Podiatry Management Online


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Query: Hallux Valgus Repair

We are trying to the locate the appropriate code(s) for a hallux varus repair by capsulotomy and Mini-TightRope.

Joy Constanzo, Billing Supervisor, Office of Kirk Koepsel, DPM,

Houston, TX

Response: There is no specific code for this service. You should bill for the actual procedure(s) performed. It this case, your options could include CPT 28270 which is capsulotomy metatarsal-phalangeal joint, or CPT 28313 (reconstruction angular deformity of toes, soft tissue procedure only).

There is no code for the TightRope use. It is a product used in the primary repair procedure. If you feel the work done was significant enough, append a "-22" modifier. The op report should clearly document that work. Be sure to include a letter of explanation.

Tony Poggio, DPM, Alameda, CA

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Other messages in this thread:



Query: Evaluation & Treatment of the Same Condition on the Same Day


An established patient presents with a new complaint. I do a thorough evaluation, including history of present illness (NLDOCAT) and physical exam (4 systems). The patient is educated on her diagnosis, and the condition is treated the same day with a steroid injection. My understanding has been that I bill for either E/M or injection. My office manager is not in agreement, since a separately identifiable evaluation and management service was provided, even though it was for the same condition. Please advise. 


Richard Wolff, DPM, Oregon, OH


Response: Your office manager is correct. If the E/M service is separately identifiable from the procedure performed, you may bill for that E/M service in addition to the procedure. This is true if the E/M and procedure are for the same problem and also true for an established patient. 


It is important that the documentation for this encounter supports the fact that a separately identifiable E/M service was performed and that it was necessary. 


Jeffrey Lehrman, DPM, Springfield, PA



Query: Debriding a Cutaneous Horn


Is debridement of a cutaneous horn-type hyperkeratosis that protrudes from the tip of the toe about 6 mm on a diabetic who's on Medicare covered? How about if the patient has qualifying diagnoses and class findings? The gentleman has a rigid hammertoe which has caused this callus on the tip of the toe about 5 mm from the nail. Can I bill for the nail debridement as well? 


Joseph Borreggine, DPM, Charleston, IL


Response: This is a covered service, CPT 11055, if the patient meets the criteria for callus debridement under your routine foot care LCD. Same rules apply with the diagnosis and class findings. 


Jeffrey Lehrman, DPM, Springfield, PA 



Query: ICD-10 for Plantar Fibroma


What is the ICD-10 code everyone is using for plantar fibroma? 


Monica Link, DPM, Houston, TX


Response: I believe the code you are looking for is M72.2 (plantar fascial fibromatosis), which is the same code you would use for plantar fasciitis. 


Paul Kinberg, DPM, Dallas, TX



Query: Removal of Benign Cyst


What CPT code is most appropriate for removal of a benign lesion/cyst such as a ganglion cyst? 


Monica Link, DPM, Houston, TX


Response: The location of the cyst would determine which CPT code is best. 


A cyst excised from the toe would be coded using CPT 28092. 

A cyst excised from the foot would be coded using CPT 28090. 


Howard Zlotoff DPM , Camp Hill, PA 



Query: Post-Op ORIF Care for Another Surgeon


I saw a new patient yesterday who had open reduction internal fixation (ORIF), left ankle, 2 weeks ago while on vacation up north. She was referred by her primary care physician to me for "post-op care." She was a new patient to my practice, and required x-rays, removal of sutures, and a walking cast application. She will need follow-up and subsequent office visits, cast changes, x-rays, and other post-op care. Needless to say, I am assuming care. 


Do I bill an office visit, cast application, x-ray study, or do I use the ORIF procedure code with modifier "-55" (post-op management only)? What do I bill for subsequent care if I use the ORIF code? 


Jeffrey Klein, DPM, Waterford, MI


Response: Keep life easy and bill a new patient office visit along with whatever else you did. Don't bother with the post-op management coding. 


