Podiatry Management Online


Podiatry Management Online
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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Query: Coding for Trauma Wound with Hematoma


I have an 80 year old female non-diabetic patient with normal peripheral vascular status who was cleaning her oven and bumped into the open door causing bilateral skin tears of both legs. She also had an organized hematoma of the right leg at the margins of the wound. The only code for “hematoma” that I can find states “with skin intact”. The ICD-10 Alphabetic Index then suggests to look at “Contusion” by location. Even there, I could not find a code mentioning “hematoma” that did not mention “with skin intact”. Also, these wounds are traumatic not pressure or diabetic and they are not lacerations. Am I missing something or is it just ICD-10 overload and we just take our best guess?


Kevin Brattain, DPM, Peoria, IL


Response: I recommend looking at “laceration” ICD-10 coding. You said “bilateral skin tears of both legs. She also had an organized hematoma of the right leg.” So it seems this was the initial encounter for the acute episode of care and you would select for both legs:

S81.811A  laceration without foreign body, right lower leg

S81.812A  laceration without foreign body, left lower leg


Additionally, you stated this is a hematoma which is the same as a contusion.

S80.11xA  contusion of right lower leg


You are using injury codes, so make sure you document the date she injured her legs.  It would be called the date of injury in your billing software.


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


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Query: CPT 17110 Denials


Does anyone know why Medicare in Pennsylvania has stopped paying (“non-covered”) for CPT 17110 (destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to14 lesions) for the treatment of plantar warts?


Edwin S. Hart, DPM, Bethlehem, PA


Response: Try coding it using a primary diagnosis of wart (B07.0) and a secondary diagnosis of pain, such as


M79.671   pain in right foot

M79.672   pain in left foot

M79.674   pain in right toe(s)

M79.675   pain in left toe(s)


Jeffrey D Lehrman, DPM, Springfield, PA


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Query: ICD-10 Coding: Enlarged and Hypertrophic Nails


I am having a problem locating the appropriate ICD-10 code for an enlarged and hypertrophic nail to be used with the debridement of the nails, CPT 11720 and CPT 11721 codes. My code search takes me to Q84.5 (enlarged and hypertrophic nails; congenital), but most of the nail thicknesses seen are acquired. What ICD-10 code should we be using to describe acquired enlarged and hypertrophic nails in a diabetic patient?


Deb Lewis, CPC, Colorado Springs, CO


Response: Noridian is my Medicare contractor. I use ICD-10 L60.2 (onychogryphosis) to describe enlarged and hypertrophic nails.


Tony Poggio, Alameda, CA


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Query: Penalties for Using CR vs DR X-Ray Systems


Is there a penalty in 2017 for using a CR rather than a DR x-ray system? I was led to believe that there would be a downward payment adjustment for not upgrading our old ScanX to a direct digital system.


Wendy Siegel, DPM, Smithtown, NY


Response: Medicare/CMS as of January 1, 2017 began reducing payments to providers submitting claims for analog x-ray studies by 20%. The reduction is deducted from the “Technical Component” of the x-ray service.


Starting in 2018, payments for x-ray studies performed using computed radiography (CR) equipment will be reduced by 7% for the next five years and 10% after that. The goal is for all x-ray studies to be performed using digital radiography (DR).


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


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Query: The Use of CPT 20500


Is CPT 20500 (injection of sinus tract; therapeutic [separate procedure]) only to be used if dealing with a sinus tract, or can it be used as a therapeutic injection for other pathology?


Barry Feinstein, DPM, North Hollywood, CA


Response: I think the use of CPT 20500 is limited to injection of a sinus tract. If you inject something other than a sinus tract, you should code the injection procedure specific to the type of injection performed.


Jeffrey D Lehrman, DPM, Springfield, PA


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Query: In-Hospital Patient Consultations


I am unclear as to what code to use for an inpatient hospital initial consultation. I have been denied by my Medicare Part B contractor on CPT 99222 (initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity), stating only an admitting physician can use that code. So, then I tried CPT 99252 (initial inpatient consultation for a new or established patient), and it was denied stating that code was invalid.


