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12/23/2009    

CODINGLINE CORNER

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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08/01/2015    

CODINGLINE CORNER


Query: CPT 97597 and Porokeratosis Debridement


 


I recently spoke with a colleague, who informed me that he is billing CPT 97597 for debridement of intractable porokeratoses...and getting paid. This seemed improper to me. The description on APMA Coding Resource reads "debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session; total wound(s) surface area; first 20 sq. cm. or less." An IPK is not an open wound. Could someone clarify whether or not this code is appropriate for debriding an IPK? 


 


Richard Wolff, DPM, Oregon, OH


 


Response: Debridement of an intractable keratosis is NOT appropriately coded as CPT 97597. You were correct to think it was inappropriate. The only code that would apply would be in the CPT 1105x series; with code selection based upon the number of skin lesions treated. Of course, reimbursement is based on CPT 1105x being a benefit and the doctor meeting the payer's qualifying criteria. 


 


In the event of an audit, the CPT 97597 misrepresentation might very well prove indefensible. The fact that payment was received for CPT 97597, obviously, does not mean it was correctly coded. It merely means the payer hasn't recognized the error...yet. 


 


Rick Horsman, DPM, Olympia, WA


 



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07/29/2015    

CODINGLINE CORNER


Query: Ganglion Cyst vs. Mucoid Cyst


 


I see a fair number of ganglion cysts. I have one on the dorsal aspect of my left hand (related to the second finger) which never bothers me at all; but I use it to demonstrate ganglia to my own patients. I had a similar one on the dorsal aspect of my right hand that was crushed with a Bible when I was young. As is suitably fitting, it has not recurred. But lately, I am seeing far more digital mucoid cysts...most commonly over the distal interphalangeal joint of lesser digits, most commonly the second, but less commonly the third. These are similar, but also dissimilar problems and presentations, and the prognosis and management are often quite different. Any suggestions on how the applicable diagnosis coding (ganglion vs mucoid cyst) might differ in ICD-9; as well as ICD-10? 


 


Rick Horsman, DPM, Olympia, WA


 


Response: The first place to go is the Alphabetic Index. In ICD-9, you will find: Cyst (mucus) (retention) (serous) (simple). Your search for "mucoid" will not find it. In the "Quick Index", however, you will find: ICD-9 727.49 - cyst (synovial, mucoid), other. To convert this in ICD-10 - there is no specific "mucoid" cyst - but ICD-9 727.49 maps to: 


 


M71.371 (other bursal cyst, right ankle and foot), M71.372 (other bursal cyst, left ankle and foot). 


 


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


 



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07/25/2015    

CODINGLINE CORNER


Query: Hallux Abductovalgus Repair


 


I have a patient with hallux abductovalgus (and a bunion). Because of her medical status, I only performed soft tissue releases including a capsulorrhaphy. How would this be coded? 


 


Mark Stempler, DPM, Staten Island, NY


 


Response: If you are not doing bone work, then the classic bunion procedure codes would not work. Your options would be CPT 28270 which is capsulotomy metatarsal-phalangeal joint with or without tenorrhaphy, or CPT 28313 which is reconstruction angular deformity toes, soft tissue procedures only. 


 


Tony Poggio, DPM, Alameda, CA


 


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07/22/2015    

CODINGLINE CORNER


Query: Billing the Debridement of 2 or More Wounds


 


What is a correct way of billing Medicare for 2 or more wounds of similar depth (say, CPT 11042) in the same extremity? To my understanding, 5 cm sq rule doesn't apply here because it's not at the CPT 97597 level. It seems like when we bill Medicare, either both, or one of two wounds is rejected, and we have to appeal it every time. 


 


Boris Raginsky, DPM, East Brunswick, NJ


 


Response: All wound debridement -- both selective and excisional debridements -- of similar wound depth are based upon actual type (level) and surface area you debrided. It is not based "per" wound. All similar tissue levels debrided are paid based on 20 sq cm. If you go over 20 sq cm, then there are add-on codes for the increased aggregate size of the combined wounds. 