Don Self, Don Self & Associates, Whitehouse, TX 



Query: Coding J3301 Units


The medical records note that 0.5cc of 0.5% Marcaine and 1.0 cc of Kenalog 10 were injected. The Kenalog bottle says 50 mg per 5 ml. 10 mg per ml. I need to report units on the claim. How many units? The product code for Kenalog 10 is J3301. Is the Marcaine included with the J3301? 


Laurie, Office of John Arsen, DPM, Lake Orion, MI


Response: J3301 is described in HCPCS as: "Injection, triamcinolone acetonide, not otherwise specified, 10 mg." The product description 10 mg triamcinolone acetonide per ml.  If you inject 1.0 ml of Kenalog 10, you would be injecting 10 mg, and billing 1 unit. If you inject 1.5 ml (10 mg), you would be billing 2 units, 2.0 ml, 3 units. And so forth.. 


The local anesthetic, be it Marcaine, lidocaine, etc., is incidental and not separately billable. 


Paul Kesselman, DPM, Woodside, NY 



From: Robert Scott Steinberg, DPM


Your exam, and then your plaster-of-Paris cast, should capture the forefoot varus or valgus. If you use a quality lab and order internal or external forefoot post correction, it should be included in L3000. Be very careful of any "creative" coding. I  also recommend using an orthotic lab that supports podiatry and is not a retail operation.


Robert S. Steinberg, DPM, Schaumburg, IL



Query: L2275 Billed with Orthotic Forefoot Posting


Does anyone have experience billing L2275 (addition to lower extremity, valgus or varus correction) when the orthotic needs forefoot posting at the time of billing L3000? Our local pedorthic lab does this and suggested that we do as well. 


Saera Arain-Saleem, DPM, Elmhurst, IL


Response: L2275 (addition to lower extremity, valgus or varus correction; plastic modification, padded/lined) can be found in the "Additions to Lower Extremity Orthosis - Shoe-Ankle-Shin-Knee" HCPCS section. 


This is separate, preceding the foot orthosis coding which resides in the section headed by "Foot (Orthopedic Shoes) - Insert, Removable, Molded to Patient Model" beginning with L3000. It would be inappropriate to choose a code for an AFO addition item and apply it as an addition to a foot orthosis device code. 


Harry Goldsmith, DPM, Cerritos, CA



Query: HIV and Qualified Routine Care


Is HIV positive status still a covered criteria for routine footcare in New York? If so, what ICD-10 code would be acceptable? Does the person need to be vascularly compromised? 


Stephen Bennett, DPM, NY, NY


Response: I checked your LCD on routine foot care. There is no listed approved coverage for HIV (B20) present. 


Jeffrey Lehrman, DPM, Springfield, PA 



Query: Diabetic Shoes in Assisted Living Facility


I was asked to order shoes for a diabetic patient (Medicare and ward of the state) who presently lives in an assisted living facility (POS = 13). Besides the necessary paperwork to be filled out by the primary MD/DO, are there any different requirements for reimbursement as there are when a patient is in a nursing home?  Do you need to have an agreement with the facility or an ABN from the family prior to fitting the shoes because the patient does not have the capacity to make decisions? 


Debra Manheim, DPM, Parsippany, NJ


Response: Before proceeding any further, be perfectly sure that this patient is eligible for Part B fee-for-service Medicare. Because she is a "ward of the state", you want to be certain that she is not enrolled in a mandated managed dual eligible plan. This would be considered a Part C Medicare plan and could carve out DMEPOS to only large commercial suppliers. If she is confirmed as Part B Medicare, then the same rules apply to a patient living at home. Assisted living (POS 13) is not the same as Part A Medicare (which would cover the patient in a skilled nursing facility - POS 31) where consolidated billing regulations should apply. 


In my opinion, no separate agreement with the assisted living facility should be required. It would be the same scenario as a patient living in a nursing home (POS=33) but not in a skilled nursing bed. 


