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10/28/2024
RESPONSES/COMMENTS (CODING AND BILLING)
RE: ICD-10 Coding for Unequal Foot Size
From: Keith L. Gurnick, DPM
Many foot complaints and conditions are directly related to wearing an improper shoe size on our patients who have unequal foot sizes. Some obvious conditions include plantar fasciitis, subungual hematomas, metatarsalgia, ulcerated hammertoes, tailor's bunion bursitis, and others. These are caused or aggravated by wearing improperly sized shoes due to unequal foot size. This can include either foot length or foot width or both.
There exists a group of ICD-10 codes to designate unequal lower extremity limb length (this includes M21.7 series). I suggest that a group of codes should be created that would be useful to designate unequal foot length or foot width when claims are submitted.
Keith L. Gurnick, DPM, Los Angeles, CA
Other messages in this thread:
09/09/2024
RESPONSES/COMMENTS (CODING AND BILLING)
From: H. David Gottlieb, DPM, Ron Werter, DPM
Chart what your exam finds. Treat what you find. Bill what you treat. Document it all. Play by the real rules, not your wallet. Also, don't cheat yourself or the payor, whomever it might be.
H. David Gottlieb, DPM, Baltimore, MD
I have two questions:
1) My patient has 2 painful mycotic toenails which I debride and bill Medicare 11720. Because I'm a nice guy (or a fool) I then trim the other 8 non-mycotic or non-dystrophic nails at no charge to the patient or insurance. One of the posts seem to indicate that I specifically need to put in the chart that I am not billing for the trimming for the other nails as charity or whatever. I usually just put down I have trimmed the other nails but I don't make a point of saying I am not charging for them. Do I have to document that I am not charging?
2) My patient has 2 painful mycotic nails which I debride on a regular scheduled basis 11720. Because I have done such a great job of debriding the nails, on the next appointment the nails are still mycotic and have grown back, but are not painful. If I didn't see the patient on a regular basis, the nails would become painful. Do we have to wait for the patient to experience pain before they are able to have the debridement covered? If so, that seems to be against our oath to keep the patient pain-free and unfair to the patient that they must have pain before we can treat them.
Ron Werter, DPM, NY, NY
09/05/2024
RESPONSES/COMMENTS (CODING AND BILLING)
From: Michael M. Rosenblatt, DPM
Cheers and congratulations to the PM News subscriber who passed his Medicare RFC audit! I’m sure that doctor’s chart notes very carefully delineated medical necessity and a careful description of how the patients demonstrated need, and exactly the services the doctor performed.
The doctor also had RECORDS of active billings for ancillary services that were not covered by Medicare. Considering this doctor’s knowledgeable experience, I hope that the successful DPM provides lectures to new podiatrists coming on the scene locally.
It would be both a tragedy and a shame for this NOT to be transmitted to other DPMs in his/her community. By doing this, the DPM may very well be saving lives in our practice community.
Michael M. Rosenblatt, DPM (Retired), Henderson, NV
09/04/2024
RESPONSES/COMMENTS (CODING AND BILLING)
From: PM News Subscriber
I rarely bill CPT 11721. If it's for covered foot care, I will bill 11720 with 11719 or G0127. If not covered foot care, but eligible mycotic nail debridement, I will bill 11720 for only one toenail and charge the patient out-of-pocket ($50) for services to the remaining nails. Last year, I underwent a Medicare audit (passed with flying colors).
When I was asked by the RN why I was only billing 11720, I explained that I charged the patient to pay for services rendered to the other nails. I cannot routinely justify that someone has SIX or more toenails that are so thick and painful that they cannot walk or wear their shoes, especially after the first visit.
PM News Subscriber
09/03/2024
RESPONSES/COMMENTS (CODING AND BILLING)
RE: Routine Foot Care
From: Michael M. Rosenblatt, DPM
I noted a skilled nursing group is recruiting mobile podiatrists for one to two day commitments in an “underserved” patient group. They advertise their own equipment, software, and billing services to DPMs. I am not clear as to the framework of this care. I will reiterate that routine foot care is STILL not a Medicare covered service except under specific, defined, and well documented conditions. It is the obligation of DPMs to very carefully document and PROVE both the qualification for each patient and for medical necessity.
Medicare expects about 10-40% of this care to be either privately billed or donated by the DPM. This also means that patients and their families be informed ahead of time that the DPM services are not covered by Medicare. This is a well-known investigation channel for government regulators and auditors to seek and find podiatrists who violate these statutes and obtain convictions for Federal prison sentences. If you are taking part in any of these care positions, it is YOUR responsibility to prove you are following all the regulations clearly.
Absent private billing for non-covered services, a target expectation would be for podiatrists to openly donate 30-45% of these services and document them to prove to government auditors that they are following Medicare regulations. If a podiatrist can document donation of a significant percentage of foot care, it will be much more difficult for auditors to convict them of Medicare fraud.
