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05/12/2022    

CODINGLINE CORNER



Query: Onychocryptosis Scenario


 


My patient returned to my office for painful onychocryptosis. I performed bilateral, temporary nail procedures at the medial border of the hallux nail. Do I bill this as CPT 11730 with a -50 modifier or CPT 11730 T5 and CPT 11730 TA?


 


Codingline Archive


 


Response: The best approach and most accurate when doing additional nails is the CPT 11730 and CPT 11732 for additional/add on. I do recommend the digital modifier as some payers demand it, although some do not. You do NOT need a -59 with add codes, so remember that. The add-on codes are designed when doing the same procedure but in a different location or expanding the surface area treated.


 


CPT 11730 Avulsion of nail plate, partial or complete, simple; single


 


CPT 11732 Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure) (add-on code)


 


Michael King, DPM, Nashville, TN



 


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Other messages in this thread:


05/18/2022    

CODINGLINE CORNER



Query: Matrixectomy Follow-Up


 


I have a patient who has Blue Cross insurance. He came in for a matrixectomy on February 8th and returned on February 15th for follow-up. I billed CPT 99213 using M79.673 and T81.40XA for the follow-up and the claim was denied. Is there another code or modifier that I should include?


 


Codingline Member


 


Response: This is an issue with 10-day global procedure for CPT 11750-Excision of nail and nail matrix, partial or complete, (e.g., ingrown or deformed nail) for permanent removal. The only thing that can be billed for is an unrelated E/M. Your diagnosis you related is nice but does not get you a new E/M. T81.40XA-Infection following a procedure, unspecified and M79.673-Pain in unspecified foot. Why unspecified? However, the bottom line is that this is not an E/M because there is an infection.


 


Only if you take the patient back to the operating room or procedure room in the global period can you bill for it. That scenario would necessitate a modifier -78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Post-operative Period.


 


The only way an E/M is billed is if it is unrelated to this service which clearly it was not. This is called post-op care. In my practice, we use CPT 99024-Post-operative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a post-operative period for a reason(s) related to the original procedure and it is a $0 charge. Don’t appeal and don’t append any modifiers.


 


David J. Freedman, DPM, CPC, Silver Spring, MD



 


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05/16/2022    

CODINGLINE CORNER



Query: New or Established?


 


We have a new provider who has come to our office from a previous practice. Some of her patients are following her to our practice. We do not have access to any of the previous records from the provider's previous practice. If she has seen them at a previous practice within 3 years, can we still bill for a new patient visit when she sees them at our office?


 


Codingline Archive


 


Response: The simple answer is no. The patient is being seen by the same provider with the same NPI, even though the provider may be re-assigning the benefits to a new practice.


 


Alan Bass, DPM, CPC, Manalapan, NJ



 


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05/13/2022    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Brian Kiel, DPM


 


I don’t mean to insult anyone but a temporary nail procedure is called trimming, and the use of CPT 11730 for this is a red flag. The code 11730 is for avulsion from distal to proximal which requires anesthesia. It is not for a trimming no matter how much nail was visible. If I am wrong, please inform me what a temporary nail procedure involves for this code. 


 


Brian Kiel, DPM, Memphis, TN

05/10/2022    

CODINGLINE CORNER



Query: Plantar Fascia Rupture


 


What would be the best code or codes to represent an acute, ruptured plantar fascia? 


 


Codingline Member


 


Response: A rupture of the plantar fascia can occur in two fashions: traumatic and atraumatic or spontaneous.


For an atraumatic or spontaneous rupture of the plantar fascia, the most appropriate ICD-10-CM codes would be the following:


M66.871 Spontaneous rupture of other tendons, right ankle and foot


M66.872 Spontaneous rupture of other tendons, left ankle and foot


 


For a traumatic rupture of the plantar fascia, the most appropriate ICD-10-CM codes would be the following:


S96.811 Strain of other specified muscles and tendons at ankle and foot level, right foot


S96.812 Strain of other specified muscles and tendons at ankle and foot level, left foot


Due to the fact that is a traumatic injury, a 7th character is needed to appropriately complete the above, two ICD-10-CM codes for specificity.


