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03/29/2023
CODINGLINE CORNER
Query: ABNs For Ingrown Nail Procedures
I billed for an ingrown nail procedure, denied for “too many services.” The patient has Medicare. The denied procedure was done in January 2023. The same toe had the same procedure done in November of 2021. The recent rule change regarding this took effect on June 6, 2022. We are appealing this denial. Are others running into this problem? I am wondering if my colleagues are having Medicare and Medicare Advantage patients sign an ABN at the time of service. There is no modifier -76 or-77 allowed as this was taken out in a follow-up revision.
PM News Subscriber
Response: This new, and egregious policy, in my opinion, is and will create more and more of these issues. I would appeal with records and make a note that the policy just changed and the prior procedure was done before the policy took effect. Don't hold your breath, but appeal and make note of the border, the digit affected, and that this procedure was later than what the policy cites. If this is a CPT 11750, you might have a harder time as they now expect these to be permanent, period. I would have a ABN signed and make it clear it is Medicare policy, not your office policy, and that they have changed the rules for allowing medically necessary care.
Michael King, DPM, Nashville, TN
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Other messages in this thread:
01/02/2024
CODINGLINE CORNER
Query: Coding For Injection
We had a little discussion in a meeting about the coding of an injection of the plantar fascia. The question revolved on whether or not to use CPT 20550 (that actually says “plantar fascia”) or CPT 20551 which says injection of a ligament or tendon origin or insertion. When we administer a plantar fascia injection, we are injecting the origin of an aponeurosis (a form of ligament-loosely speaking). Anyone want to weigh in?
Pennsylvania Codingline Subscriber
Response: When it comes to coding and selecting the most appropriate CPT code to bill for a procedure or service that was provided to a patient, specificity is the key. When it comes to administering a cortisone injection into the plantar fascia at its insertion into the calcaneus, CPT 20551 might appear to be an option. The problem is that when you look at the definition of CPT 20551, Injection(s); single tendon origin/insertion, clearly it is specific for the injection of a tendon and the plantar fascia is not a tendon.
You can describe the plantar fascia as an aponeurosis or as a ligament, but the bottom line is that CPT 20550 is specific for an injection of the plantar fascia. It is defined as the following: Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”). End of story.
Michael G. Warshaw, DPM, CPC, Lady Lake, FL
Editor's note: For the past 17 years, it has been our privilege to present excerpts from Codingline.com, founded by the legendary Harry Goldsmith, DPM. As Codingline ends its publication on December 31st, we wish to thank the Goldsmith Family for allowing this tradition to continue until now.
Starting January 1st, PM News invites readers to send your billing and coding questions directly to us at pmnews@podiatrym.com.
01/01/2024
CODINGLINE CORNER
Query: Storing Charts
I will be closing my clinic in the next few months. I have heard different things regarding how long doctors’ offices need to hold/keep/store charts. Typically, I hear 7 or 10 years. Is there a magic number or a source (like in California) to officially check?
Codingline Archive
Response: The time frame I use is 7 years, which addresses the outer limits of any Medicare or commercial insurance audit. Medicare regs specifically say you must keep all billing records for at least 6 years. From a medical malpractice standpoint, 7 years is more than enough for adult patients. For minors, you must keep charts until the age of majority, plus the statute of limitations period—2-3 years in most states.
J. Kevin West, Esq, Boise, ID
Editor's note: For the past 17 years, it has been our privilege to present excerpts from Codingline.com, founded by the legendary Harry Goldsmith, DPM. As Codingline ends its publication on December 31st, we wish to thank the Goldsmith Family for allowing this tradition to continue until now.
Starting January 1st, PM News invites readers to send your billing and coding questions directly to us at pmnews@podiatrym.com.
12/22/2023
CODINGLINE CORNER
Query: Tendon Resection
My question is regarding CPT coding for resection of exposed tendon. I have a patient with diabetes and a chronic ulceration. There is an exposed and devitalized anterior tibialis tendon that will need resection from its insertion and extensively within the expansive wound. I will be doing this in the operating room. What would be the appropriate CPT for this?