Vanessa Sloan, Effingham, IL


Response: Medicare eliminated “consultation” codes so, yes, those are invalid. You are allowed to use the initial hospital care codes, if, as you say, you meet the code’s requirements. These codes for Medicare are not exclusive to the admitting doctor. Your Medicare contractor denied you incorrectly.


You may want to call and ask for a supervisor. If you get the same information, I would then notify your state association and bring this to their attention. Get the reference number of the call you made as that can be used to track down what happened.


Tony Poggio, DPM, Alameda, CA


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Query: MIPS: Registry vs. Claims Made Basis


After listening to a number of webinars, our group practice would like to report via a registry for the former PQRS measures. In past years, we have always done this on a claims made basis. Since our EMR was already set up this way, all providers have been answering the questions in 2017, and sending them on claims as before. Does this action mean we are forced to continue claims made submission for the coming year? If so, I will make sure this doesn’t happen in 2018.


Jane Graebner, DPM, Delaware, OH


Response: My understanding is that you can switch over to registry reporting for 2017 even though your providers have been submitting via claims so far.


I think when the registry reports your quality data that will trump the claims that have been submitted. I also think we are going to be given the opportunity to designate our reporting period and you can choose your reporting period for your Quality category to be during the time you were using the registry.


Jeffrey D Lehrman, DPM, Springfield, PA

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Query: Place of Service Injection Denial


I injected a patient for her plantar fasciitis during a home visit. She has Blue Cross/Blue Shield. She herself is not homebound, but due to having a number of children, it makes it easier for me to do this at her home. It is admittedly a convenience. I did not bill an office visit, just the plantar fascial injection. It was denied due to place of service. It there any way to appeal this?


Jeffrey B Klein, DPM, Waterford, MI


Response: You can always appeal, Whether you win or not is another question.


You should ask if there is a difference in reimbursement for that injection based upon the site of service. If there is not, then you can argue that the injection was medically necessary, there is no added cost to the carrier and, therefore, it should be paid.


Tony Poggio, DPM, Alameda, CA


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Query: Coding for Plantarflexed Metatarsal


I have a new Medicare patient that presents with a plantarflexed 5th metatarsal and localized bursitis. I evaluated the patient and gave an injection of lidocaine and dexamethasone, along with an offloading pad. What ICD-10 and CPT codes would you suggest?  


Adam Klein, DPM  Lynbrook, NY


Response: CPT 20550 is defined as “injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar fascia)”. Your post did not state that you injected either a tendon sheath or ligament.


CPT 20600, on the other hand, is defined as “arthrocentesis, aspiration and/or injection; small joint or bursa (e.g., fingers, toes); without ultrasound guidance” which appears to meet your coding needs.


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

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From: Joel Lang, DPM 


So often, I read of podiatrists having multiple problems getting their insurance claims paid. They jump through hoops, spend time on phone calls with minimum wage insurance clerks and negotiate fees with patients who are unexpectedly denied. My advice is not to be the “ball” in a ping-pong game between patients and their insurance carriers. It is the weakest position you can be in. 


In my practice, I required that orthotics be paid in full at the time of casting. After submitting the claim and the insurance paid for the service, the patient was promptly refunded the amount of the insurance payment. This was all stated in a signed release at the...


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



From: Tom Silver, DPM


We ran into this situation with two children last December. We called and got prior authorization on Rx orthotics. We have an internal form for prior authorization calls that has diagnosis, orthotic codes, name of rep talked to, etc., and scan this into the patient's chart. We were told that these two patients had met their deductible and the orthotics were covered under their policy at 100%, but got rejections on the claims that this was "not a covered service under their plan." My office promptly called the insurance company who told us "sorry, you were given misinformation by the rep." We asked for the claims to be reviewed, and after they listened at their recorded prior authorization calls, they promptly paid us for the orthotics.   


Both parents of one of these children also needed orthotics. As all were on the same policy, we automatically assumed they would also have 100% coverage like the rep said their child had.   Since we didn't call on the parents to check their coverage, their claims were rejected! They are neighbors and when I told the father that his insurance wouldn't pay on their orthotics, he quickly responded, "well I guess you'll just have to eat the charges"! We are currently negotiating a reduced fee for the orthotics they got in mid-December!