*** Use Non-Fracture Seventh Character Codes:


A = Initial encounter and treatment


D = Subsequent encounter


S = Sequela


 


Michael G. Warshaw, DPM, CPC, Lady Lake, FL



 


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05/04/2022    

CODINGLINE CORNER



Query: When To Use CPT 97597


 


I am not exactly sure when it is appropriate to use CPT 11042 versus CPT 97597. CPT 11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less


GP: 000 | Assist: N | NF RVU: 3.87 | FAC RVU: 1.76 | Work RVU: 1.01


 


CPT 97597: Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session; total wound(s) surface area; first 20 sq cm or less


GP: 000 | NF RVU: 3.03 | FAC RVU: 1.06 | Work RVU: 0.77


 


The difference appears to be in the definition of CPT 97597 where the language states “for ongoing care.” Is this the only reason to use CPT 97597 versus CPT 11042?


 


Codingline Archive


 



Response: CPT 1104X codes are used to debride wounds based upon the type of tissue that was removed. Hence the coding for debridement down to and included subcutaneous tissue CPT 11042. If the wound is down to subcutaneous tissue BUT subcutaneous tissue is not documented as being removed, then you can not use this code.


 


CPT 95797 is for debridement of skin down to and including dermis and slough over the wound. This code in part replaced CPT 11040 and 11041.


 


The difference in associated RVU between these two codes is based upon the increased complexity of debriding subcutaneous tissue versus only skin/slough. So the basic difference between the codes is due to the type of tissue that was debrided and documented.




 


Tony Poggio, DPM, Alameda, CA


 


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05/02/2022    

CODINGLINE CORNER



Query: Neuroma Treatment with Radio Frequency Ablation


 


I am interested in feedback on how to code for a radio-frequency ablation of a neuroma. Any thoughts or information would be helpful. 


 


Scott Rogers, DPM, American Fork, UT


 


Response: CPT 64632 is in the section “destruction by neurolytic agent (e.g. chemical, thermal, electrical or radiofrequency) plantar common digital nerve. This would seem to be the best option.


 


That said, not all insurances accept radiofrequency treatment as an appropriate option instead referring to this option as investigational. Clearly document the medical necessity of this treatment, failed conservative care, etc. and pre-authorize its use. Don’t simply ask if CPT 64632 is a covered benefit. Rather ask if radiofrequency is a covered service/modality.



 


Tony Poggio, DPM, Alameda, CA


 


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04/27/2022    

CODINGLINE CORNER



Query: Bunionectomy Question


 


I performed an Akin osteotomy and a Mcbride bunionectomy on the right foot. Are these separate procedures or should I use CPT 28299? 


 


Codingline Archive


 


Response: The simple answer to this question is no.


 


CPT 28299 is a bunionectomy code that describes two osteotomies. What you described is an osteotomy (“an Akin osteotomy”) and soft tissue work with the associated bunionectomy (“Mcbride bunionectomy”). For this scenario, I would consider CPT 28298 as a better choice for what is described.


 


Jon Goldsmith, DPM, Omaha, NE



 


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04/25/2022    

CODINGLINE CORNER



Query: Revisional Lapidus Bunionectomy


 


I have a patient whose original Lapidus bunionectomy failed. It resulted in a broken screw and loss of correction. We are planning to return to the operating room. The plan will involve obtaining calcaneal autograft from the ipsilateral foot, removing the broken and intact hardware, re-prepping the articular surfaces, re-positioning the first metatarsal and then applying a sturdier construct for fixation. Does anyone have any thoughts on coding this scenario?


 


I am not resecting the “bunion” again so I was not planning on re-billing a bunionectomy. I am not sure if CPT 28315 or CPT 28315 make any sense in this case. 


