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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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Other messages in this thread:


08/29/2015    

CODINGLINE CORNER


Query: Supervising Physician Issue for Diabetic Nail Trims


 


Has anyone recently had an issue with claims getting denied due to the supervising physician's information not showing up on the correct electronic claim form line (2310D) for diabetic nail trims, or other services that require a supervising doctor for diabetic patients? My clearinghouse is McKesson.  


 


Mary White, DPM, Rockford, IL


 


Response: When confronted with an issue such as this, I check with two resources. First, I check with the Medicare EDI Department to verify that the referring physician is not showing up at all or is possibly in the wrong loop. Then I contact the clearinghouse to make sure they are mapping the claims correctly. If there is a problem they should be able to fix it. Sometimes they have to write a special rule to make sure that the info is there every time. If all that fails, then you need to go to your software vendor for help. 


 


Katherine Sharp, Woodbury, TN 


 



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08/26/2015    

CODINGLINE CORNER


Query: Post-Operative Non-Compliance Issues


 


My patient was non-compliant post-operatively and experienced a lot of pain related to edema and tight dressings. She presented to the emergency department instead of calling me, got the usual work-up for deep vein thrombosis, etc. The ED physician placed her on 23 hour observation, and then called me to see her. I saw her in her room in the observation area, explained (for the umpteenth time) to the patient and her daughter about the need for elevation and very limited walking post-operatively. Is there a CPT code/modifier that we can use with the edema or pain diagnosis so that we can be reimbursed for the hour I spent dealing with this situation? The patient has Medicare. 


 


PM News Subscriber


 


Response: The only available modifier for an E/M service (which is what you performed in the observation area) is the "-24" modifier which is for an E/M service that is performed during a post-op global which is for a reason unrelated to the procedure for which the patient is in the global. 


 


Your documentation would have to support that the E/M was unrelated to the surgery, and it doesn’t sound like that was the case here. 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 



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08/22/2015    

CODINGLINE CORNER


Query: CPT 64450 Denial - Not Medically Necessary


 


How do we get CPT 64450 paid for when treating neuritis or neuralgia? ICD-9 729.2 was rejected. 


 


Jeffrey Klein, DPM, Waterford, MI


 


Response: In my experience, and according to my state LCD, CPT 64450 is only payable and medically necessary when billed with ICD-9 355.6 (Mortons neuroma). 


 


Michal Levinsky, Office of Dr. Arnold Ravick, DPM, Washington, DC


 



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08/20/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Lloyd S. Smith, DPM


 


CPT 64450 is a problematic code. It used to be the correct code for injecting neuromas with cortisone. That was changed years ago as CMS demanded that CPT and RUC create new codes and revised values.  It is still in the CPT book but now should only be used in relatively rare instances and NOT for neuromas. The correct code for a cortisone injection with a neuroma diagnosis is CPT 64455.


 


CPT 64632 is to be used for sclerosing injections with alcohol. There are restrictions by many carriers on use of CPT 64632. In any case, there are stories of CPT 64450 abuse due to ignorance about these changes and differential reimbursements. 


 


Lloyd S. Smith, DPM, Newton, MA

08/19/2015    

CODINGLINE CORNER


Query: CPT 64450 Audit


 


I received a CMS recoupment letter for services covering 2008 to 2013 requesting repayment for CPT 64450 (injection, anaesthetic agent, other peripheral nerve or branch) that was submitted with diagnostic code ICD-9 355.8 (neuritis, peripheral nerve). 


 


1) Were these the appropriate procedure and diagnosis codes (in 2013) for a digital neuritis treated with a trigger point injection consisting of a steroid/anaesthetic mix? 


 


2) Is it worth the headache to go through the rebuttal process? After all, as they so pointedly state, apparently I was "not without fault" and "received payment for services (I) should have known (I was) not entitled to." 


 


Name Withheld by Moderator


 


Response: If the recoupment letter is for any significant amount of money and you think Medicare is wrong, you should appeal. 


