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07/29/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: $40 or $45 custom orthotics?
Is this too good to be true?
Response from thedoctorline.com: If it turns out you are not providing a truly custom device derived directly from the patient's images, then there could be implications if you are audited.
The only way to know whether these devices meet the HCPCS definition of custom fabricated, would be to know the exact manufacturing process of the device. Will the manufacturer allow you access to that? Will the lab provide you with an attestation that the device was made from a positive impression of the patient's foot (from your negative)? Furthermore, will the lab state that the patient's exact positive was used (not a derived one from a sample library) to manufacture the device from raw material?
If there was any deviation from that, then it would not meet the current definition of custom fabricated according to the HCPCS definition. This could be problematic if the third-party payer asked for proof that the device was custom fabricated. To summarize, yes there could be implications for both you and the manufacturer should they not be providing you what the HCPCS definition stipulates is custom fabricated.
Paul Kesselman, DPM, Oceanside, NY Additional coding and billing questions and responses can be found at thedoctorline.com
Other messages in this thread:
08/04/2025
RESPONSES/COMMENTS (CODING & BILLING Q&As FROM THE DOCTORLINE.COM)
From: Elliot Udell, DPM
It’s true that a good lab probably cannot make custom orthotics for 45 dollars. There is, however, a greater issue behind this problem. Why are so many of our colleagues attracted to labs that are charging 45 dollars for "custom" orthotics?
Several years ago, when I was casting for and dispensing a great deal of orthotics, I ordered a set of custom tennis orthotics for a patient. He agreed to pay me for them. They addressed his problem nicely and all was well until I received a call from his wife and the insurance company. They informed me that I am contractually obligated to accept only what the insurance company is willing to pay.
Bottom line: I had to refund what the patient paid me and agree to accept twenty-six dollars and fifty cents for the orthotics. I lost money, but learned that with most of my insurance carriers, I would no longer be able to cast for and dispense orthotics. I consulted with the APMA insurance expert and was bluntly told that if I opt out of the contract, I could kiss all other podiatric services goodbye. I had to make a hard choice.
Elliot Udell, DPM, Hicksville, NY
07/31/2025
RESPONSES/COMMENTS (CODING & BILLING Q&As FROM THE DOCTORLINE.COM)
From: Timothy Messmer, DPM
I agree wholeheartedly with Jeff Root when he said, “I can assure you that it is not economically feasible for a company to make a profit and therefore stay in business selling custom orthoses for forty-five dollars a pair; and comply with the HCPCS definition of custom (i.e., an L3000 device) at the same time.”
Having been in private practice for over 27 years, and now serving as Medical Director for one of the premier custom orthotic laboratories in the world, I can say with confidence that all of us involved in the business of fabricating (truly) custom foot orthoses know what “custom” means and what it does not. Any company or vendor that is promoting what they offer/manufacture as truly custom orthoses knows what the HCPCS definition is for such a device (e.g., L3000).
Custom means the device is made from a plaster or foam or digital replica of the patient’s foot. Labs that use a library system are not creating actual patient-specific custom devices from a positive model of the specific patient’s foot. Taking a device from a library and ‘customizing’ it does not make it a truly custom orthosis either. Labs that take either of these manufacturing paths are choosing to not follow the universally-accepted definition, usually for their own economic gain and hopes of gaining market share.
Perhaps our podiatric organizations as well as publications that receive revenue from these dubious companies should have higher standards for what they will accept from vendors – rather than letting them say/sell whatever they want as long as they pay the advertising bill. We can do better as a profession and for our patients.
Timothy Messmer, DPM, Medical Director, Northwest Podiatric Laboratory
07/31/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Facility Accreditation and Surety Bonding
I've recently heard that Medicare, in an attempt to combat fraud, is going to institute a yearly facility accreditation and they have also started cracking down on something I never heard of, surety bonding. What is this, and as a DPM, do I require this?
Response from thedoctorline.com: All physicians, including DPMs, are exempt from the Facility Accreditation (FA) and Surety Bond (SB) requirements. However, this exemption applies only as long as you are providing the DMEPOS to your own patients. Once you start filling Rxs from other doctors and that's all you are doing, you have crossed the line, and at that point you may be subject to...
