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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:


05/24/2018    

CODINGLINE CORNER



Query: Wound Care LCD Update


 


I’ve recently been getting denials for medical necessity when billing CPT 97597 with the diagnosis L89.891. When the wound care LCD was updated 4/16/18 (Wound Care Coding Companion for Wound Care L37228 (A55909)), it appears that CPT 97597/97598 were grouped together with CPT 11042-11407, so L89.891/L89.892 are no longer considered medically necessary diagnoses.


 


Does anyone have a recommendation on what to do besides appeal every one of these claims?


 


Hannah Gross, CPC, Bingham Farms, MI


 


Response: The fact is you are using the wrong ICD-10 root codes. Do not use L89, but rather L97 codes instead. Then, resubmit and you will be paid in earnest.


 


Joseph Borreggine, DPM, Charleston, IL



 


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05/22/2018    

CODINGLINE CORNER



Query: Q Codes


 


Recently, we were instructed to not use the Q modifiers for routine nail care. This is specifically when we are using the Q modifier for callus care on the same claim. Is this an issue with the Q modifier or with the combination of these two procedures?


 


Gary Raymond, DPM, Altoona, PA


 


Response: I assume you are referring to the Q7-Q8-Q9 modifiers and Medicare billing? These modifiers are to be appended to RFC CPT codes when you are using vascular based ICD-10 codes only. The Q codes are used to further clarify the vascular condition. There has been confusion in the past that some carriers required these Q modifiers for even neurologic based ICD-10 codes – which is impossible. When billing combination nail and callus care CPT codes, the Q modifiers do not separate/unbundle these codes. The -59 modifier is required for this. Q codes would be used on all billing lines (for nail and callus care).


 


You may want to run this source of this information past your state association and have them investigate this further.



 


Tony Poggio, DPM, Alameda, CA


 


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05/17/2018    

CODINGLINE CORNER



Query: Hallux Rigidus - Arthofibrosis


 


I have a patient with hallux rigidus and arthrofibrosis. I am planning to take this to the operating room to preform manipulation under anesthesia. I am not sure if there is a CPT code that represents this procedure.  Thoughts?


 


Douglas Robinson, DPM, Campbell, CA 


 


Response: There is no specific CPT code for this so you would use the unlisted procedure code.


 


Make sure you pre-authorize this as I do not think many carriers would cover this procedure for the foot. The patient could then be responsible for all costs



 


Tony Poggio, DPM, Alameda, CA


 


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05/15/2018    

CODINGLINE CORNER



Query: Billing Medicare as a Secondary Insurance


 


We never have success getting paid when Medicare is the secondary insurance. Any thoughts or guidance on this?


 


Mark M. Goldberg, DPM, Chestertown, MD


 


Response: The general rule for Medicare as a secondary insurance is the following: If the primary “pays” more than Medicare would approve, then Medicare does not pay. The same applies for Medicaid secondary to Medicare. Typically, Medicare is secondary to a group insurance product.


 


Donald R Blum, DPM, JD, Dallas, TX



 


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05/11/2018    

CODINGLINE CORNER


Query: Diagnosis Codes


 


A diabetic presents with cellulitis and a newly formed blood blister, plantar aspect of the right foot. (12mm in diameter) The office documented E/M code 99213-25 and CPT code 10140-RT for the encounter and procedure; ICD10 code L03.115 for E/M code and S90.821A for CPT code. Is a secondary diagnosis code needed for the CPT code or is this correct for submission to Medicare? 


 


Chris Panagoulias, DPM, Nashua, NH


 


Response: This coding looks good to me. The only other thing to consider would be to use (S90.31XA) – Contusion of right foot for the “blood blister” diagnosis code if this was more of a hematoma and depending on its etiology. Otherwise, with a -25 modifier on the E/M be sure the E/M was separately identifiable and that this is supported by the documentation and medical necessity. The E/M service for the cellulitis should be able to stand on its own as a service separate from the I&D.


