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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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Query: GraftJacket Plantar Fat Pad Augmentation


How would you code placement of an acellular matrix (using the parachute technique) for augmentation of the fat pad underlying a lesser metatarsal head? Or more than one? I was thinking of using CPT 15002 wound bed preparation with CPT 15777 (implantation of biologic implant [e.g., acellular dermal matrix] for soft tissue reinforcement [e.g., breast, trunk]) for graft placement, as it is not a stand-alone code. Or does this fall in the unlisted procedure box? 


Wendy Winckelbach, DPM, Greenwood, IN


Response: There is no code for this. I believe the most appropriate code is CPT 28899 (unlisted procedure, foot or toes). CPT 15002 is not appropriate because there was no wound bed preparation performed. I suggest you pre-certify or check with the payer before performing this procedure as some may consider this "experimental" and not reimburse it. 


Jeffrey Lehrman, DPM, Springfield, PA 


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Query: Billing Bioguard Gauze


We are beginning to dispense Bioguard gauze rolls ( from our office for Medicare recipients. We are using the appropriate A6266 code for this product. We are, however, having a very difficult time locating information on how many units patients are eligible to receive monthly. When appropriate, I thought we could dispense up to 120 units, regardless of number of wounds we are treating. We are only getting reimbursed for 30 units when there is only one wound. Our LCD does not mention how many units are reimbursable. Can anyone provide guidance?  


Daniel C Albertson, Office of Paul Krestik, DPM, London, KY


Response: This product appears to be an impregnated gauze (other than with saline, water zinc paste or hydrogel). It can be billed once per day per wound. On a monthly basis, you would be limited to no more than 30 per wound. This is clearly stated in the Medicare DME "Surgical Dressings" LCD. 


If you are treating four non-contiguous wounds which required four separate sponges (where cutting the sponges would not allow for adequate coverage), then you could be paid for 120 units. Your claim form would indicate this by using an "A4" modifier. Your documentation would, of course, need to support this level of service. 


Paul Kesselman, DPM, Woodside, NY  


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Query: Coding Lesser MPJ Joint Replacement


What code is used for a total joint replacement of a lesser metatarsal-phalangeal joint? I believe CPT 28293 is only for the 1st metatarsal-phalangeal joint. 


Jeffrey Cohen, DPM, Englewood, NJ


Response: There are no codes for joint replacements of the lesser metatarsal joints. You would need to use CPT 28899 (unlisted, foot/toe) and provide documentation with an operative report. Request a peer review. 


Howard Zlotoff, DPM, Camp Hill, PA


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Query: Medicare: *-59* Modifier - Allowed or Not?


I have heard conflicting advice regarding being able to use the "-59" modifier with Medicare. Are we allowed to use it only under certain circumstances or at our discretion or not at all? 


Andrew Resler, DPM, New Windsor, NY


Response: Well, you have to meet the criteria for the use of modifier "-59" in order to use it in the first place. If another modifier -- for example modifier "-51" or "-76" - appropriately describe the special circumstances, then you shouldn't be using modifier "-59" at all. But if your question had to do with using modifier "-59" instead of the new "X" modifiers, then, yes, at this point in time, you can use EITHER "-59" or the applicable "X" modifiers. 


I'm telling my clients to stick with modifier "-59" until CMS comes out with better clarification for how the "X" modifiers should be used. That transmittal last year was confusing and in some cases, redundant (meaning it looked like they were telling you that two of the 4 modifiers could apply to the same kind of situation). I'd hate to start using the "X" modifiers only to find out that CMS meant something entirely different by the definitions for some or all of them. Essentially, the most conservative way to go is to stick with modifier "-59" until CMS tells you that "-59" can no longer be used. Hopefully, by that time, they'll have figured out what they really want to accomplish with the "X" modifiers and will have done a better job of communicating their intent to the provider community. 


Joan Gilhooly, CPC, CPCO, Lebanon, OH 


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Query: B/P, BMI - How Often Does It Needed to Be Done?


How often do we need to take a blood pressure and BMI to satisfy requirements? Does it have to be at each visit? 