Michael M. Rosenblatt, DPM, (Retired) Henderson, NV
06/10/2024
RESPONSES/COMMENTS (CODING AND BILLING) - PART 1B
From: Michael King, DPM
I would say, not likely... if not no. This would be looked at as an attempt to get paid for a nerve block for the debridement (which is not separately payable) vs. sympathectomy. You certainly can try with the appropriate ICD for vascular insufficiency and very distinctly and clearly document the reasoning behind such a block.
I would expect denial, and you would need to appeal and explain with your notes the clinical reasoning and medical necessity. I would be surprised as it will appear to be "gaming the system" to get paid for the block. Unfortunately, not all of our well-meant attempts to assist the patients are paid for, PT blocks being a big one in many cases of vascular and neurological pain.
Michael King, DPM, Nashville, TN
Editor's note: Do you have a question about Coding or Billing? If so, email bblock@podiatrym.com and we will try to publish answers to your question from certified Coding and Billing experts.
06/10/2024
RESPONSES/COMMENTS (CODING AND BILLING) - PART 1A
From: Michael G. Warshaw, DPM, CPC
The simple, most accurate and direct answer would be NO! However, support and justification for this answer is necessary. If a patient has PVD with ulcers that need to be debrided, and the ulcers are painful necessitating the administration of a nerve block such as a local sympathectomy of the posterior tibial nerve in order to perform the debridement(s), the necessity of the nerve blocks does not justify their reimbursement. Why?
The CPT codes that are used for the debridement of necrotic tissue out from within the base of the ulcer (i.e., 97597, 11042, 11042, 11044) are all classified as minor surgical procedure codes that have a post-operative global period of “0” days. When one accesses the “Global Policy for Minor Surgeries (0 or 10 day follow-up),” the 3rd item that is listed is the following: “ALL intra-operative services such as a local anesthesia, injections, dressings, casts, splints, post-op shoes, wires, pins, supplies, etc. that are a necessary part of a surgical procedure are included in the surgery fee.” I don’t think that it can be any more specific than this.
However, for those that are skeptics and don’t believe the above, here is more proof and support. Just access the NCCI edits. The CPT code of note that is used for the nerve block is CPT code 64455 which is defined as the following: INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH. When the NCCI edits are obtained, ALL of the ulcer debridement CPT codes (i.e., 97597, 11042, 11043, 11044) are the Column 1 code(s) to CPT code 64455, the Column 2 code. Therefore, since the administration of the nerve block is directly related to the debridement of the ulcer(s), CPT code 64455 is bundled with ALL of the ulcer debridement codes and is not separately reimbursable.
05/30/2024
RESPONSES/COMMENTS (CODING AND BILLING)
From: Marco A Vargas, DPM
I have been using Beacon Podiatric Billing services for 2 years now and have been extremely happy with their service. They work with several podiatrists and are ethical, meticulous, consistent, and tenacious. They are also very easy to get a hold of and have worked with my staff to improve our processes to code more efficiently, and have even gone back and recovered money from old claims that had previously been written off. I highly recommend them.
Marco A Vargas, DPM, Sugar Land, TX
05/29/2024
RESPONSES/COMMENTS (CODING AND BILLING) - PART 1B
From: Bill Beaton, DPM
I highly recommend checking out Practice Defenders in St. Petersburg, Florida.
Contact Lisa Merkow.
Bill Beaton, DPM, Saint Petersburg, FL
05/29/2024
RESPONSES/COMMENTS (CODING AND BILLING) - PART 1A
From: Steve Gershman, DPM
I use Clayburn Medical Billing in Media, PA. Margaret Clayburn is the owner and does the billing for several podiatrists. I have used her for several years now and am quite satisfied.
Steve Gershman, DPM, Auburn, ME
05/24/2024
RESPONSES/COMMENTS (CODING AND BILLING) - PART 1B
From: Keith Gurnick, DPM
The late great Harry Goldsmith, DPM, founder of Codingline discussed this issue as follows:
A Haglund's deformity is a prominence of bone located at the posterior-superior aspect of the calcaneus. It may be associated with "prominence of a bursal projection" (retrocalcaneal bursitis), posterior calcaneal spur, and/or Achilles tendinitis. The proper CPT code for correcting a Haglund's deformity depends on what specifically was performed, what was independent, and what was a component.
Excision of a Haglund's deformity may be coded either as CPT 28118 - ostectomy, calcaneus (ostectomy being the surgical removal of bone) - RVU 13.99 facility or...
Editor's note: Dr. Gurnick's extended-length letter can be read here.