Editor's note: Dr. Kesselman's extended-length letter can be read here. Additional coding and billing questions and responses can be found at thedoctorline.com
07/30/2025
RESPONSES/COMMENTS (CODING & BILLING Q&As FROM THE DOCTORLINE.COM)
From: Jeff Root
I’m very surprised that someone hasn’t questioned the validity of these so-called “custom” orthoses being sold for forty to forty-five dollars per pair, including delivery, prior to this thedoctorline.com inquiry. Also, I’m disappointed that the concern expressed is related to coding liability as opposed to the possibility that the practitioner and or the patient may be a victim of fraud. In addition, one should question the efficacy of such devices. Dr. Kesselman did an excellent job of explaining that in order to determine if a custom orthosis meets the HCPCS definition of custom fabricated, one would have to know the exact manufacturing process. I can assure you that it is not economically feasible for a company to make a profit and therefore stay in business selling custom orthoses for forty-five dollars a pair; and comply with the HCPCS definition of custom (i.e., an L3000 device) at the same time.
I am aware that some distributors who sell raw materials and pre-fabricated shells to podiatrists and labs alike, sell pre-fabricated orthotic shells to some of these companies who sell “custom” orthoses at these unbelievably low-price prices. Part of the problem is that the seller’s definition of custom may be different than the HCPCS's definition of custom. For example, if a doctor sends a cast or a scan to a lab and the lab uses a pre-fabricated shell and customizes it by adding a blue top cover as opposed to a red one, and maybe a met pad and a heel lift, is that a custom made device? One could argue it is because it was made-to-order and was customized to the doctor’s specifications, but it certainly wouldn’t meet the HCPCS definition of custom. In the interest of practitioner and patient protection, this issue needs much closer inspection.
Jeff Root, President of KevinRoot Medical
07/28/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Eccrine Disorder
What is the recommended treatment code for L74.8 (eccrine disorder) with debridement of the lesion. My first impression would be callus debridement (1105-7), but it is not really a callus. The treatment is not destruction of a benign lesion.
Jeff Leibovitz, DPM, Indianapolis, IN
Response from thedoctorline.com: Let's start with the definition of CPT 11055-11057, defined as Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus);11055= single lesion, 11056= 2-4 and 11057=5 or more. You are correct; you stated it is not a callus so it would not be appropriate. You biopsied the growth and determined it was a "L74.8 Other eccrine sweat disorders" or was it a "L85.8 Porokeratosis, acquired" or was it a "D23.7- Porokeratosis (other benign tumor)"
We often find the incorrect diagnosis is assigned to the abnormal skin growths and it is important to know that is the correct diagnosis as to what you are treating. Using the correct terminology is key. If you are removing tissue,
Editor's note: Dr. Freedman's extended-length response can be read here.
Additional coding and billing questions and responses can be found at thedoctorline.com
07/23/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Third-Party Deadlines
How long does an insurance company have to process and pay a claim? We have had several instances here in NY where insurance companies don't acknowledge receipts of claims processing nor pay the claims for months. What can I do to force them to process/pay these claims?
NY Podiatrist
Response from thedoctorline.com: In NYS, generally speaking, an insurance company has 30 days to process a claim. However, that does not mean actually pay the claim. There are a myriad of reasons why a claim may require further processing prior to it being paid. If you have not received any correspondence from the carrier 30 days after submission of the claim, they may be in violation of NYS regulations.
If continued correspondence from the insurer fails in securing any acknowledgment from the carrier that they have received the claim, you might want to contact the NYS Attorney General's...
Editor's note: Dr. Kesselman's extended-length response can be read here. Additional coding and billing questions and responses can be found at thedoctorline.com
07/22/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Q7 Modifier
How much of a patient's foot must be missing before they qualify for a Q7 modifier? Is missing one or more metatarsals a Q7? If they've had a transmetatarsal amputation, do they qualify for a Q7? If I'm reading the modifier correctly, it seems to imply that the entire foot must be missing to qualify for a Q7
Rahul Gor, DPM, Flushing, NY
Response from thedoctorline.com: Q7 is defined as "Class A findings are specifically defined as a non-traumatic amputation of the foot or a part of the foot's skeletal structure." So, as you can see, it can be any part of a foot, not just the whole foot.