Steven Rothstein, DPM, Manchester, NH 


Response: Assuming you are referring to the requirements for meaningful use, here is the explanation from CMS regarding this measure (as you can see, you must do it once per reporting period, but after that, it is your determination about updating as it is regarding how the data is obtained). Just remember if you are also doing the PQRS measure on BMI, that measure actually requires that you weigh and measure the patient to determine the BMI: Height, weight, and blood pressure do not have to be updated by the EP at every patient encounter. The EP can make the determination based on the patient’s individual circumstances as to whether height, weight, and blood pressure need to be updated. 


Vital sign information can be entered into the patient's medical record in a number of ways including: direct entry by the EP; entry by a designated individual from the EP’s staff; data transfer from another provider electronically, through an HIE or through other methods; or data entered directly by the patient through a portal or other means. Some of these methods are more accurate than others, and it is up to the EP to determine the level of accuracy needed to care for the patient and how best to obtain this information. 


Jim Christina, DPM, Bethesda, MD 


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Query:  New *X* Modifier Use


With the farewell to modifier "-59", would someone clarify the usage of modifier "XS" and "XU" with reference to the following scenario? If CPT 11721 is performed with a CPT 20550 (and J1100-A5), would the correct submission be CPT 11721-XS, CPT 20550, J1100-A5? 


Howard Dinowitz, DPM, Brooklyn, NY


Response: Modifier "-59" is not gone. If you are compelled to use these new modifiers, then select whichever of these best fits your service. Here are the CMS definitions for the two modifiers expected to be used by foot and ankle specialists: 


XS - Separate structure, a service that is distinct because it was performed on a separate organ/structure 

XU - Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service 


In the example you gave, prior to January 1, 2015, the coding for Medicare would be: CPT 11721, CPT 20550, J1100. There is no CCI edit bundling of CPT 20550 and CPT 11721. Medicare, however, has said that if or when there is an edit between two codes, it will still recognize the "-59" modifier. I feel that modifier "-59" should be able to be used in 2015. We are all looking for more information and direction from CMS on their modifier creations. 


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


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Query: Surgery Coding for Joint Replacement


A patient came to our office who had left foot surgery performed (lesser joint replacement with Swanson implants) by another podiatrist. However, the joint implants on the 3rd, 4th, and 5th metatarsals have broken and the implants need to be removed, and either replaced or the joints stabilized by pinning the toes to hold their position while they heal. How do I code these procedure options? 


S.F. Charley Hartley, DPM, Houston, TX


Response: If the implants are removed and nothing else done besides pinning the joint, then I would suggest CPT 20680 (removal of implant; deep), each.  If you are removing and replacing the implants, there is no single code that defines this. You either have to use the removal code, CPT 20680, with or without a "-22" modifier, or use the unlisted foot/toe procedure code, CPT 28899. Note that a number of payers still consider use of lesser metatarsal-phalangeal joint implants as investigational, so pre-authorize the surgery. 


Tony Poggio, DPM, Alameda, CA 


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From: Gregory Mowen, DPM


It was recently debated whether we can bill for an office visit for performing a comprehensive diabetic foot exam along with a routine care code (i.e.11720); or should the exam be scheduled separately? I think it is absolutely appropriate and defendable to do them on same day if your allotted time allows. Often, at this visit, I have Doppler and/or more advanced neurologic testing done if the risk factors are met.


We do try to make it convenient for the patient, when possible, versus re-appointing. I do feel that the comprehensive exam is excellent for the patient, plus it may open new revenue streams for the practitioner. 


Gregory Mowen, DPM, Ventnor, NJ



Query: Annual Lower Extremity Examination


A patient with diabetes and the appropriate class findings (excluding neuropathy) returns for treatment of painful mycotic hallux nails (laboratory +) and plantar hyperkeratosis. Assuming there are no new complaints and no significant changes in medications or medical status, can an "annual lower extremity examination be performed (E/M code CPT 99213) as well as nail debridement (CPT 11720) and debridement of the hyperkeratoses (CPT 11056)? 


Charles F. Ross, DPM, Pittsfield, MA 


Response: It is good medical practice to perform at least a yearly (or more frequent) lower extremity examination or what Ken Malkin, DPM termed a comprehensive diabetic foot exam (CDFE) based on your patient's diabetic symptoms. However, based on some MAC LCDs and other retired LCDs from previous Medicare carriers, it is my suggestion that you perform that examination on a different day from the day you perform covered routine foot care services. Some LCDs and a lot of the retired LCDs (or their associated articles) say that you cannot perform (and be paid for) an E/M visit on the same date as the covered foot care services for the purpose of qualifying the patient for that covered service. 