 


For example, CPT 11042 is for the first 20 sq cm of tissue debrided and CPT 11045 is for each additional 20 sq cm debrided. If you bill CPT 11042-RT and CPT 11042-LT or CPT 11042-59, the claims will get kicked out as inappropriate billing. 


 


Tony Poggio, DPM, Alameda, CA



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07/15/2015    

CODINGLINE CORNER


Query: Post-Operative Ulcer


 


If following an amputation, the patient develops an ulcer at the site of the amputation, is the treatment of the ulcer billable? Or is it considered a complication following the surgical procedure? 


 


James Holdermann, DPM, Medford, OR


 


Response: The answer may depend on the payer and what needs to be done to treat the ulcer. For Medicare, it would probably be lumped into the global period. If the post-op ulcer care is more of a local dressing type treatment, then it may be not payable outside the global allowance. If you had to return to the operating room, then that would be payable and the global period resets. 


 


Payment of ulcer supplies, dressing material, skin substitutes should be pre-authorized as best you can. You may want to enlist the help of home healthcare agencies to render some of the "post-op' ulcer care and take some of the strain off your office. 


 


Tony Poggio, DPM, Alameda, CA 


 



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07/11/2015    

CODINGLINE CORNER


Query: Medicare Rejecting Billing for X-Rays with E/M Code


 


Recently, we have had many rejections by Medicare for x-rays when billed with an E/M code (both new and established). The rejection code is CO-16: "Claim/service lacks information or has submission/billing errors which is needed for adjudication." We modify the x-ray coding "LT" or "RT". One example that came in today: CPT 73630-LT (3 views), ICD-9 826.0 


 


Suggestions? Is anybody else getting these denials? 


 


Tamara Marsh, DPM, Apalachicola, FL


 


Response: I had a similar problem and when I spoke with Medicare, they told me that there needs to be an 'ordering physician'. Since then, I've been putting 'DK' (ordering provider) and my name and NPI in box 17 of the CMS claim form and they've paid the claims. 


 


Jay Seidel, DPM, Baltimore, MD


 



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07/08/2015    

CODINGLINE CORNER


Query: Lidocaine/Marcaine Coding


 


One of my providers did an injection for post-op pain. I am having a time trying to find a "J" code for one of the medications used. The provider used 10 cc lidocaine and 10 cc Marcaine with epinephrine. I have considered J2001 for the lidocaine, but the only thing I'm finding for the Marcaine is "S0020" and "C9290".  Do I need to use an unlisted code for the Marcaine and list the description, or is there a "J" code for the Marcaine? 


 


Jennifer, Office of Christian Smith, DPM, Memphis, TN


 


Response: Unfortunately, the supplies are included in the biopsy CPT code. Therefore, you would not code for the lidocaine as it is all inclusive to the procedure and, no you cannot bill for local anesthetic; it is inclusive to the procedure. The HCPCS codes of which you speak are for IV administration only.  Source: aapc.com/memberarea/forums/showthread.php?t=115089 


 


Joseph Borreggine, DPM, Charleston, IL


 



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07/04/2015    

CODINGLINE CORNER


Query: Removal of Failed Joint Implant


 


What is the recommended CPT coding for removal of failed silastic double stem implant with revision cheilectomy? I suspect the removal would be incidental to the cheilectomy and therefore included. Is that correct? 


 


Donald Brann, DPM, Orland Park, IL


 


Response: Because the implant removal and the cheilectomy are in the same location and because most of the dissection to get the implant out is the same dissection that is performed for the cheilectomy, I think that you should just bill for the cheilectomy, CPT 28289. 


 


If you feel that the effort/time/work required to remove the implant in conjunction with the cheilectomy led to a service that was substantially greater than what is typically required for CPT 28289, then you can add "-22" modifier to CPT 28289 and submit the required documentation supporting the addition of the "-22" modifier. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 



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07/01/2015    

CODINGLINE CORNER


Query: Destruction of Verrucae Via Silver Nitrate


 


I have a colleague whose standard of practice in destruction of symptomatic verrucae is to use topical applications of silver nitrate. Can such applications reasonably be considered "destructive"? 


