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: Bilateral Diagnosis


When coding a patient who has hammertoes bilaterally, do you have to use both M20.41 and M20.42 (other hammer toe(s) (acquired), right foot and left foot, respectively)? Obviously, dealing with feet, we have many patients with bilateral problems. Can anyone shed any light on this for me? 


Ellyn Black, Greenville, TX


Response: Yes, Ellyn,you do need to use both codes if coding for bilateral hammertoes. In the updated ICD-10 for 2017, we have a few bilateral codes added, but not for hammertoes. So, I would use both the M20.41 and M20.42 if coding for bilateral hammertoes. Be sure to link the proper laterality to the proper treatment rendered for each, when indicated. 


Mike King, DPM, Alpharetta, GA


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From: Michael G. Warshaw, DPM, CPC


After reading the response by Dr. Poggio to this query, I must disagree. For the appropriate way to bill a hospital visit on a Medicare patient, it would not be appropriate to use the initial hospital care coding, E/M services. One need look no further than the CPT Manual. Under Initial Hospital Care, New or Established Patient: "The following codes are used to report the first hospital inpatient encounter with the patient by the admitting physician. For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231-99233) as appropriate."


There was no indication in the query that the physician in question was the admitting physician and based upon the fact that the initial inpatient consultation codes do not apply, it is clear that the most appropriate E/M codes to use for the scenario described in the query are the subsequent hospital care codes.


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



Query: Billing An Established Patient Hospital Visit


When a patient has already been established with care by the physician in the last 3 years, and then has to be seen in the hospital for another diagnosis, do we code CPT 99232 (subsequent care hospital) or CPT 99222 for initial hospital care since the diagnosis is new? 


Vanessa Sloan, Effingham, IL


Response: When billing a hospital visit on a Medicare patient, you would use the initial hospital care coding. The description is new or established patient. The key is that you are seeing a patient for the first time for that admission. If you need to see that patient again during the same admission, then you would bill the subsequent care code series based upon medical acuity of the services you rendered. 


If that same patient were seen X weeks later during a different admission, then you would still bill the initial care code series. 


Tony Poggio, DPM, Alameda, CA 


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Query: Correct Location for DME Dispense


We do not dispense many items to be billed to DMERC (Noridian is our MAC), but we do dispense fabricated Richie and Moore Balance braces. My billing department has been billing out the location of "12" for home because they were told to do so (not sure by whom) a long time ago. They think we were denied when we listed the office as the dispense site a long time ago and were told to use 'home' as the location. Is this correct? 


Cheryl Christensen, Ankle & Foot Clinic, Everett, WA


Response: DME covers services when they are used not in a medical facilty, but rather in the patient's home. Therefore, the use of POS =12 is correct. 


Paul Kesselman, DPM, Woodside, NY


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Query: ICD-10 Metatarsal Coding


With the new ICD-10 code for metatarsal varus (Q66.22 [congenital metatarsus adductus; Inclusion Term: congenital metatarsus varus]), which of the metatarsal codes would be most appropriate for a prominent metatarsal head? M77.41 (Metatarsalgia, right foot), or M21.6x1 (Other acquired deformities of right foot), or Q66.22? 


Edward Stein, DPM, Peters, MO


Response: The answer to your question starts with, is this "acquired" vs "congenital"? A prominent metatarsal head is a deformity which is usually acquired. The most specific codes for an acquired deformity are: 


1) Other acquired deformities of right foot M21.6X1 

2) Other acquired deformities of left foot M21.6X2 


Q66.22 is "congenital metatarsus adductus or metatarsus varus". This is defined as a foot deformity noted at birth that causes the front half of the foot, or forefoot, to turn inward. 


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


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Query: Cheilectomy and Amniotic Interposition


If a doctor does a cheilectomy and interposes an amniotic membrane into the joint prior to closure, is that a billable fee separately? I thought that the surgical center would bill for the supply and the surgeon really doesn't bill anything except the CPT 28289. Is that correct? 