New York Codingline Subscriber
Response: I believe that the appropriate code for tendon debridement would be:
CPT 11043 debridement muscle, deep fascia, deep tissue layers, excluding bone.
Howard Zlotoff, DPM, Camp Hill, PA
Editor's note: For the past 17 years, it has been our privilege to present excerpts from Codingline.com, founded by the legendary Harry Goldsmith, DPM. As Codingline ends its publication on December 31st, we wish to thank the Goldsmith Family for allowing this tradition to continue until now.
Starting January 1st, PM News invites readers to send your billing and coding questions directly to us at pmnews@podiatrym.com.
12/21/2023
CODINGLINE CORNER
Query: Depo Medrol
How many units do you bill for injection using 1 cc of Depo Medrol 80 mg/ml?
Todd Pinsky, DPM, Boca Raton, FL
Response: The HCPCS Level II code for Depo Medrol 80mg/ml is J1040 which is defined as the following: Injection, methylprednisolone acetate, 80mg.
Since 1 cubic centimeter (cc) is synonymous with 1 milliliter (ml), either one will equal 1 unit of Depo Medrol. Taking this one step further, if an amount less than 1 cc/1 ml up to 1 cc/1 ml is injected, it will still be billed as 1 unit.
Michael G. Warshaw, DPM, CPC, Lady Lake, FL
12/19/2023
CODINGLINE CORNER
Query: Post-Operative Complications
I performed a hallux interphalangeal joint fusion on a patient 65 days ago. Against medical advice, he was walking in a regular shoe from day one. I documented it and put in the non-compliance ICD-10 in my note as well. This past Friday, he showed up in my office with the screw nearly poking through his skin. I plan to remove it this week; however, I wanted to bill an E/M for the encounter during the global with a -24 for this encounter. I would use the ICD-10 T84.84XA, pain due to internal orthopedic prosthetic devices, implants, and grafts, initial encounter. Would this be justified or is this a complication that is included in billing for the surgery?
PM News Subscriber
Response: A patient had a hallux interphalangeal fusion 65 days ago. The appropriate CPT code to bill is CPT 28755 which is defined as the following: Arthrodesis, great toe; interphalangeal joint. CPT 28755 is classified as a major surgical procedure code with a post-operative global period of 90 days. The patient presented to the office with the screw that was used for the fusion almost coming through the skin due to non-compliance. The patient is going to have surgery to remove the screw shortly, but the physician wants to bill an E/M service for the encounter in the office. Can this be done?
In order to bill an E/M service during the post-operative global period set by the CPT code/procedure, it is important to determine first whether or not the E/M service is directly related to the procedure. If the E/M service is not directly related to the procedure, the appropriate level of E/M service would be appended by the -24 modifier. The -24 modifier is defined as the following: unrelated E/M service during post-op period. Use this modifier (only on an E/M code) when you perform an evaluation and management service during the follow-up period of an unrelated surgical procedure. You are entitled to bill for an E/M service performed during the follow-up period if that service is not related to the original surgical procedure. In this case, add the -24 modifier to the E/M service code. Make sure you reference this service code to the appropriate unrelated diagnosis on the billing claim.
Unfortunately, ICD-10-CM code T84.84XA which would be linked to the E/M service is indeed directly related to the procedure that set the 90-day post-operative global period, and therefore the E/M service is not reimbursable.
Michael G. Warshaw, DPM, CPC, Lady Lake, FL
12/12/2023
CODINGLINE CORNER
Query: Denial of Steroid Injection Codes
Medicare continues to deny any and all steroid injections (i.e. CPT 20550, CPT 20551, CPT 20552, CPT 20660, CPT 20605) using appropriate associated diagnostic codes. The denials are usually accompanied by: “REM: 115 not medically necessary.” The denials occur with and without modifiers LT/RT. Any advice from Codingline would be appreciated.