 


Jeffrey D Lehrman, DPM, CPC, Springfield, PA


 


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05/08/2018    

CODINGLINE CORNER



Query: Modifier Use of -GX and -GY Modifier


 


Can someone tell me definitively whether the following example would get a -GX or a -GY modifier? A patient who is diabetic presenting for “Routine Care” (nails and calluses) with no complaint of pain and who does not meet the ABC criteria. They will not meet those criteria at any time. The debate at the meeting was “Are they statutorily non-covered (-GY) because they never meet the ABC criteria, or would they be otherwise non-covered and get the somewhat misunderstood (-GX ) modifier?


 


And whichever your choice, do they need to sign an ABN for each visit or is one sufficient per year with the proper notation about monthly or bimonthly visits, etc.? The hospital personnel stated that “Routine Foot Care Codes and rules” are the most complex group of codes they have ever had to work with.


 


Kevin Brattain, DPM, Peoria, IL


 


Response: Specifically related to RFC, if the patient does not meet medical criteria, then there is no requirement for an ABN to be signed as RFC is statutorily not covered. If the patient requests you to bill as possibly a secondary carrier might cover the service, then a GY modifier would be used. For an ABN, it must be signed every time the service is rendered.



 


Tony Poggio, DPM, Alameda, CA


 


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05/03/2018    

CODINGLINE CORNER



Query: Correct Modifer Usage for CPT 28225


 


When performing a tenolysis on an extensor (multiple extensors) tendon, what is the correct location modifier to use? Indeed, it is a “foot” tendon but the insertion is in the digit. Would the modifier be “RT” or “LT” —or—- T2,T3, etc.? 


 


Howard Dinowitz, DPM, Brooklyn, NY


 


Response: CPT code 28225 is: Tenolysis, extensor, foot; single tendon


CPT code 28226 is: Tenolysis, extensor, foot; multiple tendons


 


Whether the described procedure is being performed on one extensor tendon or multiple extensor tendons, the operative word in the descriptions is “FOOT.” The issue is not where the tendon inserts, but rather where the procedure is being performed. Thus, the appropriate modifiers to use for either 28225 or 28226 would be RT or LT.


 


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



 


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05/02/2018    

RESPONSES/COMMENTS (CODINGLINE CORNER)


RE: Horizon NJ Direct Medicare Advantage Plan L3000 Denials


From: Jim Ricketti, DPM


 


Prior to casting and fabricating the L3000 devices, make  a pre-authorization phone call or go out on NAVI net to obtain the authorization. It is approved 99.9% of the time. If you have received a rejection (even after that process), you must inform the Insurance Committee of the NJPMS and they will get it resolved. If you are not a member, please join the Society.


 


Jim Ricketti, DPM, Hamilton Square, NJ

05/01/2018    

CODINGLINE CORNER



Query: Horizon NJ Direct Medicare Advantage Plan L3000 Denials


 


We’ve been having a problem getting L3000 paid for our retired patients who are now covered with Horizon NJ Direct Medicare Advantage (they were previously in the state plan Horizon NJ Direct before retirement). Has anyone had this same issue? If so, how did you resolve/appeal it? We also heard that the coverage from the previous policy is supposed to be grandfathered into the new Medicare advantage policy. We’d really appreciate any guidance on this.


 


Kevin M Healey, DPM, Clifton, NJ


 


Response: This situation has been discussed at the Board of Trustees of the New Jersey Podiatric Medical Society (NJPMS) in the past. We have been attempting to work with Horizon on a resolution. I suggest, after contacting the insurance plan and trying to resolve the claim(s) on your own, contacting the insurance committee of NJPMS and submitting your documentation. They may be able to assist with the appeal of your claim(s).


 


Alan Bass, DPM, Manalapan, NJ



 


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04/28/2018    

CODINGLINE CORNER



Query: Billing a Post-operative Complication


 


I have a patient about 12 weeks post-bunionectomy. She had a deep suture that was irritating her. I anesthetized the area locally, scrubbed it and went in via a small incision and removed the suture. This was done in the office procedure room. She did well and I didn’t bill thinking it should be in the global period. I know that “return to operating room” for a complication should be covered but my office procedure room is not an OR so I did not bill. My front office is in disagreement with that decision.


 


Could this have been billed as a retained foreign body? If so, since it was actually a suture, what code would it be billed as? Then can it be billed as removal of foreign body? I figured this was just one of those things where you do what is right and don’t worry about billing. Am I wrong?