Mike King, DPM, Alpharetta, GA


Response: Correct, you would bill for the cheilectomy procedure. The insertion of the amniotic graft would be incidental to your procedure and would not be separately billable by you. 


You or the ASC should pre-certify the graft to see if the insurance company will pay the ASC for that item. Most insurance companies in my area consider that graft material experimental and investigational, and therefore a non-pay item. 


Paul Kinberg, DPM, Dallas, TX 


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Query: Heel Fissures?


We commonly see complaints of heel fissures. Isn't a "heel fissure" by definition an ulcer, whether it be partial or full thickness, and therefore eligible for a debridement code? 


Jennifer, Office of Charles Perry, DPM, Cambridge, OH 


Response: If you are treating an open wound (e.g., full thickness) beneath cracked and bleeding heel fissures, then CPT 97597 would likely be your code. The more common scenario, however, is a presentation of hyperkeratotic tissue (cracked skin around the heels) without an open wound. There is no debriding of dermis; there is debridement or paring of hyperkeratotic tissue. If that is the case, CPT 11055 is your likely code. And, yes, that is a routine foot care code...and, yes, most payers will not reimburse that code without "at risk" findings present. 


Harry Goldsmith, DPM, Cerritos, CA


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Query: Health Net Demanding Refunds


Recently, we have had Health Net take back portions of payments from years 2008 and 2007. The explanation code is BD - Bad Debt adjustment & OA-216 - Based on the findings of a review organization. When I called Health Net, they refused to give any information, as I could not verify the patient's date of birth. Since it has been over 7 years since these patients have been in our office, we no longer have any records on them and cannot provide that information. So, in essence Health Net is taking money away from us far after the allowed time and refusing to give any details as to why. Does anyone have any advice on how to proceed? 


Rob Kelso, Office of Michael DiGiacomo, DPM, Oakland, CA


Response: Ask to speak to a supervisor about the process they are taking, not so much the individual patient aspect. I think, in all reasonableness, 7 years is a very long time period to go back and ask for money (who has those records at their fingertips, especially in an "inactive" patient). If you run into a brick wall, I would tell them that you will be calling the state insurance commissioner to file a formal complaint and request an inquiry into the payer's practices. Health Net might recognize that the effort to recover a 7-year overpayment is not worth the scrutiny. 


I believe there are provisions in California law that if you acted in good faith and delivered medically necessary and reasonable care, and the insurance company paid on it, they cannot come after you later to get the money back. You might also wish to contact your malpractice carrier to see if they have an administrative defense provision/benefit, or the California Podiatric Medical Association for assistance and possibly assist/join you in filing a complaint. If Health Net is demanding refunds like this from you, it is possible others are in the same boat. 


You did not mention how much money they are asking back. Obviously, that can be a very relevant issue in terms of time and effort on both you and whether the payer is willing to defend or pursue this. That said, sometimes it's the principle of the thing not to get walked over by an insurance company. Making a stand might stop this process for the next doc in line to get such a letter. 


Tony Poggio, DPM, Alameda, CA 


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From: Paul Kesselman, DPM


There are two "orders" which are required by Medicare regarding DMEPOS items. The first is a dispensing order, the second is the detailed written order. A dispensing order is akin to a prescription, which can be verbal or written. It is quite simple and may be oral and without specific name brand, model numbers, and with very brief information about the patient. A dispensing order is required prior to the item being provided to the patient.


As for the detailed written order, this requires much more information about the item being provided (e.g. name brand, size, width, model number, etc.) as well as very detailed information about the patient. In addition, a detailed written order must be provided prior to the claim being sent to Medicare. However, as physicians who supply our own patients, these separate documents are not required. Rather, the elements of the dispensing order (prescription) and Detailed Written Order (DWO) are required within the patient's medical record. 


Paul Kesselman, DPM, Woodside, NY 



Query: Medicare DME Orders


Medicare DME dispensing rules require an "order" by the physician, but what does that entail? Is that part of the physician's note or a separate note such as a written prescription? Please advise. 


