Kenneth Meisler, DPM
The doctor treated a fracture of the proximal phalanx of the right hallux. He billed codes 99203, 28510, and L3100. The complaint by the patient about the fees charged and it being a "surgery code" are something we see frequently. Patients frequently don't understand that some things they don't consider surgery such as partial nail avulsion under anesthesia or cauterization of pyogenic granulomas are coded as surgery, and that is usually very easy to explain to the patient.
Dr. King said he agreed with the codes the doctor billed, however code 28510 is NOT the code for a hallux fracture. Closed reduction of a "great toe" fracture without manipulation is CPT code 28490. Code 28510 is for Closed, other toe (2-5) without manipulation.
Regarding billing an initial office visit in addition to the hallux fracture code 28510, I have always billed for an initial visit in addition to the fracture care. I don't think I have ever had an insurance company reject it as being included in the fracture code. I frequently bill for subsequent office visits rather than a fracture care code depending on how often I think the patient will be returning and the amount of time I spend with the patient. A patient with a complex fracture or an anxious patient may need to come in more often. Deciding how to bill it is usually up to the doctor.
Kenneth Meisler, DPM, NY, NY
11/06/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Farshid Nejad, DPM
For those who provide services in these facilities, know that there is no perfect way to determine 31 or 32 POS. We are depending on staff there to give us accurate information and, like insurance eligibility, it can change for the same date of service, even if you have done your due diligence. OIG has published a letter on this that identifies CMS also does not have a mechanism to adjudicate these claims correctly. So if CMS cannot identify the correct POS during claim adjudication and CMS does not have an online mechanism to check accurately, the burden is being incorrectly placed on us by OIG.
My assumption is that CMS does not want to deal with this mess, and therefore the reason it is coming directly from the OIG. This needs to be fought by all specialists vehemently. When do we as physicians take a stand that enough is enough. Do not let your administrative defense tell you otherwise. And shame on those sitting in their Ivory Towers and not in the trenches, telling you it’s CMS’s right to recoup. The devil is in the details on this particular issue.
Farshid Nejad, DPM, Beverly Hills, CA
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
10/11/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Joel Morse, DPM
I recommend that you excise them with a punch biopsy tool. I’ve done this many, many times, and it works very well on the recalcitrant ones. Of course, you can say it’s non-covered and have the patient pay any fee you want. However, you may not use CPT 17110 - chemical destruction of a wart- unless you feel that it is a wart. I know that there are some studies out there that say that IPKs are warts. Sometimes you don’t know, so I say do a biopsy.
Joel Morse, DPM, Washington, DC
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
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
06/16/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Paul Kesselman, DPM
It has been a while since I performed at-risk foot care in New York. However, all the information you require about coding is the policy article attached to L33636 – Routine Foot Care and Debridement of Nails. The policy article and LCD are quite lengthy and often misinterpreted by podiatrists, and you are not alone in this. The CPT codes used for routine foot care are the most frequently used codes by podiatrists and the number one set of codes audited by Medicare for podiatrists. Thus it is important that you thoroughly understand the answer to your question and apply it to those clinical scenarios you may face.
As to specifically answering your question: The policy article lists a myriad of ICD-10, including I73.89 (other peripheral arterial disease) as a covered diagnosis, (I73.9 is not listed). For this ICD-10, your name and NPI may be listed as the referring doctor, but you must have a narrative description of the vascular findings (class findings), and an appropriate Q modifier (7,8, or 9) must be amended to the CPT 1105X code. The ICD-10 which provides for the local findings of callus (L85) is not listed as required. Even if it were the L85, by and of itself, it would not merit coverage and reimbursement for at-risk foot care. I urge you to go the NGS website and find the LCD and attached policy article for more information.
Paul Kesselman, DPM, Oceanside, NY
06/14/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: W. Kevin Pearson, DPM, Joe Gonzalez, DPM
We use Purple VRI app in our offices on an iPad. You are connected with a live person and are able to log on and off during patient care to keep costs manageable.
W. Kevin Pearson, DPM, Stockbridge, GA
I was having the same issue with sign language interpreting until I found an online solution at Jeenie.com. I have no financial interest in Jeenie.com, but have used their services a few times and it worked out well. It is a HIPAA-compliant app that remotely connects you to an interpreter. Sometimes, it may take a few minutes to get an interpreter, but it hasn't been an issue the few times we used it.
They charge by the minute (like $2/min), no monthly fees, no start-up costs, and no minimums and maximum. I used them twice in the past 3 months and was billed $46 for an initial office visit with the patient, and then $6 for a post-op nail check. I just had my assistant hold the iPad up behind me so the patient could see both me and the interpreter. It's very simple and affordable. It has been a perfect solution for us; otherwise, we were paying an interpreter $220 for the $80 office visit.
Joe Gonzalez, DPM, East Lansing, MI
04/25/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Peter Bregman, DPM
In response to the coding questions of Dr. Warshaw’s post about “neuroma coding” which is really cutting out a nerve that is entrapped, not a true neuroma. I would like to add that perhaps instead of cutting it out and risking a stump neuroma, perhaps learning and offering something more advanced and likely a better option would be better. Many surgeons falsely believe that the success rate of a neurectomy is over 90% but the literature does NOT support this and the many patients I treat every week from all over the country with stump neuromas would say otherwise.