 


Codingline Archive


 


Response: I will assume that you are planning this surgery beyond the 90-day post-operative period of the original Lapidus bunionectomy. That being the case, you are repairing a malunion or nonunion of the first metatarsal – medial cuneiform joint. I would suggest using CPT 28322, which includes bone graft. One could argue using CPT 28320, repair on malunion or nonunion of tarsal bone, since there is no septic code that combines the tarsal and metatarsal bones. If this were a primary fusion of the tarsometatarsal joint, then I would recommend CPT 28470, arthrodesis midtarsal or tarsometatarsal, single joint.


 


Howard Zlotoff, DPM, Camp Hill, PA



 


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04/21/2022    

CODINGLINE CORNER



Query: CPT 11750: Aetna Medicare and Denials


 


We have been receiving denials for CPT code 11750 on patients with Aetna Medicare. All other insurance carriers are reimbursing this CPT code within our practice and without problem. When we appeal (often times more than once for each individual claim), Aetna Medicare replies back with denial code – 96 “non-covered service”. We have contacted this insurance carrier multiple times and the representatives are unsure why it is being denied. They state “it is a computer glitch, and we do not understand why the denials are occurring.” They also state that we are not allowed to bill the patient.


 


I have sent multiple letters to Aetna Medicare and still nothing. I have contacted our representative for Aetna Medicare and they are unable to help. We are using the correct ICD-10 codes and modifiers. Per CMS guidelines, Aetna Medicare is supposed to be covering this CPT code as it is a covered service recognized by CMS. Is anyone else having this issue?


 


PM News Subscriber


 


Response: Bill the patient directly for the entire fee for the services that were improperly denied by Aetna Medicare. The patient will not pay the bill; however, the patient will likely phone your office to inquire about the bill. Then you can inform the patient that they need to get involved and call their insurance to get the bill paid by the insurance company. Once you have the patient calling the insurance company, this tool is often more helpful than your office calling to get the issue resolved and get you properly paid.


 


Keith Gurnick, DPM, Los Angeles, CA



 


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04/19/2022    

CODINGLINE CORNER



Query: Application of an External Fixator


 


I am part of a recovery audit from CMS for using a modifier -59. Cotiviti Healthcare has been hired by CMS to review my use of modifier -59. They stated that my operative report supports documented Charcot reconstruction and the use of application of external fixator (CPT 20692) but modifier -59 was inappropriately used since both procedures were performed at the same session. Should I have used a different modifier in this situation? Is application of an external fixator (CPT 20692) not considered a separate procedure if it is performed at the same session as other reconstruction procedures?


 


Codingline Member


 


Response: You bring up a very interesting scenario for which there are multiple answers, all of which are correct but that all depends on the CPT code you billed for the Charcot reconstruction. There are likely hundreds of CPT codes for open reduction of dislocations or fracture codes throughout the body, which simply state “open reduction of…,” and others which state “open reduction with or without internal or external fixation.”


 


The latter code descriptor therefore includes your placement of a frame and its removal. The majority of open fracture or dislocation repair for the foot and ankle do, however, include that last statement, but there are some where there is no mention and for those, the additional billing for application of the external fixation would be fair game. Where there is some leeway is in the arthrodesis coding, where most do not contain any reference to the application of a fixation device. So the specific answer to your question depends on how you coded your original Charcot reconstruction.


 


Paul Kesselman, DPM, Oceanside, NY



 


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04/14/2022    

CODINGLINE CORNER



Query: Ganglions and Soft Tissue Masses


 


I would like an opinion on billing for an excision of ganglion cyst. I like to use D21.21 until the pathology returns. What are others’ thoughts on submitting before the pathologist has weighed in with their diagnosis? I know that ganglions are very easy to spot, but could it indeed turn out to be a tumor or other benign mass after the surgical path is taken?