PM News Subscriber
Response: The first thing I would do is check on your Medicare carrier’s website to see if they have a policy on these types of injections. If so, there will be a list of acceptable ICD-10 codes that are payable, as well as other coding/billing guidelines. If you are using an ICD-10 code that is maybe “appropriate” BUT IS NOT on the approved list, then your claim could be denied with the denial remark listed.
You could also ask the provider line for some assistance. They will not tell what the acceptable ICD-10 codes are, but they might be able to dig a bit deeper and see if there is more specific explanation for the denial. It could be even a technical issue with some information not coming across in cyberspace.
Lastly, check with your state association to see if this is a more widespread problem and not just your claim. They may need to contact your carrier about possible policy changes.
Tony Poggio, DPM, Alameda, CA
12/11/2023
CODINGLINE CORNER
Query: Matrix Biopsy
I have a patient with melanonychia of recent onset. It is unclear as to benign or malignant. I will be doing a nail avulsion and biopsy of the matrix. What code do I use for diagnosis? I am thinking it should be the skin lesion – behavior unspecified code, and I am unable to locate that code. Regarding the appropriate CPT code for the procedure, I am thinking of using the biopsy code, CPT 11755. Is that correct?
Iowa Codingline Subscriber
Response: a patient has melanonychia and a nail avulsion and a biopsy of the nail matrix will be performed on the affected toe. The most appropriate ICD-10-CM code would be D49.2 which is defined as Neoplasm of unspecified behavior of bone, soft tissue and skin.
With respect to the appropriate CPT code, I find the most appropriate CPT code to be CPT 11755 which is defined as the following: Biopsy of nail unit (e.g. plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure). If the toenail is avulsed to gain access to the targeted area, CPT 11730 is a Column 2 code to CPT 11755 the Column 1 code within the CCI edits and is not separately reimbursable.
Michael G. Warshaw, DPM, CPC, Lady Lake, FL
12/09/2023
CODINGLINE CORNER
Query: Billing E/M and Injection Codes
A new patient presented to my office for heel pain. I diagnosed plantar fasciitis and taught the patient posterior calf stretches. We discussed shoes and over-the-counter arch supports. I injected the plantar fasciitis at both feet and at the same visit, prescribed an NSAID. Is billing an E/M code acceptable along with the injections appropriate in this case?
California Codingline Subscriber
Response: To bill an evaluation and management code, you not only have to evaluate (perform an examination) but also manage the problem. Educating the patient about what the problem is, treatment options such as stretching, education on proper footgear and supports, and prescribing an NSAID is management.
You also happened to inject the heel. So you should be able to bill for both. Remember, it ultimately boils down to what you documented!
Tony Poggio, DPM, Alameda, CA
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
12/01/2023
CODINGLINE CORNER
Query: Nail Avulsion And Matrixectomy
I am resident and had a conversation among my peers about the coding for a surgical nail procedure. We have a patient that suffers from onychocryptosis, and in the clinic we perform a digital block using lidocaine. We then perform a partial nail avulsion of the medial border of the hallux. To complete the treatment, we apply phenol to destroy the matrix of the offending portion of the nail. Our question: Can we bill for CPT 11730 and CPT 11750?
Pennsylvania Codingline Subscriber
Response: No, you cannot. The CPT 11730 is inherent in the procedure with CPT 11750. This would be like billing for an exostectomy of the 1st metatarsal when doing a McBride or similar. It is part of what is required to do the “bigger” procedure. This unbundling may have been happening in the past but it would equate to double billing essentially the same procedure.
Michael King, DPM, Nashville, TN
11/30/2023
CODINGLINE CORNER
Query: G2211
I have been trying to educate myself on G2211. Does anyone have any scenarios when this might be appropriate to bill? I am not sure I understand when this might apply to something a podiatrist would see and treat.
Codingline Archive
Response: It is important to be aware that HCPCS Level II code G2211 is not a primary code. It is an add-on code.