When given a choice of A= no chance of a stump neuroma vs. B= somewhere between 10-30% of a stump (which is much worse with life-altering pain than the original nerve entrapment), why would anyone choose B? I doubt many of my colleagues are telling patients that the chance of a stump is at least 10% which is not a small number. I am proud to say in the last 20 years, I have never caused but have treated many. If anyone is interested, I and Dr. Steve Barrett on his Pod of Inquiry podcast discuss Morton’s entrapment and our experience which emulates the experience of the many AENS members.
Peter Bregman, DPM, Las Vegas, NV
04/06/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Daniel Kormylo, DPM
It should also be kept in mind that if and when we may eventually get paid on appeal for 11721/11056, they are paying the 2nd line item at 50%. This is not in lockstep with Medicare guidelines.
Daniel Kormylo, DPM, Rocky Point, NY
04/04/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Jay Seidel, DPM, Justin Sussner, DPM
If you upload your medical notes on Availity, it will be paid within a month (assuming notes are well documented).
Jay Seidel, DPM, Deerfield Beach, FL
We have been having the same trouble. And yes, you can appeal and eventually get paid. But why should we have to? It costs us time and money. It has been mentioned on this forum in the past months before, so it is not new.
We are considering having our Aetna Medicare patients sign an ABN, making them aware of the situation, so we can bill them and the patient can fight. Has anybody tried this approach?
Justin Sussner, DPM, Suffern, NY
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.
02/13/2023
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Jack Ressler, DPM
I have received several requests from Ciox asking for patient charts. I fax or email them an invoice and can honestly say I do not think they have ever paid. Ciox is relentless at calling our office and repeatedly sending faxes requesting charts. Some of their calls even appear on the caller ID as Spam. My fee for sending them charts is $50 per chart. They will even go so far as to try to negotiate a price per chart. Needless to say, I do not send any charts unless the invoice gets paid. This company borders on total harassment.
Jack Ressler, DPM, Boca Raton, FL
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
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
12/23/2022
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Jeffrey Kass, DPM
A PM News subscriber wrote in informing readership that they were being denied on claims from Aetna Medicare advantage when billing CPT 11721 with 11055 (with appropriate modifiers). Lori Stack was kind enough to inform readership she appeals denials with “the APMA appeal letter” and gets paid. If Ms. Stack appealed to Aetna Medicare Advantage and they paid her, then they are aware of the problem and should have fixed it so that the problem does not repeat itself.
I think a better solution would be that the next person that gets denied for the same problem start a class action lawsuit. The solution is not for every individual practice to send in appeals letters separately every time they get an individual denial. The solution is to fix the problem once and for all and to put an end to abusive payment practices performed by insurance companies. Each time a practice takes the time to send the appeal letter in, it is costing you money to do so and in the process reducing the payment one receives.
Jeffrey Kass, DPM, Forest Hills, NY
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
12/21/2022
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Jon Purdy, DPM
I was collecting the lower amount, if the office visit was less than the co-pay. I have been told by the “experts” that I am obligated to collect the entire co-pay even if I know I will have to issue a refund. Are there other opinions out there?
Jon Purdy, DPM, New Iberia, LA
10/31/2022
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Eddie Davis, DPM
I agree with Dr. Anthony Hoffman concerning the lack of a specific ICD-10 code for plantar fibromatosis or Ledderhose disease. Keep in mind that the lack of a specific diagnosis code not only affects our ability to bill for treatment of this malady but also affects data collection with respect to the incidence and prevalence of this disease. Ledderhose disease is classified as a rare disease, but I question how rare it actually is.
I have had an interest in Ledderhose disease for several decades and have developed an off-label treatment for it involving use of enzyme injections into the lesions. Hyaluronidase has worked well for me and I am happy to share my protocol with...
Editor's note: Dr. Davis' extended-length letter can be read here.
08/22/2022
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Kristin Happel
I think you need a new billing company. My long answer is: if you are PAR with the insurance companies in question, such as Medicare, you absolutely cannot bill patients for what is considered over U&C. To do so would be to violate your contract with insurances. Just hazarding a guess here, but I bet you pay your billing company based on a percentage of what they collect from insurance/patients (Not the way to do it, you should be on a flat fee rate) .
If so, it is in THEIR best interest to collect as much as possible, so that you have to pay them as much as possible. If I am understanding the situation correctly, they are completely wrong in what they are telling you, and taking you for a financial ride, to the detriment of your patients/practice.
Kristin Happel, Podiatry Biller, Chicago, IL
08/08/2022
RESPONSES/COMMENTS (CODINGLINE CORNER)
From: Tim Vogler, DPM
Our medical group is facing the same question as the unnamed inquirer. While the points Dr. Kesselman pointed out are correct, his comments didn’t add anything to the discussion regarding possible solutions. I too am very interested to see how other medical groups handle this situation.
Tim Vogler, DPM, Winston Salem, NC
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