Tom Silver, DPM, Minneapolis, MN 



From: John F. Swaim, DPM


This has been a problem in Northern California for quite some time. I handle this issue by always having the patient call and ask if orthotics are a covered benefit of their insurance policy. I also have them sign that they are responsible for any balance and we get a credit card number as well. This way, I am not in between patients and their insurance company. The insurance companies can lie to me with little risk for retribution, but it is a different story if they lie to the premium payer.


John F. Swaim, DPM, Red Bluff, CA



From: Keith L. Gurnick, DPM


Stop letting insurance companies and patients burn you on getting paid for orthotics. I have been in private practice since 1982 and, after making every mistake possible and trying not to anymore, here is how we have refined and incorporate the financials of orthotics in my office: 


1) If you are contracted with the patient's health insurance plan, always check benefits in advance of casting for orthotics. 2) Have a well designed insurance "orthotic coverage form" with all the necessary questions and make sure it is...


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



Query: Denial of Foot Orthotics Despite Doing Everything


We are running into a problem with insurance companies telling us that custom foot orthotics are a covered benefit, giving us specific coverage details (% coverage, co-insurance, whether or not authorization is needed, deductible status, and so forth).


Then, after telling us that the orthotics are covered, that the patient’s deductible has been met, and that pre-authorization is not needed, they deny our claims. Although we provide our contact names and call reference numbers, some of the payers won’t budge in their denials. In some cases, it is some piece of information they did not give us over the phone, such as they only cover foot orthotics with a diabetes diagnosis. Sometimes, they just say not a covered benefit of their plan.


We do have the patient sign a form that they will pay if their insurance plan does not pay, so they will not blame the denials on us, but…how do we avoid the denials of the original clams and appeals?  


Jeff Bean, DPM, Carson City, NV


Response: When getting a pre-authorization, always give the specific CPT/HCPCS code vs “are orthotics covered?” Ask for exclusions or limitations of coverage because payers tend not to mention that unless asked. That’s about all you can do from your end.


You should mention this to your state association so that they could lobby for changes in policy for this payer which should carry more clout. Lastly, appeal to your state insurance oversight board. You can also have the patient file a complaint with their payer related to the unfair practice of giving out incorrect information, and then not be willing to make good on THEIR error.


Tony Poggio, DPM, Alameda, CA

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Query: New FX Modifier for X-Ray Films


Does anyone know if the new “FX” modifier (x-ray taken using film) applies to commercial insurers as well as Medicare?


Anthony Hoffman, DPM, Oakland, CA


Response: We were submitting the “FX” modifier to all payers for one of our satellite locations only to have the claims denied by everyone except Medicare. We are now only submitting x-ray claims with an “FX” modifier to Medicare.


Julia Gold, MHA, CMPE, Office of Robert Kukla, DPM, Hickory, NC

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Query: CPT 11042 Diagnosis


When billing CPT 11042 (debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less), can you use a wound diagnosis code, such as S91.312A (laceration without foreign body, left foot, initial encounter)?


Danielle LaLonde, Belvidere, NJ


Response: I think that diagnosis is fine. I think the ulcer debridement codes are typically intended for use in chronic ulcers rather than traumatic wounds. However, I reviewed your New Jersey Novitas Wound Care LCD, and did not find anything saying that CPT 11042 could not be performed on an acute / traumatic wound.


Jeffrey D Lehrman, DPM, Springfield, PA

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Query: Billing 2 Border Nail Avulsions Left Hallux


If two partial nail avulsions are performed on the left toe, would it be billed: CPT 11730-TA, CPT 11732-TA?


Medical Staff, Office of Wendy Wu, DPM, Monterey Park, CA


Response: CPT 11730 represents a partial or total nail avulsion.


A single code is billed whether you are doing a complete nail avulsion, a single border avulsion, or both part medial and part lateral borders. “TA” is the correct modifier for the left great toe. You only bill CPT 11732 for additional toes that had avulsions, not on the same toe.


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

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Query: Coding for Arthrodesis 1st MPJ


How should I bill for an arthrodesis of the 1st metatarsal-phalangeal joint when it is for a severe bunion/hallux abductus? I was inclined to use CPT 28296 (correction, hallux valgus [bunionectomy], with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method), but then I realized the first metatarsal-phalangeal joint arthrodesis code, CPT 28750, is specific for arthrodesis.  