05/24/2024
RESPONSES/COMMENTS (CODING AND BILLING) - PART 1A
From: Donald R Blum, DPM, JD
I recommend using CPT 28118 - ostectomy, calcaneus (ostectomy being the surgical removal of bone) with CD-10 code M89.37 for Hypertrophy of bone, ankle and foot, For resection of Heel Spur I recommend CPT 28119 - ostectomy, calcaneus; for spur (with or without plantar fascial release) with ICD-10 M77.32 (this is for left foot and M77.31 for right foot).
I use 28120 resection of bone "tarsal bossing" with ICD-10 code M89.37 Hypertrophy of bone, ankle and foot for the dorsal "bump" of bone usually located at the met cuneiform joint.
Donald R Blum, DPM, JD
05/10/2024
RESPONSES/COMMENTS (CODING AND BILLING)
From: Brian Lee, DPM, William Beaton, DPM,
We've used E-Professionals for about 7-8 years now and have been very pleased. Ask for Lisa.
Brian Lee, DPM, Mt. Vernon, IL
I have been using Practice Defenders for more than 10 years and they provide much more than just billing for the same rate. They service many podiatry offices throughout the country.
William Beaton, DPM, Saint Petersburg, FL
04/15/2024
RESPONSES/COMMENTS (CODING AND BILLING)
From: Robert D Teitelbaum, DPM
The second posting of the Michigan podiatrists' exhaustive essay on the murky origins and unjustifiable requirements for a nail avulsion procedure evoked a negative response from a reader which was critical of the repetitious, redundant, and long-winded nature of the post. Which it was on all counts, but with a very good reason.
This was a letter to the National Government Services (NGS) for an LCD reconsideration of this code. In this type of letter, which was tantamount to a legal brief, and was read by bureaucrats who are surely negatively disposed against the thesis of this type of letter, repetition is essential, and an incremental build of the logic of the argument is required.
In this they succeeded on all counts, and hopefully there will be some positive response to their letter. This is podiatry's dealing with 'the deep state', and it is boring, unfair, but absolutely essential to make this argument in this way.
Robert D Teitelbaum, DPM, Naples, FL
04/10/2024
RESPONSES/COMMENTS (CODING AND BILLING)
From: Jack Ressler, DPM
We as podiatrists can moan and complain about the guidelines Medicare has adopted for procedure code 11730 but the bottom line is those guidelines are not going to be changed. The procedure that podiatrists must perform to substantiate billing a 11730 code to Medicare truly sets our profession apart in skill level, training, and expertise from other healthcare workers, and more importantly nail technicians working in salons and non-medical environments.
One cannot argue that simply cutting back a small slant section of the nail border as compared to infiltration of anesthesia followed by removing a section of the nail border to the level of the nail matrix is the same procedure. There is no doubt that there are circumstances that performing the procedure required to bill a 11730 is considered overkill. If that is the case, how could one justify the fee generated from that procedure code and doing a much less complex procedure?
Proper surgical technique by the physician and post-surgical care by the patient should not significantly increase the risk of infection or other complications. For those who present the argument of putting your diabetic and other “at risk” patients in danger if you adhere to Medicare guidelines of performing a 11730, you should select a different procedure or explain to your patients that the treatment needed to remedy their problem is not covered by Medicare.
Jack Ressler, DPM, Boca Raton, FL
04/08/2024
RESPONSES/COMMENTS (CODING AND BILLING)
From Mark Spier, DPM
I'm not a computer scientist, I don't play one on TV, and I didn't sleep at a Holiday Inn Express last night, but I think this letter is an example of an endless loop. Or in Latin vernacular, simply ad nauseum. Or in Internet slang TLDR. Unfortunately, I did read it.
Mark Spier, DPM, Reisterstown, MD
04/05/2024
RESPONSES/COMMENTS (CODING AND BILLING) - PART 1
From: Sean Hodson, DPM
Just use L4397. Same reimbursement, no requirement for fitting or adjusting.
Sean Hodson, DPM, Crestview, FL
04/05/2024
RESPONSES/COMMENTS (CODING AND BILLING) - PART 2
RE: Nail Avulsion Procedure and Guidelines CPT 11730 Local Coverage Reconsideration/ Challenge
From: Ralph Zicherman, DPM, Herman Zicherman, DPM
Nail infections and treatments have been recorded and written about for the past 4,000 years. Nail infections affect about 25 to 35 million patients per year in the United States, and are responsible for considerable complications, ranging from pain, swelling and inflammation, to limitations in ambulation, gangrene, amputation, and death.
The treatment for nail infections has been termed a partial nail avulsion, which up until the early ‘80s simply required the excision and removal of the infected nail segment for Medicare reimbursement. This was a simple effective treatment, with little complication or difficulty, for the temporary correction and treatment of a nail infection. Depending on the extent of...
Editor's note: This extended letter can be read here.
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