So as not to confuse the issue and run the risk of having the E/M denied or worse, bring the patient in and do your evaluation on a different day. 


Paul Kinberg, DPM, Dallas, TX 


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From: Estelle Albright, DPM


I suggest instead doing a punch biopsy rather than a destructive procedure. I have found these often are verrucae rather than porokeratomas. Code dx = skin neoplasm of uncertain etiology. You can bill for the skin biopsy based on the size of the lesion. 4mm or less needs no sutures, and these heal quickly and leave no scar, and I have never had a recurrence.


Estelle Albright, DPM, Indianapolis, IN



Query: Revisional Lapidus Non-Union Coding


How would you code a revisional Lapidus-type procedure non-union using bone allograft? 


Elliot Michael, DPM, Hillsboro, OR


Response: There are three codes that could apply:

CPT 28320 which is repair of non-union tarsal bone or 

CPT 28322 which is repair of non-union metatarsal bone or 

CPT 28740 which is an arthrodesis tarometatarsal joint, which you are repeating (i.e., you are repairing only the fusion part of your original CPT 28297 procedure). 


The first two are typically reserved for intraosseous non-union pathology. The attempted fusion of the first metatarsal and the medial cuneiform tried to "create" a single bone. The latter code takes what did not work, and repeats that portion of the procedure. Select the codes that you best feel reflects the procedure you perform. The use of allograft is not coded. 


Tony Poggio, DPM, Alameda. CA 


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From: Todd Lamster, DPM


These lesions, the small punctate epidermal hyperkeratoses, exist within the epidermis, and should be coded as nothing more than 700 or 701.1, in my opinion.  If one looks up 757.39 in any ICD-9 book, or on, the definition is "other specified anomaly in the skin", under the section of CONGENITAL ANOMALIES OF THE INTEGUMENT. These lesions, which we see so often, are not congenital, so I have stopped using that code as I feel it is a misrepresentation of the pathology.


There is an article on this subject by Drs. Bakotic and Shavelson from Podiatry Management. It did not review how to code the lesions we see daily in the office. I would like our experts in podiatric dermatology to weigh in.


Todd Lamster, DPM, Phoenix, AZ



From: Paul Hilbert, DPM


I believe that ICD-P 757.39 is also an acceptable code to use for this condition. It may even be more appropriate, whereas the code mentioned in the article more aptly corresponds to bromidrosis.


Paul Hilbert, DPM, Navarre, FL



Query: Coding the Treatment of a Porokeratosis


How do I properly bill (diagnosis and procedure code) for treating a painful porokeratotic plantar discreta lesion that I treated with cantharidin? The patient has Medicare. 


Carlos Dimidjian, DPM, Big Spring, TX


Response: The question is how successful, long-term, is the treatment? I will assume the application of canthardin is meant to destroy the benign lesion. The procedure coding would be CPT 17110. The ICD-9 code for a typical acquired painful porokeratotic plantar lesion is ICD-9 705.89 - disorder of sweat glands, other. 


You should check with the Novitas (Texas) Medicare for coverage guidelines. 


Tony Poggio, DPM, Alameda, CA 


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Query: Suture Removal Coding


Is there a specific code for suture removal? This is not for post-op surgery, but for the patient who presents for removal of sutures after a laceration. 


Samuel Ruggiero, DPM, Cheektowaga, NY


Response: CPT 15851 - removal of sutures under anesthesia (other than local), other surgeon - is the only CPT code available. You did not say if you placed the sutures yourself or if there was a need for general anesthesia to remove them. If you did suture the site, you might have very well performed one of the following: 


CPT 1200x - repair of simple wound(s); 

CPT 12041 - CPT 12047 - repair of intermediate wounds; or 

CPT 13131 - CPT 13133 - repair of complex wounds. 