Here’s my dilemma, under the Medicare CPT to ICD-10 coding, billing CPT 28750 has a potential link to primary diagnostic codes for traumatic arthritis, hallux varus, hallux rigidus with potential secondary code of hallux abductus. In this case, there was no arthritis, but due to medical circumstances, the arthrodesis was performed strictly for hallux valgus resolution. Therefore, should I bill CPT 28296 with M20.11 (hallux valgus [acquired], right foot)  or CPT 28750 with M20.11?  Does it matter what ICD-10 code I use?  


Anthony R. Hoffman, DPM,  Oakland, CA


Response: The procedure you performed was a joint fusion, but not to be confused with an osteotomy code substitution. CPT 28750 would be the correct code to use. The next question is the ICD-10 code. It will matter. Generally, the fusion procedure is done on an arthritic painful joint. It is not unusual for a payer to have software edits linking accepted ICD-10 codes to specific CPT or HCPCS codes. You should understand also that there are no universally accepted CPT to ICD-10 code links. Other than the payer, lists available by commercial companies or even specialty organizations are nothing more than suggested links. 


Regarding the diagnosis, if the patient has a hallux valgus, and that is the reason for the procedure performed, then use M20-11 as your ICD-10 code because that is what the patient presented with. Obviously, if there are other relevant pathologies present, include them. Having said that, despite any denial based on edits, you do have the opportunity to appeal and make your case. Ask for a peer-to-peer review and provide citations supporting the medical necessity for the procedure.


Tony Poggio, DPM, Alameda, CA


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Query: DME Denial: Modifier Issue


When billing DME, we have always add “RT” or “LT” as well as the “KX” modifier to show we have met the requirements including medical necessity. We also add a “GA” to show we have a signed waiver from the patient. We just received a denial from Noridian DMAC stating “invalid combination of HCPCS modifiers”. Has something changed that I am not aware of? Please advise.


Roy Rothman, DPM, Debary, FL


Response: The “KX” modifier is only needed if the policy dictates the need because there are specific variables present.


Not every DME should have a “KX” appended. It should only be appended if that criteria is met and documented. You also do not need an ABN for every single item, but it won’t hurt to get one. When policies exist, they are clear on what modifiers are acceptable.


Ruby Woodward, CPC, COSC, Prior Lake, MN


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Query: Austin Bunionectomy and Akin Osteotomy Coding


What CPT codes can we use to get paid for both an Austin-type bunionectomy and Akin-type osteotomy performed during the same surgery on the same foot? I have been using CPT 28296 for the Austin and CPT 28310 for the Akin. The insurance companies are bundling them into the CPT 28296 code. We all know the procedure takes longer and there is twice the risk the surgeon takes of complications including delayed union/non-union/malunion. Also, what ICD-10 codes would be appropriate?


Douglas S. Stacey, DPM, Henderson, NV


Response: The correct coding for an “Austin and Akin-type” bunionectomy is CPT 28299. The latest edition of the CPT has a picture representing a distal 1st metatarsal osteotomy with bunionectomy and proximal phalanx osteotomy. The APMA Coding Resource Center also has those illustrations in the Reference section under “Bunionectomy Illustrations”.


The coding for the Austin-Akin-type bunionectomy is not new; neither are the CPT illustrations. The ICD-10 coding for acquired hallux valgus would be M20.11 (right foot) or M20.12 (left foot), depending on the patient’s presenting problem.


Paul Kinberg, DPM, Dallas, TX


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Query: Plantarflexed Metatarsal


I have a new Medicare patient who presents with a plantarflexed 5th metatarsal and localized bursitis. I evaluated the patient and gave an injection of lidocaine and dexamethasone, along with an offloading pad. What ICD-10 and CPT codes would you suggest?


Adam Klein, DPM, Lynbrook, NY


Response: The ICD-10 code that I suggest for the plantarflexed metatarsal would be M21.6X1 Acquired foot deformity, right; or M21.6X2 Acquired foot deformity, left.


For the injection, I would use CPT code 20600 –, presuming the injection is in the foot with a the ICD-10 code, M77.51 Other enthesopathy of right foot; or M77.52 Other enthesopathy of left foot, whichever is appropriate.


