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03/29/2024
RESPONSES/COMMENTS (BILLING & CODING)
Query: Source for Coding Questions
Can anyone recommend a source to adjudicate coding questions. Our podiatry group has an ongoing back and forth with our coding specialist on a simple billing question.
Nathaniel E Applegate, DPM, Tulsa, OK
Other messages in this thread:
09/06/2025
RESPONSES/COMMENTS (BILLING & CODING)
RE :Call To Action For Anyone Who Bills Office Visits
From: Richard Silverstein, DPM
Recently, CMS released the 2025 NCCI Policy Manual, which includes clarifications on billing Evaluation and Management (E/M) services with procedures. See Chapter 1, pages 28-29.
Here is what CMS has said. Here’s what CMS emphasizes:
Minor procedures (000 or 010 global days):
The decision to perform the procedure is included in the procedure’s payment. An E/M service on the same day is not automatically billable, even for new patients. To bill both, the E/M must be significant and separately identifiable beyond the decision for...
Editor's note: Dr. Silverstein's extended-length letter can be read here.
04/01/2024
RESPONSES/COMMENTS (BILLING & CODING)
From: Kristin Happel
I have been billing/coding podiatry for almost 30 years, and I don't know of any "one source" that can adjudicate any particular question you may have. My suggestions are look to at your Medicare LCD, or look at the other insurance LCDs, if the question pertains to an insurance other than Medicare, and also use the coding tools provided by the APMA/your state podiatry association, if you are a member of either of them.
Also, The Podiatry Coding Companion is a must have for any podiatry office, but it doesn't necessarily address the vagaries of certain billing/coding questions offices may have. I am sure that if you post your billing question, I or other billing/coding experts on this forum would be happy to answer it.
Kristin Happel, Podiatry Biller, Chicago, IL
03/14/2024
RESPONSES/COMMENTS (BILLING & CODING) - PART 1B
From: Donald R Blum, DPM, JD
In a previous PM News an expert recommended:
CPT 28232 - T_
CPT 28232 - T_ - 59
When I go to NOVITAS (the Medicare carrier for my region), the descriptions might be the reason for the denial.
CPT 28230 - Incision of foot tendon(s)
CPT 28232 - Incision of toe tendon
The 28230 could be for multiple tendons because of the "s" and described as "foot" tendon(s) vs 28232 which is singular (no "s") and states "toe" tendon. According to the Novitas fee schedule, the 28230 reimburses about 15% more than the 28232 code.
Donald R Blum, DPM, JD, Dallas, TX
03/14/2024
RESPONSES/COMMENTS (BILLING & CODING) - PART 1B
From: R. Alex Dellinger, DPM, Eddie Davis, DPM
According to CMS, the MUE (Medically Unlikely Edits) for CPT 28230 is ONE. That means CMS only pays one unit per date of service. I have found most private insurances follow these edits that CMS have created. I imagine this is your issue, and my guess is you can appeal and appeal and appeal and it won't get paid. But they certainly should pay one time. More information can be found here:
R. Alex Dellinger, DPM, Little Rock, AR
The code 28230 is for an open flexor tenotomy of a single or multiple tendons. As such, attempting to bill it per toe would be rejected as it is only to be billed once. The code 28232 is for an open flexor tenotomy for a single tendon. It may be rejected if billed more than once because the insurance company would consider multiple tenotomies to be billed under the existing multiple code, 28230.
What procedure was actually performed? I usually would perform such tenotomies in the office, not as an open procedure. The traditional flexor set procedure is a percutaneous flexor tenotomy/capsulotomy. The code 28272 is for such a capsulotomy and is performed individually.
Eddie Davis, DPM, San Antonio, TX
03/13/2024
RESPONSES/COMMENTS (BILLING & CODING) - PART 1B
From: Jacob Panici, DPM, Keith L. Gurnick, DPM
You may be using an inappropriate code. When I have performed said procedures, I will utilize CPT 28220 for a single flexor tenolysis or CPT 28222 when performing multiple toes.
Jacob Panici, DPM, Raleigh, NC
CPT 28230 is for single or multiple tenotomies done at the same setting (same day). You can only bill 28230 code once. You should rebill 28230 T8 and then 28232 59T5.
CPT 28230 - Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure)
CPT 28232 - Tenotomy, open, tendon flexor; toe, single tendon (separate procedure)
Keith L. Gurnick, DPM, Los Angeles, CA
03/13/2024
RESPONSES/COMMENTS (BILLING & CODING) - PART 1A
From: Michael G. Warshaw, DPM, CPC
More often than not, it appears that it is the Medicare Advantage Plans that always find a way to not reimburse for a claim that was submitted. In the posted scenario, two flexor tenotomies were performed and billed for using CPT code 28230 appended by the toe modifiers. The payer denied charges stating" denied for exceeds number/frequency approved/allowed. Unfortunately, in this instance, the issue is not the Medicare Advantage Plan, but rather the incorrect way that this procedure code set was billed.
CPT code 28230 is defined as the following: Tenotomy, open, tendon flexor; foot single or multiple tendon(s) (separate procedure). Clearly, this CPT code is not intended to be used to indicate that a flexor tenotomy was performed on a toe. The definition of the CPT code demonstrates that the flexor tenotomy is performed within the foot, not the toe, and the CPT code is billed if one or more flexor tendons are addressed. It is apparent that this CPT code can only be billed one time per date of service. Billing the CPT code on two lines and appending a toe modifier on both lines was incorrect. Therefore,...
Editor's note: Dr. Warshaw's extended-length letter can be read here.
06/17/2019
RESPONSES/COMMENTS (BILLING & CODING)
RE: Your Claims Could be Deemed Unprocessable: RT LT Modifiers
From: Joseph Borreggine, DPM
The DME MACs issued a "Correct Coding - RT and LT Modifier Usage Change" joint publication on December 6, 2018, which provided instructions for billing right (RT) and left (LT) modifiers on separate claim lines. This is applicable when two of the same items or accessories (same HCPCS codes) are provided on the same date of service (DOS) and the items are being used bilaterally, and was effective for DOS on or after 3/1/19. These instructions have now been changed in several policy articles.
Bilateral items not billed on separate claim lines will be returned as unprocessable. Claims returned as unprocessable must be re-submitted. Unprocessable claims do not have appeal rights and cannot be re-opened or submitted for adjustment. Between May 29th and June 6th, 16.6% of JB claims would have been rejected with the outdated instructions, so be sure to review them.
Joseph Borreggine, DPM, Charleston, IL
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