All of these codes have a 10-day Medicare global. If you placed them yourself and are taking the sutures out within 10-days following their placement (on or before the 11th post-operative day), then the suture removal is part of the global surgical service. If someone else placed the sutures or it is beyond the global period. then you would need to bill the service as an E/M code following the E/M guidelines. If it were me and I placed the sutures, and they needed to come out beyond the global period, I would not charge the patient for just that simple service. From an ICD-9 coding standpoint, you would code V58.32 - encounter for removal of sutures. 


Paul Kinberg, DPM, Dallas, TX,,


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Query:  Correct Billing of Treatment of Nail Trauma


How would I bill repair of a laceration of the nail bed of the right hallux that I closed with 7 sutures? There was damage to the nail. 


Craig Sapenoff, DPM, West Palm Beach, FL


Responses: Laceration coding is typically found in the "repair" sections of CPT. However, for a laceration involving the nail bed, if you look in the "integumentary" section of CPT under nail codes, you will find CPT 11760 - repair of nail bed which describes your treatment of nail bed trauma. It would also include the avulsion of the nail if necessary. 


Tony Poggio, DPM, Alameda, CA 


To add to Dr. Poggio's post, the ICD-9 code, presuming the presenting condition is primarily the laceration, would be ICD-9 893.0 - open wound of toe(s) (includes: toenail); without mention of complication. Of course, there may be additional ICD-9 codes depending on whether there are complications or a contusion, toe (including toenail) (ICD-9 924.3). 


Harry Goldsmith, DPM, Cerritos, CA 


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Query: Can I Defer Meaningful Use Attestation?


I successfully attested for meaningful use for Stage 1 for 2011, 2012, and 2013, but feel that my records are and will not be up to snuff in a timely manner for Meaningful Use attestation for Stage 2 for 2014. Is there anything wrong with not doing Stage 2 this year, and waiting to do it in 2015? Will I lose the final stimulus check by doing that? 


Steven D Epstein, DPM, Lebanon, PA


Response: If you do not attest to Meaningful Use for 2014, two things will happen. 


First of all, you will not get your scheduled incentive payment for your fourth year of attesting to Meaningful Use. If you attest in 2015, you will get the fifth and final payment for MU (you simply skip the fourth payment and lose that amount). 


The second thing that will happen is that by not attesting to MU in 2014, you will be subject to the MU penalty in 2016 (a 2% reduction in all of your Medicare Part B payments for that year). Attesting in 2015 to MU will avoid the MU payment reduction in 2017 (3% of all Medicare payments). 


Jim Christina, DPM, Bethesda, MD


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Query: Billing for Custom Orthotics 


Are we required to bill at time of dispensing the foot orthotics? Or can we bill at the time of casting for foot orthotics? 


Michael DeKorte, DPM, Medford, OR


Response: All items of DME are or should be billed at time/date of dispensing - NOT time of casting, or evaluation. In fact, if your medical and billing records disagree on date of billing/dispensing, most payers (especially Medicare) will reject and/or audit the claim, then reject the claim. 


On post-payment review (with Medicare), if your records do not reflect a billing date as the same date of dispensing, they consider the service invalid, and "ask" (a kind term for what they actually say, and do) for the money back. 


Rick Horsman, DPM, Olympia, WA 


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RE: ABN Question Regarding DME


I have received a few denials on therapeutic shoes and inserts for my advance beneficiary notices for not having the proper wording in box E of the ABN. Box E is part of the section beginning "Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D below." 


"D" is the description of the item in question.  "E" is the "Reason Medicare may not pay" box associated with "D". Please help if you know of the correct wording they are looking for in box E. 


Trina, Office of Neil Kelley, DPM, Fortuna, CA


Response: That is correct. Your section "E" explanation has to be the specific reason you expect it will not be covered, usually referencing the Medicare policy guidelines. It cannot be a general "if Medicare does not pay, then ..." Example: "previous shoes received less than 12 months since the last pair." When in doubt, verify with the DME MAC for your region prior to ordering the shoes. 


Rich Papperman, MBA, CHBME, Cape May Court House, NJ 


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From: Steven Selby Blanken, DPM


I would put the KX modifier prior to the RT or LT modifier. Maybe it was just a glitch for that reason? L4360-KX-RT. I was told that most DMEs to Medicare need this first.