 


Miranda Hook, Wichita, KS


 


Response: I recommend waiting until the pathology report comes back. The worst case scenario is that the report could take one week, so it is not a deal breaker. Any soft tissue mass could be either benign or malignant. Nine times out of ten it is a ganglion… but it could be something else. If you are wrong, then you have to submit a corrected claim. This will probably go through a manual review and that takes time. The patient may also question this when they get the EOB.


 


If the lesion is malignant or not a ganglion and additional surgery is required, getting a prior authorization could be an issue if there are other previous related authorizations already in the patient’s history. This should not be that common of a scenario, so I don’t see a need to rush the billing.



 


Tony Poggio, DPM, Alameda, CA


 


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04/07/2022    

CODINGLINE CORNER



Query: Time-Based Coding with an Unrelated Procedure


 


My young partners and I have recently taken over a practice and are trying to establish ourselves in the world of the new billing guidelines. My general concern is how to use time based billing if you are also doing a procedure. I cannot find any great reference for doing an E/M code with a procedure on the same day when billing for time. Is there a reference that says you are allotted 15 minutes for a partial nail avulsion, 10 minutes for aspiration of a ganglion, etc? If you spent 30 minutes talking about another condition after spending time performing a procedure for a completely separate issue, can you then bill a 99214 with a modifier? Should you then have a blurb in your note to say, I spent 15 minutes performing the partial nail avulsion and 30 minutes examining the patient, diagnosing, managing, etc. the patient for the separate issue? Does the 15 minutes you took for your procedure count towards your time based E/M? I would assume not, but I haven’t found anything that specifically explains this.


 


Catherine Jacobs, DPM, Chestnut Hill, MA


 


Response: The E/M guidelines established at the start of 2021 only pertain to the performance of the E/M, not performance of procedures. There is no reference to state how long it should take to perform a nail avulsion, aspiration of a ganglion, etc. The other important thing to remember is that all procedure codes have an element of an evaluation and management built into them already. Depending on your specific patient encounter, it may or may not be appropriate to bill for an E/M code along with a CPT code. E/M coding is based on two different parameters, medical decision-making, or time...not both. There are many good references on the APMA website, in addition to the AMA website.


 


Alan Bass, DPM, CPC, Manalapan, NJ



 


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04/05/2022    

CODINGLINE CORNER



Query: Denials Using L84


 


We used to bill Medicare for mycotic toenail debridement and callus paring for our diabetics with neuropathy, using E11.49, L84, and B35.1 with XS modifier. We have had no problems getting paid until recently. The recent claims have denied the CPT 11056, stating that the diagnosis of E11.49 and L84 do not meet CMS guidelines of medical necessity for payment on a CPT 11056. In fact, when looking in the Medicare Online Only Manual, L84 is no longer present. Is this a recent change and if yes, what are practitioners using as a callus code? Help please!


 


Brant Burnham, DPM, Payson, UT


 


Response: There were changes in the Noridian RFC policy. This impacted both JE and JF regions (you are JF region). There is a list of allowed codes for nail and callus codes as well as allowed pain and systemic codes on the Noridian website. Some codes were expanded and some restricted. Particular emphasis was placed on unlisted and unspecified ICD-10 codes. Update your computer system to reflect these changes.


 


That said, I would call Noridian to make sure the use of this code is what triggered the denial. There could be other reasons for the “not medically necessary” denial remark code.



 


Tony Poggio, DPM, Alameda, CA


 


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03/30/2022    

CODINGLINE CORNER



Query: Documentation for E/M


 


Let’s say a patient came in with acute plantar fasciitis and low risk treatment options were performed. Is it needed or advised to include sentences like these in the plan while documenting?


 


“The patient had an acute, uncomplicated illness or injury addressed today.”


“There is low risk involved with this pathology, testing, and its treatment considerations.”


 


PM News Subscriber


 


Response: Documenting an E/M that is low risk in your example of acute plantar fasciitis is as follows. My plan that I would say: “Medical management: The etiology of the problem today is an acute plantar fasciitis, this is considered an acute injury. The plan of care involves a low risk of morbidity as the patient treatment recommended includes: stretching (which was demonstrated), ice or heat, elevation, and rest.”