David Freedman, DPM, Silver Spring, MD
Additional coding and billing questions and responses can be found at thedoctorline.com
07/14/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Is it compliant to go back and rebill a wrongly-sized CTP application?
My practice put on the smallest size, so we thought, for a graft needed for a patient. Only, to find out the company sent a larger graft 3x the size than we ordered. They feel we should go back and rebill as wasting the 3/4 of the graft not used. Is this okay?
Olney Doc
Response from thedoctorline.com: If you only put on the smaller graft size and documented that you used a smaller graft, it would be inappropriate to go back and bill wastage when you really did not waste graft. Plus, how can you justify ordering a larger graft size when you were using the smallest graft? You are supposed to use the smallest graft option that fits the wound size you are treating. I would tell the graft company that it is not compliant to go back and say you wasted 3/4 graft.
David Freedman, DPM, CPC, Silver Spring, MD
Additional coding and billing questions and responses can be found at thedoctorline.com
07/08/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Custom Diabetic Inserts
I was referred a Medicare patient with a chronic DFU to make custom inserts (A5513). He recently received shoes and pre-fab inserts from a vendor this calendar year. Am I allowed to make (and get paid for) a pair of the custom insert (A5513) without dispensing the shoes and especially since he has gotten 3 pairs of the A5512?
Ron Werter, DPM, NY, NY
Response from thedoctorline.com: This is an excellent question and one I both faced clinically when I was in practice and continues to be problematic for both the supplier and patient. First off, if a patient has already received shoes and three pairs of inserts, no matter which code, then they have exhausted their Medicare coverage.
If the patient has a clinical need for custom inserts, then they need to be informed that Medicare will not cover these devices simply because the Medicare policy only permits them to receive three pairs of inserts, regardless of their clinical needs.
As for which device to chose and resolve, you have two choices...
Editor's note: Dr. Kesselman's extended-length response can be read here. Additional coding and billing questions and responses can be found at thedoctorline.com.
06/23/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Plantar Plate Repair
I recently repaired a PL tendon with moderate resection of a diseased/torn tendon with re-tubularization. I also placed a collagen implant (It is not considered a graft, but an implant)-Regeneten-Smith and Nephew. Would I bill bone spur removal-28118? Would CPT 28313 be accurate?
Enzo Leone, DPM
Response from thedoctorline.com: You asked about coding: CPT 28210 Repair, tendon, extensor, foot; secondary, with free graft, each tendon (includes obtaining graft). Doesn't the peroneus longus evert and plantarflex the foot? So, I would use instead CPT 28202 - Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft).
When you say, "Bone spur removal-28118" CPT 28118-Ostectomy, calcaneus; this means you removed bone on the part of the calcaneus that was not related to the peroneal repair.
Last you asked, "Is there also a code for debridement of the tendon - extensive debridement?" Tendon debridement is tenolysis. In this case, if we are talking about a different anatomical place than repair, then CPT 28220-Tenolysis, flexor, foot; single tendon would be that option for that additional work. Additional coding and billing questions and responses can be found at thedoctorline.com.
David Freedman, DPM, CPC, Silver Spring, MD
06/16/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
From: Robert Scott Steinberg, DPM
From the Hospital for Special Surgery: "Disclaimer: Most “regenerative medicine” treatments including platelet-rich plasma, bone marrow cells, adipose-derived cells, and materials derived from “birth tissues” (amniotic fluid, amniotic membrane, placenta, and umbilical cord blood) are not FDA-approved for treatment of musculoskeletal conditions."
Yes, talk to your malpractice carrier. It's a free phone call.
Robert Scott Steinberg, DPM, Schaumburg, IL
06/13/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Amnionic cell membrane injection/umbilical cord injection for muscular skeletal injuries
What is your view of the use of these products for Achilles tendinitis and plantar fasciitis. There was a article by the FDA in 2021 which stated that amniotic products are only to be used for experimental treatments. However, when reviewing this, this is the only article that I have located that says that it should be experimental.
What is your thought on whether we can offer this to our patients as long as in the consent we spell out that the FDA has approved the use of this item for human use, although it is experimental in terms of its use for these conditions.