Paul Kesselman, DPM , Woodside, NY 



Query: Tier 1 and Tier2


Recently, insurance companies are designating our practices into Tier 1 or Tier 2 according to our utilization of certain services. Patients who seek a Tier 2 doctor generally have to pay a higher co-pay than if they choose a Tier 1 provider. How can we, as providers, find out what Tier we are in with the various insurance companies? 


Sandy, Office of Allan Hetelson, DPM, Bensalem, PA 


Response: We currently have two plans that our office deals with which have the tier system. The first plan is pretty simple and has guidelines that we have to follow in order to be a tier 1 (lower co-pay) for patients who present in our office. With this said, we have to provide MU and PQRS to them on a regular basis as well. They put a tracking system in our software to assist in gathering the MU/PQRS data. The second plan is a Highmark plan in the state of Pennsylvania. This plan is specifically a marketplace plan. With this Flex Blue PPO plan, we are also told that we are in the higher co-pay bracket. When I called the insurance company and our insurance rep, all I was told was that we are not enhanced because our doctor is not affiliated with Penn State Health or Pinnacle Health System. As a result, we have new patients presenting with this marketplace plan showing a $120 co-pay. 


When I dug as deep as I could to find out how we could be considered part of the Penn State Health plan/Pinnacle, I got no where. All I was told was that they are not adding new doctors to their preferred network at this time. Our doctor is also on staff at our local Penn State Hospital and sees patients at their clinic. Apparently, seeing patients at the Penn State Clinic doesn't grant you the ability to be in the lower co-pay tier. It is important to note that this marketplace plan was tiered this way in 2016 to allow for a lower monthly premium. As a result, patients are finding out that it comes with some restrictions on which doctors they can and can not see. We have encountered many patients who felt that they were misled on this Flex Blue Highmark plan. 


Jennifer Fields, Office Manager, Office of Paul LaFata, DPM, West Lawn, PA 



Query: Senior Housing POS & Coding


Has anyone had any experience with coding podiatry services to residents of senior housing? The place of service is not assisted living in any way. These are just apartments for seniors. The facility contacted our office about coming there and treating the residents. Would this be considered "home care", and is it covered? 


Nancy, Biller, Podiatry Associates of Rocheser, Office of Michael Giordano, DPM, Mt Kisco, NY


Response: Place of service would be "12" which is "home." The scenario you presented is not "assisted living."


Joseph Borreggine, DPM, Charleston, IL



Query: CPT 20600 Injection


I am looking for the code to use for an injection of an arthritic joint. I am proposing CPT 20600, however, no LCD exists for the code. Any thoughts? 


Donald Carlson, DPM, Hermiston, OR


Response: For injection of an arthritic interphalangeal joint or metatarsal-phalangeal joint, I suggest CPT 20600. For injection of a midtarsal, subtlalar, or ankle joint, I suggest CPT 20605. 


Pick the diagnosis code(s) that best describes the pathology and qualifies the therapeutic injection. 


Jeffrey Lehrman, DPM, Springfield, PA



Query: Coding Skin Substitute Graft Application


What is the proper way to bill skin graft substitute for bilateral extremities? Does the code, CPT 15275 or CPT 15271 include the application of graft to both extremities if the total square centimeters is less than 25? Are you able to bill for the product code individually if there are two separate product units? 


Anthony Fiorilli, DPM, Howell, NJ


Response: Yes, exactly as you stated: 1 unit of CPT 15275 includes applications to multiple areas within an anatomic category if the total wound area combined in that category is less than 25 sq cm. That does include both feet. If you applied graft to foot and leg wounds, then you would be able to use both the foot and leg codes with the exact code dependent on the total square cm of each. 


As for the product, you can code for as many units as you purchased for that encounter. If you cut one piece of product X in half and apply it to two wounds, you can only bill for one piece of product X. If you bought two of them and applied one to each wound, then you can bill for two of them. The number and sizes you purchase should be appropriate based on the size of the wound(s). 