HCPCS Level II code G2211 is defined as the following: Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)
HCPCS Level II Code G2211 was first proposed by CMS in 2021 as a way to compensate physicians for the extra work required for coordination of care for complex or serious conditions. Congress mandated a delay in implementation of the code until January 1, 2024.
The following information is from the 2024 Final Rule which was released November 2, 2023:
1. This code is for practitioners who use E/M services to report most of their...
Editor's note: Dr. Warshaw's extended-length response can be read here.
Michael G. Warshaw, DPM, CPC, Lady Lake, FL
11/29/2023
CODINGLINE CORNER
Query: Bundling Of Codes
Recently, there was a problem with Aetna Advantage Medicare plans refusing to pay for codes CPT 11720(1) and CPT 11055(6) together. I believe it was resolved. However, we now started seeing the same issue with EmblemHealth/HIP plans. This started in October 2023. The denial code: F86.F86: This service is part of the procedure that has already been billed. Submit records showing this is a separately payable service.
Recently, there was a case where a patient had a nail procedure (CPT 11730) and a diabetic ulcer debridement (CPT 97597) on the other foot. The CPT 97597 code was not paid with the denial code F88. F88: This service is part of a procedure that has already been billed. Separate payment will not be made.
Yelena Dreyzina, Office Manager, Bronx, NY
Response: And the story continues. Medicare Advantage plans just refuse to follow the rules and regulations as stated by traditional Medicare when it comes to “at risk” routine foot care. As long as the patient has a covered systemic disease and class findings and it is supported by the documentation within the medical record for the date of service in question, CPT 11055/CPT 11056 and CPT 11720/CPT 11721 should be both reimbursed when performed together on the same date of service. Aetna Medicare Advantage plans appear to be reimbursing for this code set after pressure was applied by the APMA. The correct coding scenario is:...
Editor's note: Dr. Warshaw's extended-length response can be read here.
11/28/2023
CODINGLINE CORNER
Query: Emergency Room Coding
My group takes call at our local hospital and this necessitates seeing patients in the emergency room (ER) on occasion. We are not all in agreement regarding what E/M codes should be used in this scenario. We have come up with different encounters:
-A patient seen in the ER. The patient is then discharged to follow-up for out patient care.
-A patient is seen in the ER and then admitted for continued medical treatment.
-A patient is seen in the ER and emergently taken straight to the operating room for surgical
treatment.
What E/M code series would you recommend using for these different scenarios?
Texas Codingline Subscriber
Response: When a patient is seen in the emergency room (ER) or in the emergency department of a hospital, it is important to know the rules that need to be followed regarding the billing of E/M codes:
• Time is not a descriptive component for the emergency department levels of...
Editor's note: Dr. Warshaw's extended-length response can be read here.
11/27/2023
CODINGLINE CORNER
Query: Diagnoses Codes Regarding Kidner Procedure
I have a patient that we are planning to move forward with surgical correction. The planned surgery will be a Kidner procedure at the left foot. I was hoping to get some input regarding the diagnosis codes. The patient has a prominent navicular exostosis. There is no os tibiale externum or accessory navicular. The patient has insertion pain and tendonitis at the tibialis posterior tendon. She does not have a significant pes planovalgus deformity. Thoughts on coding these?
Codingline Archive
Response: CPT 28238 is defined as the following: Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (e.g. Kidner type procedure). This is quite specific. The accessory navicular or os tibiale externum is excised and the posterior tibial tendon is advanced. In the above post, there is not an os tibiale externum present. The patient has an exostosis on the navicular. The posterior tibial tendon demonstrates insertional pain and tendonitis. What would be the most appropriate CPT code(s) to bill and the best ICD-10-CM code or codes to link to the CPT codes that are billed?
To address the prominent exostosis on the navicular, the most appropriate CPT code to bill for the excision or the removal of the exostosis is CPT 28122, which is defined as the following: Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (e.g. osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus.
To address the detachment and the re-attachment of the posterior tibial tendon, the most appropriate CPT code to bill is CPT 28200 which is defined as the following: Repair, tendon flexor, foot; primary or secondary, without free graft, each tendon.