Steven Selby Blanken, DPM, Silver Spring, MD



RE: CAM Walking Boot Denial


On June 13, 2014, I dispensed a pneumatic CAM walking boot to a patient diagnosed with Achilles tendinitis as well as a posterior calcaneal spur. I coded the device as L4360-RT-KX and coded ICD-9 726.73 (enthesopathy, calcaneal spur) and ICD-9 726.71 (Achilles tendinitis). The claim was denied by Medicare stating it did not meet medical necessity. No records were requested. While I am aware that there are new codes for walking boots, I do not think this has any bearing on this claim denial. Where am I lacking medical necessity? 


Jack Reingold, DPM, Solana Beach, CA


Response: I cannot really see anything that you are missing. It would be important to take a look at the Medicare LCD to find out if they have any recent (last 6 months) changes that might apply to the use of the CAM walker. It appears - at least to me - that recently, many Medicare contractors have been subjectively, and without comment, changing the LCDs...sending us ridiculous statements about the lack of medical necessity. I would first take a look at your local carrier LCD, then appeal, resubmitting the claim. 


Mike King, DPM, Fall River, MA 


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Query: Storage: X-Ray Film vs. Digital


How long do I have to store my old x-ray films? 


Mark C. Baxter DPM, Kingsport TN


Response: X-rays are the same as any other part of a patient's chart and must be kept the same length of time that the rest of a chart should be maintained. 


Most experts recommend that charts be held for (7) years. X-rays (and charts) for minors should be held for a variable length which is calculated as until the child reaches the age of majority (usually 18) plus the statue of limitations for malpractice in your state.  Click here for state by state requirements.


Barry Block, DPM, JD, Forest Hills, NY 


[Dr. Block will be a featured speaker at the Codingline-NYSPMA "Foot & Ankle Coding" Seminar, January 22, New York 


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From: Brian Kashan, DPM


This topic hits a nerve with me, yet affects all of us on a daily basis. We are forced to accept the standards, rules, and policies stuffed down our throats every day. We can’t do this. We have to do that. We have to use this form for this. No form for that. This requires authorization. We can’t hold the member responsible. We can do this in 61 days, but not in 60. This is no guarantee of payment.  On and on for eternity.


Now, we get a chance to have the tables turned, and we can tell a patient, “ your insurance company is the one who dictates when we charge you.” After 10 days, your visits will be...

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



From: James W. Clark, DPM


I prefer to be reimbursed for my knowledge and expertise, particularly when it involves surgical patients. Have you ever seen what a general surgeon does with an ingrown nail? We podiatrists are SPECIALISTS when it comes to nail surgery. Try doing both borders on one nail; you will only get reimbursed for one border. Have you had a root canal done lately? What did that cost? When I began in private practice, the fee for a dental root canal and nail matrixectomy were the same. Compare those fees today - you'll be shocked!


In my area, general surgeons continue to perform cold steel matrixectomies under general anesthesic at our surgery center. We routinely perform these procedures in our office and save the insurance companies untold sums of money. Often, nail surgery patients fail to take their prescribed antiobiotics and follow soaking instructions, resulting in post-operative complications. So, do you want to see these patients for free?


A 10-day follow-up on matrixectomies is the accepted policy. After 10 days, it should be fee for service. Don't devalue your medical services. The insurance companies have already done that for us. Remember, we are no longer DOCTORS - we are now "Providers", so say the insurance companies.


James W. Clark, DPM, Salinas, CA



From: Cynthia Ferrelli, DPM


I once discussed this question with a colleague of mine who sat on the NYS Board. It was the Board’s view that these post-operative appointments were really non-billable, even after the global period, since there usually is not much to report to ascertain a CPT 99212. Ever since that discussion, I have not charged for such visits. Usually, I will see the patient twice after a matrixectomy procedure, and we just give them a window of time to show up at the office, i.e., 1-3 PM, or whatever fits into their schedule.


The front desk tells them it's just a quick check and that when a room becomes available, I will just take a quick peek and make sure that everything is okay. We tell the patient ahead of time that unless there is some kind of problem, there will not be a co-pay. This way, we don't utilize a slot in the schedule book. This has worked very well for many years.


Cynthia Ferrelli, DPM, NMD, Buffalo, NY