 


Codingline Archived Question


 


Response: I opine that silver nitrate is not a "destructive" procedure, but rather a chemocautery of the lesion after debridement. Here is a publication from the NIH on the matter in question: 


 


Joseph Borreggine, DPM, Charleston, IL 



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06/27/2015    

CODINGLINE CORNER


Query: HCPCS Code for Wheaton Brace


 


What would be the correct HCPCS "L" code for an OTC Wheaton brace for metatarsus adductus to be used on an infant? 


 


Chris Orlando, DPM, Hartsdale, NY


 


Response: I believe this is the answer to your HCPCS code brace question: 


 


HCPCS L1930 - ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment. 


 


Joseph Borreggine, DPM, Charleston, IL 


 



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06/24/2015    

CODINGLINE CORNER


Query: Foot Care and Nail Avulsion Coding


 


I am wondering if I can bill for reduction of toenails >5 and callus trim 2-4 lesions ("at risk" or routine foot care) along with a two nail avulsions (with a local anesthetic) on the same day. If so, then how would I code this, and what modifiers would I use? If not, then still can someone show me how to code this? Can I use an E/M code if I bill the nail avulsions separately? 


 


Joseph Borreggine, DPM, Charleston, IL


 


Response: There is no reason that you can not bill this combination. Not sure what you mean by using an E/M if billing the nail avulsions separately. If all the services are done on the same day, then all should be submitted on one claim form. If the E/M is significant and separately identifiable, it should be billed as well. As always, documentation is key. 


 


E/M 9921X-25 


The nails would be CPT 11721-59. The calluses CPT 11056, and the nail avulsions CPT 11730 for the first, and CPT 11732 for the second nail. 


 


Tony Poggio, DPM, Alameda, CA 


 



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06/20/2015    

CODINGLINE CORNER


Query: How Do I Bill This?


 


I performed an Austin bunionectomy, Akin osteotomy, and tailor's bunionectomy (reverse Austin), all on the right foot. 


 


Jay Seidel, DPM, Baltimore, MD


 


Response: The Austin-Akin combo would be billed as a double osteotomy CPT 28299. In the professional edition of the CPT book, there are other examples of what would be considered "double" osteotomy. One of the illustrations associated with CPT 28299 clearly demonstrates an Austin/Akin. As far as the fifth metatarsal, that would be coded CPT 28308. 


 


Tony Poggio, DPM, Alameda, CA 


 



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06/17/2015    

CODINGLINE CORNER


Query: Osteogenesis Stimulator


 


Has anyone ever billed for the application or fitting of an osteogenesis stimulator? The manufacturer bills for the actual device (E0747), but their insurance department reps won't tell us what (if any) code there is for the fitting of the device done in our office. I'm at a loss. I've seen a couple of application codes, but they seem more like application of external fixators. 


 


Jennifer P., Billing Specialist, Memphis, TN 


 



Response: There are a few codes to select from: CPT 20974-20979 depending on whether it is an electrical or ultrasound bone stimulator used. The coding differs. However, often times the reps come into our office at a pre-arranged time and do the fitting and training while the doctor is elsewhere, or otherwise seeing patients; so since they did everything, there is no actual professional component for what you did. You did not provide or add any service relative to the dispensing, fitting, and instruction. If you DID provide additional services, that is another matter. 


 


So, in the vast majority of such instances, there is nothing for you (the provider) to bill. There is not necessarily an exam performed, just the application of the unit by the rep. It just happens to have occurred in your office. 


 


Tony Poggio, DPM,  Alameda, CA 


 



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06/11/2015    

CODINGLINE CORNER


Query: Coding Cheilectomy with Akin Osteotomy


 


What would be the correct way to code the following procedures, when all performed on the same foot on the same date of service? Cheillectomy 1st MTPJ for hallux rigidus, Akin osteotomy for deviated hallux (valgus), Tenotomy and capsulotomy of the 2nd MTPJ.