What about the ICD-10-CM codes?
For CPT 28122, the most appropriate ICD-10-CM code is M89.372 which is defined as: Hypertrophy of bone, left ankle and foot.
For CPT 28200, the most appropriate ICD-10-CM code is M76.822 which is defined as: Posterior tibial tendonitis, left leg.
How about the coding scenario?
When the NCCI edits are accessed, the two CPT codes to be billed are not bundled. Therefore, the coding scenario is the following:
CPT 28122 – LT (M89.372)
CPT 28200 – 59, LT (M76.822)
Michael G. Warshaw, DPM, CPC, Lady Lake, FL
11/23/2023
CODINGLINE CORNER
Query: Functional Capacity Examination
Does anyone have experience with billing for CPT 97750 to Medicare/Noridian? What would the documentation be required when billing for this code? There is also a benefit maximum on these as well and would a -KX modifier be appropriate on rebilling those?
California Codingline Member
Response: CPT 97750 is defined as the following: PHYSICAL PERFORMANCE TEST OR MEASUREMENT (E.G, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES. This code covers a variety of physical performance tests that can help to evaluate a patient’s functional abilities. The test can be performed manually or with the use of equipment and should be separate from a regular evaluation or re-evaluation. For every 15 minutes of testing, one unit of CPT 97750 can be billed.
Specific documentation is required in order to support the billing of CPT 97550. When a physical performance test is performed under CPT 97750, it’s important to have a written report documenting the results. The report should explain why the test was performed, the specific methods used, the information collected, the time spent with the patient, and the therapist’s analysis of the results. This helps ensure that all relevant information is captured and recorded. The maximum number of units of CPT 97750 that can be billed on a specific date of service is 8 or 2.0 hours.
The KX modifier would be appended to a physical therapy CPT code if the maximum physical therapy/speech pathology annual allowance has been met. The 2023 cap for physical therapy and speech language pathology is 2,330.00. The KX modifier is defined as the following: DOCUMENTATION ON FILE – Use this Medicare modifier to indicate that specific documentation is contained in the medical record to justify the billed service.
One last point: I would consider appending the GP modifier to CPT 97750. The GP modifier is defined as the following: PHYSICAL THERAPY SERVICES – Use this Medicare modifier to indicate that the physical therapy services are being performed based on outpatient physical therapy “Plan of Care.”
Michael G. Warshaw, DPM, CPC, Lady Lake, FL
11/21/2023
CODINGLINE CORNER
Query: Sufficiently Detailed Exam
Can you describe what is a “sufficiently detailed exam” to confirm the diagnosis of peripheral arterial disease? I was audited and the payment for debridements of calluses were denied, even though documentation of every single class finding was listed. Are we supposed to do ankle brachial indexes, Buerger’s test, etc? Why have class findings if they do not qualify as “sufficiently detailed?”
PM News Subscriber
Response: I have a problem with the phrase “minimum documentation.” I believe the correct phrase should be “appropriate documentation.” With respect to the above post, the issue is a “sufficiently detailed exam.”
So, a patient qualifies for “at risk” routine foot care and is returning regularly (i.e. every 61 days) for follow-up “at risk” routine foot care encounters. Medicare Administrative Contractors do not find it appropriate to run one date of service into the next, in effect “cloning” the information from one “at risk” routine foot care encounter to the next. Medicare Administrative Contractors expect all encounters to stand upon their own documentation as if this was the only time that the patient was...
Editor's note: Dr. Warshaw's extended-length response can be read here.
11/20/2023
CODINGLINE CORNER
Query: Application of Skin Substitutes
I have been getting information from my wound care clinic regarding restrictions on the application of skin substitutions grafts. I am told that I won’t be able to apply more than four grafts for any given patient. Is this true?
California Codingline Subscriber
Response: Good news, for now; that is not correct. CMS and a few of its MACs had planned to institute a significant reduction in available cellular and tissue-based products (CTPs) and limit to 4 applications per year. Fortunately, they pulled back that change just before its scheduled start date of Oct 1. The most recent Federal Register made no mention of such change either, which could bode well for the delay in this policy. For now, it is business as usual in the use of your CTPs.