Joel Morse, DPM
Response from the Doctorline.com: I recommend contacting your medical malpractice carrier as to their policy, or your healthcare attorney when you desire to use amniotic cell membrane injection/umbilical cord injection for muscular skeletal injuries. Your post, I believe, is lacking the more recent article published. Consider reviewing the bibliography for many other articles that have been written. The best advice is contact your healthcare attorney and/or medical malpractice carrier before starting to use this in your practice. Additional coding and billing questions and responses can be found at thedoctorline.com.
David Freedman, DPM, Silver Spring, MD
06/10/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Extracorporeal Shockwave Therapy ESWT
Do any doctors have any thoughts on Extracorporeal Shockwave therapy ESWT with regards to whether it is covered by traditional Medicare? If answer could relate to New Jersey Medicare, this would be helpful. If covered, what diagnosis codes and procedure codes are used. Also, are there requirements for alternative treatments to be tried first and to fail before Medicare will cover the ESWT. Or, is this a strictly cash payment and not covered by Medicare at all?
Response from thedoctorline.com: ESWT for Novitas Medicare who covers the State of NJ does not cover ESWT (Extracorporeal Shock Wave Therapy) for various musculoskeletal conditions, including plantar fasciitis. This is because Medicare considers ESWT experimental or investigational and insufficient evidence of its effectiveness has been established. So, it is a cash service.
David Freedman, DPM, Silver Spring, MD Additional coding and billing questions and responses can be found at thedoctorline.com
06/04/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Sending Records to DPM Who Was Previously in Our Practice
Does a patient need to sign a record release authorization form if they are seeing an established DPM at their new facility? A patient had surgery from a DPM who was in our practice at the time. That DPM is now at a new location, but we still have the patient's records. Can I just forward the records to that DPM's new location, or does the patient need to sign a record release auth allowing us to forward their records to the new facility?
Response from thedoctorline.com: The answer is yes. The previous practice owns the records and they can only be accessed by those healthcare practices within that system treating that patient and the patient themselves or whomever else they authorize access to. The patient can gain access to those records by signing an authorization and they can either be sent to the patient or the patient may choose to have the records released to the new practice.
While the patient is seeing the same doctor, from a HIPAA and entity perspective, they are not. At least that's the way it works here in NY several times, when doctors moved from one hospital system to another. Lots of hoops to go through, but in essence it was no big deal. By all means, check with your professional liability perspective. I will be surprised if you receive a different answer.
Paul Kesselman, DPM. Additional coding and billing questions and responses can be found at thedoctorline.com.
06/03/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: CPT Code for Keller Bunionectomy
What is the proper CPT code for the so-called Keller bunionectomy. I'm going round and round with my coder and some recent CPT changes. It is their position that a Keller is two osteotomies (resection of the medial 1st Met. head and proximal phalanx).
Gary Mantell, DPM, Memphis, TN
Response from thedoctorline.com: The term "Keller" bunionectomy was removed from CPT on 1/1/2017. In fact, all named procedures were removed like Austin, Mayo, McBride, etc. The proper CPT terminology for CPT 28292 - Correction, hallux valgus with bunionectomy, with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method.
You stated you did "resection of the medial 1st Met. head and proximal phalanx", this is CPT 28292. The position that a "Keller" is two osteotomies is not appropriate at all, the procedure is removal of bone in two different bones. Additional coding and billing questions and responses can be found at thedoctorline.com
David J. Freedman, DPM, CPC, Silver Spring, MD
05/16/2025
CODING & BILLING Q&As FROM THE DOCTORLINE.COM
Query: Extracorporeal Shockwave Therapy ESWT
Do any doctors have any thoughts on extracorporeal shockwave therapy ESWT with regards to whether it is covered by traditional Medicare? If the answer could relate to New Jersey Medicare, this would be helpful. If covered, what diagnosis codes and procedure codes are used? Also, are there requirements for alternative treatments to be tried first and to fail before Medicare will cover the ESWT? Or, is this a strictly cash payment and not covered by Medicare at all?
Response from thedoctorline.com: ESWT for Novitas Medicare who covers the State of NJ does not cover ESWT (Extracorporeal Shock Wave Therapy) for various musculoskeletal conditions, including plantar fasciitis. This is because Medicare considers ESWT experimental or investigational and insufficient evidence of its effectiveness has been established. So, it is a cash service.
David Freedman, DPM, CPC, Silver Spring, MD
Additional coding and billing questions and responses can be found at thedoctorline.com
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