 


Lori Weisenfeld, DPM, New York, NY


 


Response: I suggest CPT 28298, which is bunionectomy by phalanx osteotomy. In the CPT professional edition book, there is an example/picture of a phalanx osteotomy with resection at the metatarsal head. 


 


That said, you have to document if the work done was significantly more complicated to warrant other procedures. The second MPJ release could be CPT 28270 depending on what was done. 


 


Tony Poggio, DPM, Alameda, CA 


 



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06/06/2015    

CODINGLINE CORNER


Query: Code for a 2nd MPJ Arthrodesis?


 


Is there a CPT code for a 2nd metatarsal-phalangeal joint arthrodesis? I see that CPT 28750 is only for the 1st metatarsal-phalangeal joint. 


 


Hyim Baronofsky, DPM, Park City, IL


 


Response: The only code available for this is an unlisted CPT code: 28899. With the claim, send an explanation of what you did and the op report. It is also suggested that you might describe an alternative procedure (with assigned RVU value) which you feel might be equivalent in value. 


 


Joseph Borreggine, DPM, Charleston, IL 


 



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06/03/2015    

CODINGLINE CORNER


Query: Insurance Denial for G0283 and OV


 


I received a denial from an insurance carrier here in Michigan (HealthPlus). The services billed were CPT 99213 and G0283 (electrical stimulation, unattended). The diagnosis code used was 728.71 (plantar fasciitis) on both claim lines. No modifier was appended to CPT 99213. I amended G0283 with a "-GP" modifier. HealthPlus denied the 99213 office visit code, stating "Denied- Procedure not indicated for separate reimbursement" G0283 paid. I do not think there is a CCI edit. Any ideas on what this carrier is looking for? 


 


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


 


Response: Check your contract. This may not be a coding edit but a coverage edit. That is, their LCD or contract with you may restrict payment to only the physical therapy code and not permit both a physical therapy and office visit (E&M) code on the same day (when provided by the same provider). As is true for many carriers, they unilaterally decide to cover only one procedure for a given diagnosis on any given day. If it's in their coverage policy or your contract, then they have every right to do exactly what they are doing. 


 


Paul Kesselman, DPM, Woodside, NY


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05/29/2015    

CODINGLINE CORNER


Query: Denial for *-25* Modifier Use


 


We recently had a denial of a claim coded as: CPT 99212-25, with linked diagnosis codes of ICD-9 735.4 (hammertoe) and ICD-9 250.60 (diabetes with neuropathy). The second line on the claims was CPT 11721, with linked diagnosis codes of ICD-9 110.1 (onychomycosis) and ICD-9 729.5 (pain). The debridement was paid, but the E/M was not, with reason for denial given as "97" - use of "-25" modifier was unnecessary. Has anyone else had a similar denial, or might they offer any explanation? 


 


Pamela Eernisse, DPM, Chicago, IL 


 


Response: I would appeal this, as the use of the modifier is correct. Make sure that the documentation in your chart supports the E/M service as significant and separately identifiable service from the nail care. Simply documenting that there is neuropathy is not enough. That said, if this patient is truly neuropathic, it might come across as strange that the patient also has "pain." Payment for pain in most Medicare LCDs relates to pain with ambulation caused by the nail, which may not necessarily be the case in a neuropathic patient. I would use neuropathy as the qualified nail diagnosis code.


 


Tony Poggio, DPM, Alameda, CA



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05/27/2015    

CODINGLINE CORNER


Query: Medicare and House Calls


 


Can a podiatrist get paid by Medicare for a house call even if the patient visits other doctors' offices? 


 


Allan Hetelson, DPM, Bensalem, PA


 


Response: Your patient typically needs to be housebound, not necessarily bedridden to qualify for a house call. There needs to be a medical necessity for the home visit versus a convenience for the patient. Check with your Medicare contractor to see if they have any specific written rules about patients qualifying for house calls. 