Michael King, DPM, Nashville, TN
11/17/2023
CODINGLINE CORNER
Query: Class Findings and Absent Pedal Pulses
I work closely with a vascular surgeon and have a hand-held Doppler in every room. Now, many times I cannot feel a pulse, but I can find it by Doppler. So, reading Medicare rules on Q8 class findings, if I cannot feel it… is it an absent pulse? Is the definition of an “absent pulse” the fact that you cannot feel it? Or must it be absent by Doppler as well?
PM News Subscriber
Response: the answer is, if you can’t feel it, as far as class findings are concerned, it is absent. The LCD also does not mention if the pulse is absent/present on the left or right foot only. While you should document laterality, the NCD/LCD do not mention it. If the dorsalis pedis (DP) artery is absent on the left and present on the right, as far as I am concerned (and I have won these on appeal) the DP pulse is absent from the perspective of the policy. Of course to qualify as Q8, you would need more (posterior tibial pulse is absent) or 3 other trophic changes to qualify.
Advanced trophic changes (at least three of the following):
Decrease or absence of hair growth
Nail thickening
Skin discoloration
Thin and shiny skin texture
Rubor or redness of skin
Paul Kesselman, DPM, Oceanside, NY
11/16/2023
CODINGLINE CORNER
Query: CMS Overpayment Request
I just received a request from CMS for an overpayment that occurred in 2019. Apparently the overpayment occurred for nursing home patients, using CPT 11721. The claims in question were paid at a level of in-office, not nursing home. No records were requested. Do I simply pay the overpayment back or request my malpractice carrier provide legal counsel? Also the claims are 4 years old. What is my recourse?
PM News Subscriber
Response: There are several issues here with this investigation and recoupment. If you were billing place of service (POS) 11 (office) instead of POS 31/32, then you did in fact bill incorrectly and depending on how the authorities view this, your billing was abusive or fraudulent. In this case, you will likely need to refund the entire amount and good luck trying to correct the POS and collect anything. This is especially true if the date of service (DOS) is more than 12 months ago.
As for billing POS 31 instead of POS 32, that is a whole other matter. It appears that many doctors billed the POS 31 because the Common Work File (CWF) told them the patient was in a Part A stay (POS=31 instead of a Nursing Home Long Term Care 32). The beds in these facilities are often interchangeable and more dependent on the patient’s stay. The costs of providing the care are equivalent, so why does CMS make a distinction to begin with?
Going back more than 6 years, it appears that the CWF was corrupt and mistaken, providing incorrect information. Should the providers be forced to refund the entire amount because the CWF was corrupt and they committed no abusive or billing action and then have to be paid the correct lower amount? The rational person would say no and simply refund the difference. However, CMS often is illogical and has no common sense. CMS and Social Security are the ones which committed the fraud here and their officials should be held accountable. This does not only affect DPMs, it affects every different type of healthcare provider, and the amounts attempting to be recouped by CMS are staggering. The amount for many physicians with SNF/Nursing Home based practices can be hundreds of thousands of dollars.
Paul Kesselman, DPM, Oceanside, NY
11/15/2023
CODINGLINE CORNER
Query: ABN
Is it necessary to obtain an advance beneficiary notice of non-coverage (ABN) for a patient that has Medicare and wants a DME item billed? In the scenario that I am dealing with, the patient does not have diabetes but would like custom-made foot orthotics.
New York Codingline Subscriber
Response: There is no statutory requirement for an ABN for foot orthotics as they are never covered unless placed into a shoe which is an integral part of a brace.
In this scenario I would bill: L30XX -GY LT and L3000 -GY RT
The patient will receive a patient responsibility notice and/or it may cross over to the patient's secondary for processing. Diabetes does not qualify a patient for foot orthotics (L3000-L3070) within the orthopedic footwear benefit. Inserts (A5512-A5514) and their requirements are explained within the Therapeutic Shoe LCD for Beneficiaries with Diabetes.