Jeffrey Lehrman, DPM, Springfield, PA 



From: Joseph Borreggine, DPM


Regarding what Dr. Hultman stated in a recent Codingline interview, I must disagree because podiatry does not have the same credible education according to our medical colleagues. The fact is that the curriculums at the podiatry colleges change every couple of years, and hence, there is no standardization in education at all. 


The actual way to an MD degree is in a conjoint venture with a medical school. Most, if not all, physicians assistants, nurse practitioners, and osteopaths are trained in medical teaching hospitals. If that were the case with podiatry, that would solve part of the problem , but alas...


Editor's note: Dr. Borreggine's extended-length letter can be read here



Query:  Dehisence of Surgical Wound Diagnosis Code


I had a patient with a dehiscence of surgical wound that required repair. At the time of the procedure, I coded the dehiscence as T81.31S (disruption of external operation (surgical) wound, not elsewhere classified).  My clearinghouse is returning the claim as "T81.31S is not a valid diagnosis code". I also tried T81.31A and T81.31D with the same results. Comments?


Lawrence Tamburino, DPM, Brandon, MS


Response: I recommend ICD-10 code, T84.32XA: "active treatment" of disruption of internal operation (surgical) wound, not elsewhere classified. In your example, you only have 5 characters of a code that requires 7 characters. In those cases, you add an "X" placeholder in the 6th character position, and then choose the appropriate "A, D, and S" 7th character. 


Joseph Borreggine, DPM, Charleston, IL


Just one more point... surgical complications are not eligible for the 7th character "S" (sequela) use. Sequela character use is limited to complication(s) after the acute phase of the injury or illness. 


Harry Goldsmith, DPM, Cerritos, CA



RE: Metatarsal Osteotomy & Plantar Plate Repair (Howard Zlotoff, DPM)

From Michael G. Warshaw, DPM, CPC


After reading the posts on this topic by Dr. Zlotoff and Dr. Mullen, I felt the need to comment. I respectfully disagree with Dr. Zlotoff that the most appropriate way to code for a plantar plate repair is either using CPT 28200 (repair, flexor tendon, foot, single) in conjunction with CPT 28308 (osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each) or CPT 28899 (unlisted procedure, foot or toes). The question at hand is what is a plantar plate tear? I agree with Dr. Mullen that this is, in effect, a dislocation of the lesser metatarsal-phalangeal joint resulting in metatarsal-phalangeal joint destabilization, incongruity, and joint wear and tear. This is not a dislocation in the true sense of the word. There is no acute injury. This is a process over time.


I agree with Dr. Mullen that the most appropriate CPT code for the repair of a plantar plate tear would be CPT 28645 (open treatment of metatarsal-phalangeal joint dislocation, includes internal fixation when performed). The question now becomes, what ICD-10 code(s) would be most appropriate to define a plantar plate tear? Since this is not an acute injury, it would be incorrect to use the S93.12_ series with a 7th character. I feel that the most appropriate ICD-10 codes would be either M24.374 or M24.375 (pathological dislocation of right foot/left foot, not elsewhere classified). 


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



From: Steven J. Kaniadakis, DPM


These are the types of posts that the profession reads which lead to so-called illegal "unbundling" acts of the CPT-related codes. Is there a global code for these two procedures? What is the authoritative source which truly provides the answer, and not just a response to these related type questions? Why wait to find out until a federal court and another paid expert tell you that the answers are not so clear, or until you are the one "sitting in the hot seat". 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



Query: Met Osteotomy & Plantar Plate Repair


Can someone please advise me of the appropriate CPT for a plantar plate repair? I will be doing this procedure in conjunction with a Weil-type osteotomy. 


Harry Cotler, DPM, Soldotna, AK


Response: There is no specific code for plantar plate repair of the lesser metatarsal joints. I recommend using CPT 28200 (repair, flexor tendon, foot, single), and recommend also billing for the Weil osteotomy using code CPT 28308. 