 


To me, this fits your low risk CPT 99203/99213 patient scenario.


 


David J. Freedman, DPM, CPC, Silver Spring, MD



 


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03/24/2022    

CODINGLINE CORNER



Query: Acute Complicated Injury


 


Under the “Number and/or Complexity of Problems Addressed”, there is a category for “acute complicated injury.” Could you give 3-4 typical examples of “acute complicated injuries” that a podiatrist might see? 


 


PM News Subscriber


 


Response: "Acute complicated injury” - here are 4 examples one might see in podiatry that come to my mind:


 


1) Fracture(s).


2) Trauma-crush injury.


3) Infection/Abscess with cellulitis that is ascending.


4) Laceration with more than skin involvement, i.e. tendon laceration.


 


David J Freedman, DPM, CPC, Silver Spring, MD



 


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03/22/2022    

CODINGLINE CORNER



Query: Two New Patients in One


 


I have a new patient scheduled who was originally due to see me for an injury to their ankle that occured at work. The injury is a Workers Compensation case. The interesting part of this is that the patient told the scheduling staff that she would also like to have an “ingrown nail taken care of” at the same visit. The patient is quick to say that the ingrown nail does not have to do with the work comp case and she would like to use her regular insurance for that problem.


 


I am planning to use the EMR system to create two encounters that day: one for the Workers Comp injury and the other for the unrelated onychocryptosis. If both encounters involve a separate and independent E/M with appropriate documentation, would they both be considered new patient visits? They both can’t be new patient visits… right?


 


Codingline Archive


 


Response: Workers Compensation is a unique entity unto itself. If the primary, major reason that the patient is coming to the office is for the injury to the ankle that occurred at work while the patient was on the job, I would bring the patient in as a new patient for an initial encounter dedicated specifically for the work-related injury. This way an appropriate diagnosis and a treatment plan can be determined and submitted to the proper health insurance carrier or perhaps the place of employment itself depending upon what entity is responsible for any pre-certification and approval for the proposed treatment to be allowed and reimbursed. The last thing that you need is additional documentation in the medical record for the date of service in question related to a situation or additional problem that has absolutely nothing to do with the work related encounter.


 


I would bring the patient back at another date of service or perhaps, if possible, on the same date of service for the issue with the ingrown toenail/onychocryptosis that needs to be addressed. These two encounters would obviously not be initial patient encounters despite the fact that two different, separate health insurance concerns are involved. In the scenario that I described, the Workers Compensation encounter/visit would qualify as the “New Patient Visit.” The ingrown toenail encounter/visit would qualify as an Established Patient Encounter. 


 


Michael G. Warshaw, DPM, CPC, Lady Lake, FL



 


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03/17/2022    

CODINGLINE CORNER



Query: Return to the Operating Room


 


A Medicare patient was admitted to the hospital for foot infection and suspected osteomyelitis of the left, fourth toe. Amputation of the toe was done at the metatarsophalageal level and billed CPT 28820-T3. However, post-operative x-rays revealed that there was residual bone, presumably from the base of the proximal phalanx that remains. The patient was taken back to surgery a few days later for removal of the residual bone. This was done during the same hospitalization. Would this be coded as CPT 28124-78? Would the -78 modifier not apply since there is no global for the amputation? Could CPT 28124 be billed without a modifier? 


 


Michael Orosz, DPM, Cedar Rapids, IA


 


Response: 1) Yes, CPT 28820 has a 0-day global period; this means there is no pre-operative period and no post-operative days. Modifier -78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Post-operative Period: It may be necessary to indicate that another procedure was performed during the post-operative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier -78 to the related procedure. (For repeat procedures, see modifier -76.)


 


2) No need to append modifier -78. There is no modifier for global related services when there is a “0” day global in your example.


 


3) A “T” modifier is required as this is a toe surgery so T3 based on your question.