Amy Meehan, Billing Manager, Potomac, MD


Response: The physician order is the prescription. In the case of DME, there would be no difference. The order would need to include patient identifying information, item name/description, diagnosis, and the expected length this device will be needed (e.g., lifetime for an AFO vs. 3 months for crutches). 


The physician-supplier does not need to produce a unique prescription for their own patient for DME or supplies. That order can be included within the physician's medical record. You should check with your DMAC to see about any other requirements. Make sure that your records include what you are prescribing, the medical necessity, why a custom device is required vs. an OTC device, the level of disability/impairment, symptoms, etc. 


Tony Poggio, DPM, Alameda, CA 


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Query: Multi-Layered Compression Dressing


When billing CPT 29581 for a multi-layered compression dressing system, does anyone bill for the supplies as well (e.g., "A" codes) or have those typically been included in the payment for the application? 


Mike King, DPM, Alpharetta, GA


Response: The costs of the supplies are included in the allowance for the application procedure and not separately. 


The key to using CPT 29581 is that you are applying a multi-layer compression SYSTEM. There are specific items that are expected to be used, if you don't purchase pre-packaged kits. While it would be cheaper to put together your own layer materials (same as in the kits), the systems kits are more convenient. 


Tony Poggio, DPM, Alameda, CA 


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Query: Amputation with I&D


I performed a procedure which included an I&D of plantar space infection and partial first ray resection. My thought is to use code CPT 28003 for the incision and drainage. Would the amputation of the toe and metatarsal head be included, or is it billable separately (CPT 28810)? The Incision was carried to encompass the partial ray resection and the I&D. 


R. Kurt Meier, III, DPM, Brick, NJ


Response: CPT 28003 is appropriate for an I&D that is done below the level of fascia in multiple areas. The description of CPT 28810 reads, "amputation, metatarsal, with toe, single”. If you did not amputate the entire metatarsal, I do not think 28110 is appropriate. For a partial first ray amputation (hallux and part of the 1st metatarsal), I suggest both CPT 28820 (amputation, toe; metatarsophalangeal joint) and CPT 28122 (partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [e.g., osteomyelitis or bossing]; tarsal or metatarsal bone, except talus or calcaneus) with a "-59" modifier on CPT 28122. 


Now the question is whether you should code both the I&D and the partial first ray resection. If the incision portion of your I&D was actually part of the incision to do the partial first ray amputation, my opinion is that the I&D was a component of the amputation and should not be separately billed. Conversely, if the I&D was its own distinct procedure or independent from the amputation, then it can be separately billed. In this situation, your documentation should indicate that the the I&D was a different procedure or surgery, different site, or a separate incision from the amputation. 


Jeffrey Lehrman, DPM, Springfield, PA 


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Query: Contusion Great Toe Left


I keep having problems understanding the right way to use "x" character in ICD-10. I saw a patient for a contusion to the great toe nail, left foot. I billed S90.45xA and Aetna rejected it. 

What did I do wrong? 


Robert S Steinberg, DPM, Schaumburg, IL


Response: You used a code for superficial foreign body in the toe, rather than for a contusion. And you would not have used the "x" as there is a valid 6th place number specifying the location. The "x" is used only as a place marker when there are no character choices listed for the sixth spot when a seventh is required (for example). There are some codes that use more than one "x" as place markers, so you need to research carefully. 


Had the patient presented with a superficial foreign body of the right great toe, active care encounter, you would have coded S90.451A.  However, you said you treated a contusion that included damage to the nail, so that would be coded S90.211A (contusion of right great toe with damage to nail, active management). You did not say what CPT code you used, but it should be appropriate for the treatment of a contusion right great toe with damaged nail. 


Katherine Sharp, Keystone Professional Solutions, Woodbury, TN 


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Query: Coverage: Medicare Advantage Plans


I was under the impression that Medicare Advantage plans must provide or offer the same level of benefits as traditional Medicare. I run into plans in New York City (e.g., UnitedHealthcare and VNS plans) that limit "routine care" to 4 visits per year. This is obviously less than the every 61 day coverage that traditional Medicare offers. Is this legal? 