 


David E Gurvis DPM, Avon, IN


 


Response: The return procedure needs to go to a similar setting as the surgery, so in your case, the complication would have to go back to an OR. But then, is it “medically necessary and reasonable” to do so vs an in-office procedure? To me, this is just a post-op complication that you handled well and I would not have billed it either.



 


Tony Poggio, DPM, Alameda, CA


 


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04/25/2018    

CODINGLINE CORNER



Query: Hospital Initial visit/consultations and Residents


 


If one of my residents sees a consultation at the hospital, contacts the attending, in this case it's me at 7 PM on any given day. The very next morning, I go and see the patient some 12 hours later: Am I allowed to bill the consultation from the evening prior? 


 


Additionally, what type of procedures can a resident do on a consultation in the hospital or in a in emergency room when I am not present (remove an ingrown toenail, removal of foreign body, sew a laceration, or apply a cast, etc.)?


 


Jeffrey Klein, DPM, Waterford, MI


 


Response: No, you cannot bill for the consult from the prior evening if you did not see the patient that evening. You cannot bill for a hospital encounter if you were not there, even if you spoke with the resident on the phone and advised the resident. And even if you sign the resident’s note the next day.


 


As far as your second question, what the resident can and cannot do is totally up to state and hospital regulations/bylaws. This can vary from state to state and definitely vary between different hospital systems. This is a question for the medical staff office at your hospital. Also, it's not a bad idea to run this question past the malpractice carrier for both you and your residents.


 


Jeffrey D Lehrman, DPM, CPC, Springfield, PA



 


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04/21/2018    

CODINGLINE CORNER



Query: Palmetto GBA blues: Home Health Certification


 


We have just been informed that podiatrists are not allowed to certify home healthcare. They say it is Medicare guidelines. Previously, Cahaba paid for home health certification by podiatrists with no problem. Is this true or should we fight it?


 


Katherine Sharp, Keystone Professional Solutions, Woodbury, TN


 


Response: I recommend fighting it based on this link from CMS.


 


Don Self, Whitehouse, TX



 


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04/17/2018    

CODINGLINE CORNER



Query: Neuropathy ICD-10


 


I have a patient who has diabetes with neuropathy and had a gastric bypass. Her A1c now is 5.2 but she still has neuropathy. What neuropathy ICD 10 should I use?


 


Doan Trinh Pham, DPM, Tracy, CA


 


Response: Medically speaking, a normal HgA1c does not necessarily eliminate the diagnosis of diabetes. You may be able to continue to use E11.42 (if type 2) depending on the medical diagnosis. If she truly is no longer diabetic, you can consider:


G60.0 – Hereditary motor and sensory neuropathy


G60.3 – Idiopathic progressive neuropathy


G60.8 – Other hereditary and idiopathic neuropathies


This is my opinion.


 


Jeffrey D Lehrman, DPM, CPC, Springfield, PA



 


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04/14/2018    

CODINGLINE CORNER



Query: Locum Tenens


 


I have hired a podiatrist to cover my office and work in my clinic for somewhere between 2 to 3 months. We have added him to our Medicare and Blue Cross groups, among other insurances. Problem: To add him to my billing program (we do it in-house), it will cost me $1,500. I am not sure I want to spend that for a part-time, temporary podiatrist. Do you think it is appropriate to bill his services as a locum tenens (using the proper modifier Q code) even though I’ll be working in the practice also? 


 


Name withheld by Moderator


 


Response: First, the correct term is now “fee-for-time compensation.” Medicare felt locum tenens was no long appropriate. Second, “the services must not be provided by the second physician over a continuous period of more than 60 days unless the regular physician is called or ordered to active duty as a member of a reserve component of the Armed Forces.” (MLN Matters Number: MM10090, effective 6/13/2017). You should speak to a healthcare attorney about the legal angles of this hire regarding contracts and other issues.


 


The modifier you’d append to services would be Q6. 


 


Paul Kinberg, DPM, Dallas, TX


 



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04/13/2018    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Sylvia Trotter, DPM


 


We got the same denial reason. We called Noridian about it. There was a system glitch causing the denials. They are aware of it and will be reprocessing the claims automatically when the system glitch is corrected. We flagged our chart to follow up on it in 30 days if it isn't paid yet. If you are certain your coding and modifiers are correct, you don't need to do anything at this point.