Your other coding option for the flexor plate repair would be to bill CPT 28899 (unlisted foot/toe procedure). If you choose this, you would need to submit an operative report with a manual claim and request peer review. 


Howard Zlotoff, DPM, Camp Hill, PA 



Query: Insurance Overpayment Request


Cigna is using a third-party to try to recoup monies on claims where the research shows they were not the primary payer on dates going back 2 years. I inquired whether Cigna can make an automatic deduction against receivables on these questionable refund requests. Cigna's response was "no."  As a provider, are you liable to refund money due to an insurance error past a certain time period? As we are subject to timely filing, one would think there is some time limitation on these refund requests. 


Shari Winkler, Nanuet, NY


Response: I am not sure about New York law, but my understanding of California law forbids insurance companies from trying to recoup payments which they claim were made in error (even if the patient was actually not entitled to the coverage for which they were paid for) as long as there was no fraud involved on the part of the practitioner. 


In the case, City of Hope Medical Center v. Superior Court, 8 Cal. App. 4th 633 (1992), "...the Court held that the insurance plan was not entitled to reimbursement from the hospital for payments incorrectly made to the hospital, and the hospital was not unjustly enriched by virtue of such payments, where the hospital correctly billed the plan for services rendered, and did so without misrepresentation or knowledge of the plan’s mistake at the time payment was made. In the present matter, the provider was reimbursed by the plan, for true and accurate claims, which the provider timely submitted to the plan, without misrepresentation or knowledge of the plan’s mistake at the time payment was made. The provider reasonably relied upon such payments as accurate, intentional representations of the rate of reimbursement for those services. Therefore, based upon these facts, and the prevailing case law stated in City of Hope Medical Center v. Superior Court, provider asserts that the claims at issue have not been overpaid, and respectfully declines the related request for reimbursement." 


Additionally, " plans are allowed to seek reimbursement from a provider for overpayment of a claim, so long as the plan sends a written request for reimbursement to the provider within 365 days of the date of payment on the overpaid claim. The written notice must clearly identify the claim, the name of the patient, the date of service and a clear explanation of the basis upon which the plan believes the amount paid on the claim was in excess of the amount due...If the health plan allows more than 365 days to elapse from the date of overpayment, they are barred from making the request." 


Vincent Marino, DPM, San Francisco, CA 



From: Lawrence M. Rubin, DPM


Regarding the presence of pain as a qualifier for Medicare payment of CPT 11055 - a somewhat similar situation occurred when I was a consultant to Illinois Medicare carriers at the time the Medicare guidelines for onychomycosis nail debridement were first published. When a patient was not at-risk because of diabetes, atherosclerosis, or some other condition, the following enabled payment: Marked limitation of ambulation, pain, and/or secondary infection resulting from the thickening and dystrophy of the infected toenail plate.


Along with am Illinois Podiatric Medical Association representative, we pointed out to the medical director of the Illinois carrier that it was ludicrous and actually inhumane to have to tell a patient suffering pain from thick mycotic nails that they had to wait to make an appointment for the next debridement until their nails were so painful they caused "marked limitation of ambulation." The carrier agreed and subsequently okayed payment of mycotic nail debridement at specified time intervals on the basis of pain when the doctor documented in his/her medical records "Failure to debrid patient's thickened mycotic toenails on a regular basis can reasonably be expected to result in pain and limitation of ambulation." 


Lawrence M. Rubin, DPM, Las Vegas, NV



Query: Continued Noridian CPT 11055 Denials


I just received an EOMB from Medicare denying ONCE AGAIN all the CPT 11055, etc. codes for the past 4 months. So much for fixing the problem. When we called Noridian, we were directed to an LCD that only covers symptomatic hyperkeratoses and ulcers, nothing for at-risk patients. So what happens now? I don't believe I can now bill the patients. Do I tell them in the future that Medicare only covers for pain, and everything else is cash? 