Stephen Bennett, DPM, NY, NY


Response: In Pennsylvania, some plans, in ADDITION to the Medicare-required routine care for at-risk patients (diabetes, peripheral arterial disease, etc.), also provide a certain number of "routine care" visits for those NOT at any risk -- that benefit would be over and above Medicare Part B's allowance, and certainly would be legal. So are you sure that is not what you are experiencing? 


Richard Rettig, DPM, Philadelphia, PA 


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Query: Physical Therapy Billing


We have a physical therapist on staff. What is the proper channel to bill physical therapy services? Do we use the NPI of the actual physical therapist administering the service? Or, do we use the NPI of the DPM? Should we use the physical therapist's NPI as rendering, and DPM as supervising? Does anyone have recent experience with the utilization of actual physical therapy services within their DPM practice? 


Melissa Robitaille, DPM, Richmond Hill, GA


Response: We have performed PT/OT billing for over 20 years, though not as part of a podiatry practice. The physical therapist should be enrolled under your group and the billing go out with the PT as the rendering provider (with the physical therapist's NPI, of course) and the DPM as the referring provider. Be sure whoever does your billing is aware of the required modifiers, particularly for Medicare. All other aspects pertain, of course - medical record documentation, Rxs, etc. 


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


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RE: Updated Taxonomy Codes for DPMs


An updated set of taxonomy codes has been developed and is set to go into effect January 1, 2017 (for some Medicare contractors, October 1, 2016). It is of utmost importance that you check your taxonomy coding which you submitted to Medicare. The following are accepted codes for podiatrists: 


Podiatrist - 213E00000X [definition] Foot & Ankle Surgery - 213ES0103X[definition] Foot Surgery - 213ES0131X [definition] Primary Podiatric Medicine - 213EP1101X[definition] Public Medicine - 213EP0504X [definition] Radiology - 213ER0200X [definition] Sports Medicine - 213ES0000X [definition].


It is especially important to note that for podiatrists, General Practice - 213EG0000X [definition], is being eliminated. Therefore, if you are registered with Medicare under this taxonomy code, you may need to contact your MAC and have the taxonomy code changed. Whether this will be something you can do without an 855 revalidation, I leave it for the enrollment specialists to comment on. 


Paul Kesselman, DPM, Woodside, NY


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Query: Digital Radiography Penalties?


I am still unclear on how to bill Medicare for x-rays beginning January 1, 2017. If we upgraded to DR (not CR) radiography, how do we show our Medicare contractor that we are not subject to the reduction? Do we need to bill the technical component and professional component separately? Are there any new or different modifiers? What does Medicare require? 


Michael Nirenberg, DPM, Merrillville, IN


Response: Whereas the final rule has the following statement about mammography: "We established a HCPCS modifier for CT services rendered on machines that do not meet an equipment standard," it does not specifically state how they will identify DR, CR, and analog systems for x-rays. It is probable that we will have new modifiers to identify the type of digital imaging system we are using in our office. 


Michael L Brody, DPM, Commack, NY 


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RE: Charcot Check-Up (Karen Banks, DPM)

From: Robert D. Phillips, DPM


I realize that I do not have the same billing issues that most private practitioners do; however, I do face the same issues of Charcot joints that chronically break down into ulcers on the bottom of the foot. The big issue here is whether the treating physician can document what would happen if he lets the patient go longer than two weeks.


What happens if he lets the patient go 2.5 weeks or 3 weeks between visits? Are there pre-ulcerative changes in the keratoses? I have some Charcot joint patients who, if I don’t see them every 2-3 weeks, will come in with a new ulceration under the foot. This is documented. The fact that a callus can build up in 2 weeks time would necessitate debridement speaks greatly about the ineffectiveness of the shoes/orthotics that the patient is wearing.