 


Sylvia Trotter, DPM, Lincoln, NE

04/11/2018    

CODINGLINE CORNER



Query: A5512 Denial, Inconsistent Modifier


 


I received a denial for A5512 for heat molded inserts billed with KX RT and KX LT modifiers with a reason that the procedure code is inconsistent with the modifier used or a required modifier is missing. Any help would be appreciated.


 


David Sands, DPM, Great Neck, NY


 


Response: This may be because you are probably billing on the same line A5512 RT LT KX and you should bill it like this:


A5512-RT-KX (3 units)


A5512-LT-KX (3 units)


 


This may work for you, and make sure you have an appropriate/documented diabetic diagnosis: e.g. diabetic neuropathy: E08.42, E10.42, or E10.42


 


Joseph Borreggine, DPM, Charleston, IL



 


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04/06/2018    

CODINGLINE CORNER



Query: E&M and Qualified Routine Foot Care in Nursing Facility


 


How often can an E&M be billed in conjunction with a nail debridement code (CPT 11720 or CPT 11721)? Once per admission? Once every 365 days? Only on the initial visit to establish the diagnosis?


 


Mark Spector, DPM, Garland, TX


 


Response: E/M services are always paid per medical necessity. An E/M must be “significant and separately identifiable” from any procedure performed on the same date of service. When you first see the new patient, an E/M can be billed to an appropriate level since you do not know anything about the patient. 


 


There is no basis to perform a routine foot evaluation on a yearly basis just to qualify the patient for routine foot care. If the patient’s condition changes impacting the feet which could be the result of a “re-admit”, then an E/M could be payable. You need to document the scenario as to why the examination is required separate form performing the nail care.



 


Tony Poggio, DPM, Alameda, CA


 


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04/03/2018    

CODINGLINE CORNER


Query: Coding matrixectomy and Initial Visit


 


A new patient presented and the decision was made to do a matrixectomy at this visit. Can I bill both a CPT 99202 and a CPT 11750? If so, what modifier should I use? 


 


Howard Miller, DPM Manteca, CA


 


Response: Billing both an initial office visit in addition to a matrixectomy at an initial visit is appropriate. After performing an H&P, I suggest that you bill a CPT 99202-25 with CPT 11750-TX (appropriate digital modifier), along with a 59 modifier.


 


Alan Bass, DPM, Manalapan, NJ


 


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03/29/2018    

CODINGLINE CORNER



Query: Midfoot Amputation


 


The surgeon reported in the operative note that a “midfoot amputation” was performed. Please provide thoughts on CPT 28805 or CPT 28800 as the correct code.


 


Della Roes, Biller, Lake Havasu City, AZ


 


Response: CPT code 28808 is: Amputation, foot; midtarsal (eg. Chopart type procedure). A Chopart procedure is a midtarsal amputation of the foot between the calcaneus and the cuboid bones (Calcaneocuboid joint) and the talus and the navicular bones (Talocalcaneonavicular joint).


 


CPT code 28805 is: Amputation, foot; transmetatarsal. A transmetatarsal amputation, also called TMA, is surgery to remove all or part of your forefoot. The forefoot includes the metatarsal bones, which are the five long bones between your toes and ankle.It would probably be best to access the operative report in order to determine which of these two CPT codes best illustrates the procedure that was actually performed.


 


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


 



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03/27/2018    

CODINGLINE CORNER



Query: A5512 Returns


 


The LCD for A5512 states that heat moldable inserts cannot be used in other than diabetic shoes. If a patient decides to return the shoes after dispensing & billing, we know we need to reimburse the insurance company for the shoe payment (A5500). The question we have is, what do we do with the payment of the 6 units of the A5512 after they have been heat molded to the patient? The manufacturer will not accept the heat molded inserts after they have been heat molded to the patient's foot.


 


Dawn Dryden, DPM, Batavia, NY


 


Response: This is a tricky situation because, in theory, the shoe and inserts have to be dispensed as a unit. Medicare will not reimburse for a shoe alone or an insert alone. You did not mention why the shoe was returned. Possibly, it could be exchanged for a shoe that fit better? You may return the shoe for some credit but obviously not the inserts.