Paul Kesselman, DPM, Oceanside, NY
For information on Codingline subscriptions, click here
11/14/2023
CODINGLINE CORNER
Query: CPT 27745
Can podiatrists bill CPT 27745 (Repair, Revision, and/or Reconstruction Procedures on the Leg (Tibia and Fibula) and Ankle Joint)?
PM News Subscriber
Response: What was asked in the question was not accurate. CPT 27745-Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibia, your CPT code description you asked about is a category Repair, Revision, and/or Reconstruction (CPT 27650-CPT 27745). If your state practice act allows tibia surgery, then sure, CPT 27745 is billable; as you know, it is within the scope of practice.
David J. Freedman, DPM, CPC, Silver Spring, MD
11/10/2023
CODINGLINE CORNER
Query: Pre-operative Consultations
We have had some discussion lately regarding if and when billing for a pre-operative appointment is appropriate. This is an example of a scenario that we are considering. A patient initially presents with a pathology, is evaluated, x-rays are taken, and surgical care is discussed. The patient schedules surgery and an appointment to return to the office.
They are seen in the office prior to the surgery as a pre-operative consultation and an opportunity to sign a consent. At that consultation, there is a discussion once again that involves review of x-rays, the procedure and its risks, along with signing of consent. Is it okay to bill an office visit at that appointment?
John Dahdah, DPM, Pottstown, PA
Response: From your narrative, it appears that the decision was made to proceed with the surgery on the initial office visit. Since that determination has already been made, unless you are making decisions regarding this patient (e.g. new information and separately identifiable problem), the visit immediately prior to surgery is not separately chargeable. Why? Because there’s an inherent pre- and post-op global period built into the surgical CPT.
To sum up, simply seeing the patient to review the logistics of their surgical date, consent signing, etc. all sounds inherent to the pre-operative evaluation/management. This is not separately payable.
Paul Kesselman, DPM, Woodside, NY
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
11/08/2023
CODINGLINE CORNER
Query: Using Fracture Care Codes
I had a patient referred to me from an urgent care for an avulsion fracture of the proximal phalanx of the right hallux. It was minimally displaced and I treated her conservatively. I dispensed a hallux valgus splint to stabilize the fracture.
My billing included the following:
Diagnosis code: S92411D
Treatment codes: CPT 99203, CPT 28510 and L3100
The patient called her insurance company because she was surprised by the size of the bill and the use of a “surgery code.” The insurance representative told the patient that I should not have charged CPT 28510. Obviously, she called me to voice her displeasure with the financial side of this encounter. I have always charged for the management of the fracture with a 90-day global. Am I right or wrong in coding the CPT 28510?
California Codingline Subscriber
Response: This is often a conundrum for providers as to when and where to use fracture coding versus visit coding. I think you are most accurate, but for the initial visit being added. I am a strong advocate for the use of the initial outpatient visit code, but the fracture care actually includes the initial visit and the treatment, with the exception of such codes as the L code you used. The insurance representative appears to have no real knowledge of coding and was trying to appease the subscriber, in my opinion. Many will bill these visits on a visit by visit basis and some will argue that is right, others not. I think you did bill properly and I would fight for the 28510 and L code; but you may have to fold on the CPT 99203 based on what is considered included in the fracture care.
Michael King, DPM, Nashville, TN
11/07/2023
CODINGLINE CORNER
Query: Consultation Coding
I have a question regarding coding for a patient who has straight Medicare and a co-insurance. When, if ever, is it appropriate or is it payable to bill for a consultation code such as CPT 99243 or CPT 99244?
Jeffrey Klein, DPM, Warren, MI
Response: Medicare will not pay for the consultation codes. And if Medicare doesn’t pay, generally neither will the secondary. You will need to use office codes, or if you see patients in the hospital, use the hospital visit codes.
Katherine Sharp, Woodbury, TN
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