 


Some things to consider: You can bill for a house call (E/M) service when medically necessary and reasonable, and when it is a significant and separately identifiable evaluation and management service not included as part of the procedure allowance. This is identical to the E/M requirement you need to meet if you saw the patient in your office. You do not get to bill for a "house call" charge simply for driving out to the home. In addition, for routine foot care, patients need to meet the "risk" criteria that your Medicare carrier has in their LCD. If you are doing routine foot care on a regular basis, then all you would be eligible to bill for would be the routine foot care services. This may mean only getting paid $20 or less for a qualified routine foot care service, even if it takes you 30 minutes (or more) to get to their house. Of course, if the patient presents a new unrelated condition that requires a work-up, you might be eligible to bill for an E/M service, too. If the patient does not meet "risk" criteria (statutorily non-covered), you can bill what you want and you are not tied to the Medicare fee schedule. Documentation here is key. 


 


Lastly, if they can go to see other doctors in their offices, why can't the patient come to see you in your office? An auditor may want to know the answer to that. You are not allowed to bill for home call services simply for patient convenience. This is a nice service to do for our elderly patients, but you also have to look at this from an affordability standpoint. Can you economically sustain doing home visits that take a significant amount of time, but may be limited to almost the same amount of reimbursement had you seen the patient in your office. 


 


Tony Poggio, DPM, Alameda, CA


 


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05/24/2015    

CODINGLINE CORNER


Query: Coding a Drop Foot AFO


 


What is the proper code for a pre-molded AFO drop foot brace? Is it covered by Medicare? Must it be custom made? 


 


Jay Lifshen, DPM, Irving, TX


 


Response: HCPCS L1930: Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment 


 


HCPCS L1940: Ankle foot orthosis, plastic or other material, custom-fabricated 


 


You must indicate side "RT" or "LT", and it may need a "KX" modifier. Modifier KX is defined as "requirements specified in the medical policy have been met." It is appropriately used when additional documentation is available to support the medical necessary service under a medical policy. 


 


Joseph Borreggine, DPM, Charleston, IL 


 



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05/15/2015    

CODINGLINE CORNER


Query: Multiple Foreign Bodies


 


My patient stepped on a sea urchin receiving 20 spines (subcutaneous) in the forefoot. Do I bill CPT 28190 x 20? 


 


Mark Stempler, DPM, Staten Island, NY


 


Response: If these were not sticking out of the skin, leading to you just pulling them out, but rather you did 20 separate procedures to remove them, then you can bill as you described as a single line item x 20 units, or you could bill CPT 28190 on 20 different lines with a "-59" modifier on 19 of them. I would expect either of these options to be met with resistance by the payer, and suggest submitting a report and maybe even photos along with your claim if you try either of these. 


 


The other option would be to bill CPT 28190 with a "-22" modifier, which indicates that the work performed was substantially greater than typically required for that code. 


 


Jeffrey Lehrman, DPM, Springfield, PA



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05/12/2015    

CODINGLINE CORNER


Query: Medicare Denial of CPT 29515


 


Why is Medicare denying CPT 29515? The EOB says, CO-4, "The procedure code is inconsistent with modifier used."  We are using the appropriate right or left foot modifier. We are not bundling this service with anything else. 


 


Lina Diaz, DPM, Englewood, NJ


 


Response: There may be other codes on the EOB that are prompting this to appear. CO-4 is a reason code. Please look at the EOB for the Remark codes (to the left under the patient's name) and see if there is another comment. 


 


You are correct - "RT" or "LT" - is appropriate for this CPT code, but I believe something else on the EOB has more information. 


 


Karen Hurley, CMM, CPC, Lakewood Ranch, FL


 



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05/09/2015    

CODINGLINE CORNER


Query: SmartSkan - CPT 95923


 


I am considering purchasing a nerve testing unit, SmartSkan CPT 95923. I was wondering and hoping that I can get some feedback on whether or not we, as podiatrists, are eligible to use this (involves placing both hands and feet on plates for measurements).  Any other info regarding reimbursement and usage would be appreciated. 