 


The next question is refunding Medicare the money since the shoe was returned. You should also refund Medicare for the inserts. The patient could pay you cash for the inserts with an ABN as they technically are not covered in this scenario.



 


Tony Poggio, DPM, Alameda, CA


 


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03/24/2018    

CODINGLINE CORNER



Query: Coding for correcting failed surgery by different Dr.


 


I recently saw a patient (new to me) who had surgery by another doctor in Sept 2017 for cyst removal and bone reconstruction. She has had continual pain since the surgery, but was basically told to get new inserts. I am treating her for a non-union fracture due to the procedure done last year. I do not know how I would go about coding this. Any assistance would be greatly appreciated.


 


Mark Willats, DPM, Scottsbluff, NE


 


Response: You would code for the non-union or mal-union of a fracture depending on which bones are involved because that is what you are treating. You could also use a secondary code for pain in the limb or painful hardware if that was an issue. No specific modifiers are needed since you were not the original surgeon and there are no global period issues to be concerned about.



 


Tony Poggio, DPM, Alameda, CA


 


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03/20/2018    

CODINGLINE CORNER



Query: Billing a fracture treatment code and Unna boot or fiberglass cast application


 


When billing a fracture treatment code, are you able to also bill for an Unna boot or casting procedure? For example, a patient came in and the doctor treated the fracture and applied a fiberglass cast - Codes: 28475 and 29405 along with the casting material, both CPT codes with the same fracture diagnosis code.


 


Scott Kurecki, DPM, North Port, FL


 


Response: In my experience, an Unna boot is only covered for venous vascular conditions. I  never recommend using an Unna boot for fracture care because it most likely will never be covered for this situation. If you want to use it on the first treatment, it would be included in the fracture care.


 


CPT 29405 is a column 2 edit to CPT 28475, so on the first casting, technically, you are not to bill the casting as it is considered part of the treatment of CPT 28475 - Closed treatment of metatarsal fracture; with manipulation, each. On a subsequent visit, you can bill CPT 29405 along with the casting material.


 


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



 


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03/17/2018    

CODINGLINE CORNER



Query: Coding Severe Equinus Procedures


 


I need help with coding for a paralytic equinus procedure. I performed an Achilles tenotomy along with a posterior ankle capsulotomy/release along with a posterior subtalar joint/release. Any coding recommendations?


 


Jeffrey Klein, DPM, Waterford, MI


 


Response: I recommend one code which, I believe, is meant to cover these procedures. CPT 27612 arthrotomy, ankle, with posterior release, with or without Achilles lengthening.


 


Howard Zlotoff, DPM, Camp Hill, PA



 


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03/17/2018    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Paul Kesselman, DPM


 


Most important here is that state Medicaid plans are free to enforce their own rules regarding the need for Surety Bonding for DME Suppliers. Fortunately, physicians under Medicare were able at the Federal level to obtain an exclusion and do not require a Surety Bond under Medicare. That exclusion appears to not be in place in Texas. I urge you to contact your state component (TPMA) to:


 


1) Inquire if your state component as well as those representing MDs/DOs and orthotists/prosthetists are subject to the same exclusion rights we have under Medicare. Based on your scenario, shoes would not be the only exclusion. Acute care needs, such as CAM boots, crutches, surgical dressings, etc., would also be in the mix. The same rationale used for exclusion from Surety Bonding with Medicare at the Federal level should be invoked with your state Medicaid program. The state associations should contact their national associations for assistance.


 


2) Your state component should be able to provide you with guidance on whether you can charge a Medicaid patient for the payments they would otherwise be paying to a Medicaid provider. Each state has different rules on this.


 


Paul Kesselman, DPM, Woodside, NY

03/15/2018    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Cosimo Ricciardi, DPM


 


Recently there was a post by Dr. Blum about collecting cash from Medicaid beneficiaries. I have always thought that you cannot do this. If a patient has Medicaid and a physician doesn’t accept that Medicaid, that physician cannot bill the patient. 


 


I write this because I’m pretty sure it’s a federal statute and I don’t want my colleagues to think it’s okay to collect cash from Medicaid beneficiaries. I would also like to know if I am incorrect. Perhaps one of the more qualified billing experts can opine.


 


Cosimo Ricciardi, DPM, Ft. Walton Beach, FL
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