Be sure to bill for the dexamethasone using HCPCS J1100 (dexamethasone 4 mg/ml [1 unit]).


Joseph Borreggine, DPM, Charleston, IL


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Query: Ulcer Debridement


We have a patient with a pressure ulcer of the left heel, stage 3; and a pressure ulcer, stage 3, left foot. The doctor debrided both open wounds. Can I bill CPT 97597 for each wound?


Kim Stalter, Normal, IL


Response: Wounds are not coded individually. They are coded based upon “aggregate size” of the similarly debrided (level) codes anywhere on the body. For example, CPT 97597 is based on “first 20 sq cm or less”. So, if one wound measures 5 sq cm and the other 10 sq cm, the total would be 15 sq cm. You would bill that under a single code (CPT 97597). If the selective debridement exceeded 20 sq cms, you would bill CPT 97597 and CPT 97598 (an add-on code).


If one wound was selectively debrided and the other excisionally debrided (CPT 1104x), you would bill two codes based on the type of tissue debrided (and documented).


Tony Poggio, DPM, Alameda, CA


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Query: Medicare ABN


Is there appropriate terminology or a “good” reason to use the Medicare Advance Beneficiary Notice (ABN) form for why Medicare may not pay for an AFO, therapeutic (diabetic) shoes, etc., other than “not covered item, does not meet Medicare criteria, could be fit with a pre-fab device, etc” to cover us, so that if the claim is denied, we can collect from the patient?


Gary Friedlander, DPM, Glendale, AZ


Response: The reason for the Advance Beneficiary Notice (ABN) and the need for stating probable denial is to inform the patient prior to treatment (or dispensing) that they may be responsible for payment.


I always include frequency of service as a possible reason for denial. The reasons you included are correct as well. If you choose possible denial because “not covered item, does not meet Medicare criteria” and Medicare indicates “patient did not meet the criteria due to frequency of service”, you can still bill the patient as long as you have the signed ABN on file and include the ABN modifier (“GA”) on the claim.


Donald R Blum, DPM, JD, Dallas, TX


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Query: Wound Biologics Wasted Product


My representative for Epifix says we now have to document the ‘waste’ of the product not used/applied to the product supply code (e.g., Q4131-JW). How is that ‘waste’ measured (i.e., a circular product measures 2.4 cm in diameter and the ulcer measures 1.0cm X 0.5cm)?


Gary Friedlander, DPM, Phoenix, AZ


Response: I suggest you document how many square centimeters of product were applied to the ulcer and how many square centimeters were wasted. Your product is a circle with a diameter of 2.4 cm. Its radius is 1.2 cm. The area of a circle is pi X radius squared. 1.2 cm squared is 1.44 cm. So now we multiple 1.44 cm by pi and get 4.5 sq. cm. Your product is 4.5 sq. cm. Your wound has an area of 0.5 sq. cm.


If you only cover the wound with no overlap, I suggest you document that you used 0.5 sq. cm. of product and wasted 4.0 sq. cm. of product. If you used more than that because of overlapping the wound, adjust accordingly. I suggest purchasing and billing for the smallest size available that will cover your wound.


Jeffrey D Lehrman, DPM, Springfield, PA


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Query:  CPT 11056 Denial 


I submitted a claim with a “Q8” on both the CPT 11720 and the CPT 11056, with only one “-59” modifier applied to CPT 11720. Again, Palmetto denied the claim. The reason for the denial remains the same, “missing/incomplete/invalid attending primary identifier” and “missing/incomplete/invalid last seen/visit date.” I listed myself as the ordering physician on one claim, and as the supervising physician on the other claim (both denied). I put my license number in the “ordering physician ID” field, thinking this may fix the problem, but it was still denied. I have so far not ever been successful in getting Palmetto to pay for callus care. 


Troy Harris, DPM, Swansboro, NC


Response: CPT 11056 requires not only a “Q” class findings modifier, but you also must list the PCP who is managing the conditions for the patient, as well as the date last seen by that provider.  It must have been within 6 months of your visit. You cannot use yourself.


Anna Sanders, Clarksville, TN


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