One of the things that would help document the need for a check-up is a pedobarograph examination of the patient wearing the diabetic shoes/orthotics. Even with the best shoe/orthotic therapy, pathological forces cannot always be adequately alleviated to prevent callus and ulcer formation in the Charcot joint patient.


Robert D. Phillips, DPM, Orlando, FL 



Bret Ribotsky: Please share a few ideas that can be implemented to improve the foot surgery experience for patients?


Dr. Ali Sadreich


Ali Sadreih: I have tried to place the patient above everything else. I have written a post-op manual that I give to each surgical patient. I direct them to my website which has many videos that explain everything from what to do if your dressing gets wet, to what to expect pre- and post-surgery.  All in all, I have tried to make the experience the best for the patient.  


Drs. Brian Fullem and Amox Saxena


Meet the Masters is broadcast each Tuesday night at 9 PM (EST). This week's guests are sports podiatrists Drs. Brian Fullem and Amol Saxena. You can register for future events by clicking here



RE: CMS Grace Period for ICD-10 to End


For those of you who never even realized it, the one-year grace period in effect for ICD-10 announced last summer by CMS and AMA will end on October 1. 


One of the complaints associated with the "grace period" was that CMS never coordinated a similar grace period from commercial payers. And the majority of those payers did not go along with CMS's "flexibility". Over the past year, I have remarked that essentially CMS's/AMA's announcement of flexibility was little more than a public relations effort for that very reason. If a practice needs to code the highest level of specific for non-Medicare payers, are they really going to change to "grace" mode for Medicare claims? Really? 


Regardless, CMS noted that on October 1, 2016, providers will be required to use the "correct degree of specificity" when coding ICD-10 on their claims. That is interpreted as, for example, only using unspecified codes when the situation warranted their use and ensuring that the ICD-10 codes billed and the medical record documentation are supportive of one another. 


Interestingly enough, the years of delays leading up to ICD-10 implementation allowed many practices - providers and coders - time to prepare for the transition from ICD-9 to ICD-10. All-in-all, the transition was relatively smooth with minimal glitches, confusion, and loss of productivity reported. 


Harry Goldsmith, DPM, Cerritos, CA


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Query: Charcot Check-Up


I have a new patient from out of state. She has Charcot deformity with associated lesions. She wears molded inserts and currently has no breakdown of her lesions. She has, by history, had ulcerations in the past. Her past podiatrist was checking her every two weeks with debridement of the lesions. He was charging an office visit on these encounters. Am I missing something here? Is this a legitimate and legal way to see this patient? I think this would fall under the category of debridement of lesions and have a 60-day follow-up. I would understand if there were any hint of breakdown. I would like to make sure this is followed well and the condition not deteriorate. At the same time, I don't want to illegally bill Medicare. Give your specific coding if you think this is worth an office visit every two weeks. 


Karen Banks, DPM, Thomasville, GA


Response: I think your suspicions are right on. I believe I understand that you are saying the doctor is seeing the patient every two weeks for a callus check and debridement of any hyperkeratotic lesions. If this is the case, the service is palliative, and would fall under the routine foot care guidelines and limits. If the paring of calluses is the primary service performed, if the patient qualifies for routine foot care or qualifies under loss of protective sensation (LOPS), the reimbursement would be based on a 60-day cycle or 6-month cycle, respectively. If the patient needed palliative care sooner, then that would be paid directly by the patient. 


The coding would be the CPT 11055 series for routine foot care (with the appropriate ICD-10 codes) or G0245 (or G0246) plus G0247 for LOPS (with the appropriate ICD-10 codes). E/M service coding only would be appropriate when there is a new diagnosis or a "significant, separately identifiable" reason for re-evaluation and management. The level of E/M would be based on medical necessity and documentation. 


Tony Poggio, DPM, Alameda, CA 


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Query: Lesser MTPJ Implant


I performed a total silastic implant on a 3rd metatarsal-phalangeal joint (MTPJ) for an arthritic condition. At the same time, same foot, I performed a partial implant on the first MTPJ. I cannot find a proper code other than an unspecified code for the lesser implant. Does one exist? 