 


David J. Freedman, DPM, CPC, Silver Spring, MD



 


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03/15/2022    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Freddie L Edelman, DPM


 


Our practice (7 DPMs) uses Practice Fusion for EMR and Medent for management. This involves extra work for staff as we maintain 2 separate scheduling softwares but it works for us. 


 


We avoided what we believed were less expensive EMRs (although Practice Fusion was free at the beginning but is very reasonable today) and looked at what we thought would be around in 10 years after switching to Medent in 2000 when our previous software company did not have a reasonable plan for Y2K. This has worked for us since 2013 with only minor issues.


 


Freddie L Edelman, DPM, North Syracuse, NY

03/15/2022    

CODINGLINE CORNER



Query: ICD-10 and Liver Function Testing


 


When ordering liver enzyme studies prior to prescribing Lamisil or after prescribing that drug, what diagnosis code do we give the lab?


 


PM News Subscriber


 


Response: When ordering liver function tests (i.e. LFTs) prior to prescribing oral terbinafine, the most appropriate ICD-10-CM code to provide the laboratory is B35.1 (onychomycosis). After all, that is the reason why you are planning to prescribe terbinafine and that is what specifically terbinafine is indicated for. However, a secondary ICD-10-CM code that would be indicated is Z13.818 which is defined as: Encounter for screening for other digestive system disorders. The reason that LFTs are ordered prior to prescribing oral terbinafine is to rule out the presence of any issues in the liver which could possibly be compounded by the terbinafine.


 


As far as ordering LFTs once the patient has been taking terbinafine regularly, the primary ICD-10-CM code would once again be B35.1. The most appropriate secondary ICD-10-CM code would be R94.5 which is defined as: Abnormal results of liver function studies. That is the reason why the subsequent LFTs are being ordered.


 


Michael G. Warshaw, DPM, CPC, Lady Lake, FL



 


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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 1B



From: Ed Prikaszczikow, DPM, David Freedman, DPM


 


Dr. Kass asked, "What am I missing?" He also asked, "Why has podiatric leadership not challenged and corrected this abusive rule created by Medicare? Dr. Kass may not be aware of the many steps that APMA has taken to improve this situation, and we want to share with PM News readers APMA’s advocacy and education efforts on this important topic. More information and resources are available for APMA members in APMA’s -59 Modifier and Routine Foot Care Claims Toolkit at apma.org/59toolkit.


 


Several years ago, APMA recognized that a code bundling problem existed involving CPT 11720/11721 and 11055-11057 when performed on the same patient on the same date of service receiving at-risk foot care. 11055-11057 would be paid, but...


 


Editor's note: This extended-length letter can be read here

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


03/11/2022    

CODINGLINE CORNER



Query: Losing DME Revenue


 


With higher deductibles, rising insurance costs, and the popularity of online sites like Amazon, we have seen an increasing number of patients refusing DME such as pneumatic walkers and braces, and opting instead to go on Amazon. I have concerns for this, as patients do not know what type of device to get (other than if we printed a picture) and also sizing themselves. From a business perspective, we are losing this revenue. How do you address this? Do you offer a cash option, of course, one that is not a “better deal” than insurance? Can we at least give them an affiliate link to the exact product we recommend, but then have them return for a fit check if they are opting for Amazon? I appreciate any input.


 


Codingline Member, Hickory, NC


 


Response: This is becoming a nationwide issue, competition with “Dr. Google”, and finding pricing less for products such as DME. A key point is that patients save the money perhaps but get substandard or the wrong devices for their problem… then want you to fix it.


 


Suggestion: find the best product for your patients, discuss in detail why it is the right one to use, and perhaps have the logo of your practice added. If you have the courage to label as the best one from your practice, it can help to show the confidence you have in the device and why you think it is best for your patients. I cannot tell you it fixes all, but can make the discussions a bit easier in some cases.


 


Michael King, DPM, Nashville, TN



 


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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


PICA


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