 


The "rebuttal process" mentioned in the letter is not helpful here--you need to appeal and submit the medical records with your explanation as to why your services should be paid. Statistically, doctors win more than 50% of these appeals, so don't be discouraged by the boilerplate language in this form letter. 


 


J. Kevin West, Esq, Parson Behle & Latimer, Boise, ID 


 



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08/15/2015    

CODINGLINE CORNER


Query: Heel Stabilizers & Medicare


 


I want to bill L3170-RT (and/or LT) - foot, plastic, silicone or equal, heel stabilizer, pre-fabricated, off-the-shelf, each. If I am a Medicare Part B DME provider and I am dispensing silicone heel stabilizer(s)...are they payable even if they are not part of the shoe? 


 


Joseph Borreggine, DPM, Charleston, IL


 


Response: These procedures are listed under the orthopedic footwear policy. As such they are not covered services when removable and not an integral part of the shoe. 


 


Paul Kesselman, DPM, Woodside, NY 


 



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08/12/2015    

CODINGLINE CORNER


Query: Unna Boot Coverage Policy


 


Does anyone know where I can find the Medicare guidelines for Unna boot (CPT 29581) coverage. Does anyone have any experience on this subject? I have searched both the CMS and Noridian sites, and only found a couple of paragraphs on the subject that really don't apply. I have a claim that is being denied as "too many services". This patient has had quite a few in the past, but this is the first time they have been denied. I am trying to find out what the limitations are that are warranting this denial. 


 


Sara Tradup, CPODCS, Office of Peyman Elison, DPM, Surprise, AZ


 


Response: Here is the strapping LCD from CMS that includes information on CPT 29580 for Unna boot application. 


 


Joseph Borreggine, DPM, Charleston, IL 


 



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08/08/2015    

CODINGLINE CORNER


Query: RFC ICD-10 Coding


 


What are the appropriate ICD-10 codes for Medicare to cover routine foot care for "nails, lesions, pain"? 


 


Arden Smith, DPM, Great Neck, NY


 


Response: Since the question is, what will Medicare cover for routine foot care, the answer is found in your MAC's "Future Local Coverage Determination" for routine foot care. The required ICD-10 codes can be found there. They will give you probably several listings of ICD-10 codes based on the various CPT codes. 


 


Paul Kinberg, DPM, Dallas, TX


 



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08/06/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Marc Jay Pinsky, DPM


 


I fully agree with Dr. Kinberg's response on billing for the CPT 64632 service. However, where have you found a supplier for the dehydrated alcohol? The few U.S. dealers making this USP certified pharmaceutical available, have it priced so high that the cost of making a 25% solution + local + syringe and needle would force you to perform this service at a virtual LOSS! (There is affordable chemical grade USP dehydrated alcohol available, but it not for human/medical use). As a result, I no longer offer this effective treatment to my patients.


 


Whether it's our government or big pharma, many perfectly good medicinals have disappeared or been made too pricey to use (i.e.: polysporin powder --> gone! [no substitute], gentamycin cream went from $1.47/15 gm 1.5 years ago to almost $30/15 gm today! --> Neosporin and Silvadene cream are available, and cost-effective, but they have a higher allergy rate).


 


Marc Jay Pinsky, DPM, Petersburg, VA

08/05/2015    

CODINGLINE CORNER


Query: Sclerosing Injections


 


We would like to bill for a sclerosing injection. It is my understanding that it is billed as CPT 64455 (neuroma injection). Can you bill for the dehydrated alcohol like you can for when you bill Kenalog? 


 


Amannda Richline, DPM, Belvidere, NJ


 


Response: The code you are looking for is CPT 64632 (destruction by neurolytic agent; plantar common digital nerve).  CPT 64455 states "injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g., Morton's neuroma)." 


 


When billing the CPT 64632 code, the charge for the alcohol is included in the payment for the procedure and cannot be billed separately. This is not the same as billing one of the "J" codes for the cortisone when performing the CPT 64455. In neither case can the local anesthesia be billed as it is part of the global surgical service. And, yes, an injection is a surgical service. 


 


Paul Kinberg, DPM, Dallas, TX 


 



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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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Thera Band