Beverly Spurs, DPM, Concord, CA


Response: The most important step is to obtain, read, and follow the LCD, if there is one. If Medicare is going to re-define what they will cover, which is what they have done, then be prepared to educate your patients accordingly. If the patient wants/needs care that is not covered by Medicare (or any insurer for that matter), we always recommend the provider obtain a properly executed ABN. ABNs have value even when they are not required - it shows the patient was fully notified and does help the patient consider the cost. The only thing worse than a patient declining a service is for them to accept it when you will not be paid. 


Of course, collect your fee on the date of service and file the claim for the patient so they can see the denial. There is no need to apologize for Medicare's policies, though patients may not be happy paying out-of-pocket. 


Richard Papperman, MBA, CHBME; Cape Medical Billing, Cape May Court House, NJ 



Query: Diabetic Charcot Joint ICD-10 Coding


Our patient has diabetes with neuropathy (E11.42) and has developed a Charcot joint. When you look up Charcot joint, ankle and foot, you get the following codes depending upon laterality:  M14.671 right M14.672 left. But this code has an Excludes1 which is Charcot joint in diabetes mellitus. (E08-E13 with .610). I would probably choose the E13.610, other specified diabetes mellitus with diabetic neuropathic arthropathy. This has an inclusion term of other specified diabetes mellitus with Charcot joints. Do you bill with E13.610 and E11.42 which doesn't really specify Charcot, or do you bill with M14.671 (or 2) and E11.42? This then documents which foot and specifies the Charcot. If I understand the coding book, I'm not supposed to use the M14.671 and the E13.610 together. 


Coleen Merrill, Office Manager, Office of Evan Merrill, DPM, Medford, OR


Response: If you have a Type 2 diabetic (E11-) patient, they CANNOT be an E13. The key with ICD-10 is that it provides additional options (co-morbidities) for you to apply to the patient's conditions. In your example, you already have the diagnosis of E11.42 (Type 2 diabetes mellitus with diabetic polyneuropathy). If they developed a Charcot joint, look at the same series, E11- for the specific code. There you will find E11.610 (Type 2 diabetes mellitus with diabetic neuropathic arthropathy; Inclusion Term: Type 2 diabetes mellitus with Charcot joints). 


Your statement about M14.6 (Charcot joint, Excludes1: Charcot joint in diabetes mellitus [E08-E13 with .610]) is correct. You DO NOT use the musculoskeletal coding because of the Excludes1 rule. 


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



Query: CMS Documentation Requirements


Does CMS require by published regulation that each and every patient note "stand alone" in its documentation? I cannot imagine it would, as medical records are always incremental as a repetition of all facts on each and every note would lead to cloning and monstrous charting. Is the same regulation applicable to office vs. hospital vs. wound center? If that is the case, can someone refer me to the exact location of this regulation as I cannot find it. 


Cyril Gostich, DPM, El Centro, CA


Response: These guidelines are from the Noridian MAC on your exact query. 


Joseph Borreggine, DPM, Charleston, IL 



From: Richard Willner, DPM


"You can always limit how many patients of any insurance you see (unless you sign a contract with a carrier stating otherwise)." - Don Self


You are then trusting your receptionist to be quite diplomatic in not discussing WHY there are no appointments open for that caller, when the patient knows how few patients the doctor sees in a normal day. And, the patient also knows that if they had Medicare, private insurance, or self-pay, they could get in perhaps the same day.  


While the reply given is truthful and technically legal, does one want to anger any patient and make her feel diminished with respect to other patients? Does the doctor want to be "set up" for a claim of discrimination or medical malpractice or a complaint to the state licensing Board? I have made an entire career consulting, advocating and advising physicians and surgeons in matters like this. A podiatrist can learn from other practitioners, or make the same mistakes.


Richard Willner, DPM (retired), New Orleans, LA