Marc Lederman, DPM, West Hartford, CT


Response: There is no code for lesser metatarsal joint implant procedures. Therefore, your options are: 1) CPT 28899 (unlisted foot/toe procedure), assign a fee, and provide operative report for manual review. Request peer review from insurer. You might want to contact the insurer prior to surgery since some consider this type of procedure investigational and won't cover it at all; or 2) CPT 28122-59, ostectomy, lesser metatarsal. Consider the procedure as an arthroplasty of the lesser metatarsal joint. 


As far as coding a partial implant of the first metatarsal-phalangeal joint, you would bill CPT 28293 (bunionectomy with implant). 


Howard Zlotoff, DPM, Camp Hill, PA 


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Query: Routine Nail Care Coding


If a patient has neuropathy from chemotherapy, but is not a diabetic and does not meet class findings (Q7, Q8 or Q9), is the patient covered under Medicare for routine nail care? I looked in the routine foot care LCD, but the language is unclear. 


Susan Yu, DPM, Urbana, OH


Response: The Ohio LCD says the patient must have class findings to be covered for routine foot care. However, directly under that it says, "Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of CLASS FINDINGS MODIFIERS IS NOT NECESSARY. This condition would be represented by the ICD-10-CM codes in the 3rd table of “ICD-10 Codes that Support Medical Necessity” listed below.” 


In the codes that are listed below, one of the options is G62.0, drug-induced polyneuropathy, which is what I consider the appropriate code for neuropathy from chemotherapy. This tells me that the patient you are asking about should be covered for routine foot care with a qualifying diagnosis of G62.0 even in the absence of class findings. I suggest you document the nature of their neuropathy and that having this done by someone other than a podiatrist would place this patient at risk. 


Finally, be aware that G62.0 has the instruction to "Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)”. You should include that if you know the drug. 


Jeffrey Lehrman, DPM, Springfield, PA


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Query: Medicare: Is a DEA Number Required to Enroll in Medicare?


If I will not prescribe narcotics in my practice, is there a way to enroll with Medicare without a DEA number? 


Troy Harris, DPM, Swansboro, NC


Response: From CMS -"Provider Enrollment - Drug Enforcement Administration (DEA) Information Required 


The Internet-based Provider Enrollment, Chain and Ownership System (PECOS) Release 7.19.0, has been enhanced to require DEA registration information in Section 2 along with license and certification information effective with enrollment applications (including revalidations) completed on or after January 12, 2015. The new requirement for DEA registration information also applies to paper applications. Because the paper CMS-855I enrollment application does not include a space to enter the state in which the DEA certification was issued, contractors will develop applications where the DEA certificate has not been submitted with the application or the state where the certification was issued cannot be found elsewhere within the application. To prevent delays and development of your CMS 855I enrollment applications and revalidations, providers should include the DEA certificate when submitting their paper CMS-855I applications." 


Joseph Borreggine, DPM, Charleston, IL 


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Query: Getting Paid for an E/M and Strapping


When billing for an office E/M visit and strapping (CPT 29540), we are finding that payers are frequently bundling the two together, and paying for the strapping (which is of course the lesser charge). How do we bill correctly to get paid for both? 


Linda, Office of Lewis Giglia, DPM, Fairport, NY


Response: The established E/M service is a component service included in the "comprehensive" strapping application according to the CCI edits [Medicare]. If, however, you use modifier "-25", you override the CCI edit. You can only used the "-25" modifier when the E/M is "a significant, separately identifiable evaluation and management service." In those cases, you should get paid for both the strapping and the E/M visit. Non-Medicare payers have similar payments, but their own versions of bundling edits. 


For example, if you are treating a patient with an established plantar fasciitis diagnosis by the application of a subsequent strapping, the E/M service would be included in the strapping allowance. 


Joseph Borreggine, DPM, Charleston, IL 


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