 


Michael Rosenblum, DPM, Fair Lawn, NJ


 


Response: First check with your state regs whether this testing is covered under your scope of practice. Then, I would check with your major insurance companies about coverage issues, and specifically the appropriate use of CPT 95923 or other coding for the testing. Many plans do not cover this type of testing or this unit, or they do so in very limited scenarios. Be very clear when asking about coverage issues to make sure that you are being given accurate information. Many carriers deem this testing/unit investigational. Do not rely on what the company reps tell you about coverage and potential income revenue. 


 


Tony Poggio, DPM, Alameda, CA


 



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05/06/2015    

CODINGLINE CORNER


Query: Skin Graft for Closure


 


How would you properly code for advancement of skin graft to allow for the skin to approximate upon one another? The skin was advanced and closure was accomplished with 4-0 nylon in simple interrupted sutures. This was for an arthrodesis of the proximal interphalangeal joint, 2nd digit, left. 


 


Susie A, Office of Jan Tepper, DPM, Upland, CA.


 


Response: I am not sure what you mean by a skin graft that was advanced. There is a code series for tissue rearrangement or transfer (versus skin graft) which includes CPT 14000-14350. That said, your operative report needs to clearly document what was performed. Usually with a fusion procedure, there is redundant tissue. Suturing the tissue to address the redundancy to make it align better is part of the overall hammertoe correction procedure and not payable separately. 


 


Tony Poggio, DPM, Alameda, CA 



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05/02/2015    

CODINGLINE CORNER


Query: Walking Boot & Night Splint Coding


 


Has anyone heard about the new codes for walking boots and night splints? 


 


Instead of L4360 and L4396, it they would be L4361 and L4397, respectively, if you use the kind of devices that do not require substantial modifications. Any additional information would be appreciated. 


 


Gina Garza, College Station, TX


 



Response: I had a meeting with our DME contractor about this very issue. The coding selection has to do with how much modifications are required. The key is whether "significant modification" was performed. The fitting and maybe adding a wedge or an off-loading accommodation does not seem to be enough to validate the term "significant". Dr. Kesselman, I believe, in previous posts on Codingline explains some of the expectations regarding the new and old codes. 


 


The good news is that there is no reimbursement differences between the two codes at this time. That may change though in the future. 


 


Tony Poggio, DPM, Alameda, CA


 



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04/29/2015    

CODINGLINE CORNER


Query: Medicare Penalties


 


During negotiations of the "doc fix", I thought I saw that they were ending all of the PQRS and meaningful use penalties and replacing them instead with an incentive. Is this true? 


 


Gary S Smith, DPM, Bradford,PA


 


Response: There are some changes coming as a result of the SGR bill that passed. Here is a brief summary of what happens to meaningful use (MU) and PQRS: 


 


The provision would create a new incentive payment system while sun setting several existing programs on the last day of 2018: (1) the meaningful use incentive program for certified electronic health record (EHR) technology, (2) the quality reporting incentive program currently called PQRS, and (3) the value–based payment modifier (VM). The Secretary would establish a replacement program, the merit–based incentive payment system (MIPS) that would accomplish the following: 


1. Develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards described below; 


2. Using the methodology above, provide for a composite performance score as specified below for each professional for each performance period; and 


3. Use the composite performance score of the MIPS eligible professional to make MIPS program incentive payments (as described below) to the professional for the year. 


 


The MIPS program would apply to payments for items and services furnished on or after January 1, 2019. So PQRS, VM and MU will sunset at the end of 2018 and be replaced with the merit-based incentive payment system (MIPS). This program will have winners and losers, so you could in theory earn an incentive or be penalized or be neutral. 


 


Jim Christina, DPM, Bethesda, MD 


 



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Dr Comfort 2