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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:


03/25/2017    

CODINGLINE CORNER


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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03/21/2017    

CODINGLINE CORNER


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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03/17/2017    

CODINGLINE CORNER


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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03/14/2017    

CODINGLINE CORNER


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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03/11/2017    

CODINGLINE CORNER


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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03/07/2017    

CODINGLINE CORNER


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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03/04/2017    

CODINGLINE CORNER


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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02/28/2017    

CODINGLINE CORNER


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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02/24/2017    

CODINGLINE CORNER


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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02/21/2017    

CODINGLINE CORNER


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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02/14/2017    

CODINGLINE CORNER


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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02/10/2017    

CODINGLINE CORNER


Query: Plantarflexed Metatarsal


 


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


 


Adam Klein, DPM, Lynbrook, NY


 


Response: The ICD-10 code I suggest for the plantarflexed metatarsal, I believe, 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 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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02/07/2017    

CODINGLINE CORNER


Query: Billing CPT 11721


 


I am billing CPT 11721 with ICD-10 L60.3 (nail dystrophy) as the primary and M79.671 (pain in right foot) as the secondary. I can’t get this claim to pass the scrubbing process. However, these ICD-10 codes are listed as billable for Medicare. Can anyone help with this problem?


 


Robson Araujo, DPM, Boaz, AL


 


Response: Since you are in Alabama, you would be billing Cahaba Medicare, as are we. The primary diagnosis code for CPT 11721 should be B35.1, onychomycosis.


 


Since you are using pain as the secondary code, and you are billing for 6 or more nails, then you should include pain for both right and left feet if that pain exists. We generally use M79.674 and M79.675 for pain in toes right and left. This combination should get the procedure paid. As always, make sure your notes support your claim.


 


Katherine Sharp, Woodbury, TN


 


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02/04/2017    

CODINGLINE CORNER


Query: Bunionectomy with Exostectomy Hallux Base


 


I performed a modified McBride-type bunionectomy with sesamoid release, etc. and clean-up of an arthritic hallux phalangeal base due to degenerative changes. I am being denied the CPT 28124 hallux exostectomy because the two procedures were done through the same incision – which is true. However, I was under the impression that since the surgery was done on two separate bones and billed as two separate sites (foot for CPT 28292 and 1st toe for CPT 28124) that both should be payable. Am I wrong in my thinking?  


 


Pete Smith, DPM Lancaster, PA


 


Response: If I understand your description of the surgery, you remodeled the base of the proximal phalanx of the hallux. If this is true, you should not expect any additional reimbursement beyond the bunion repair. The arthoplasty of the first metatarsal head for bunion repair includes both sides of the joint.


 


If there were very unusual findings and complex repair (i.e., cyst in bone requiring curettage and bone packing requiring significantly more work than the bunionectomy value), then you would be entitled to additional payment with the addition of a “-22” modifier.


 


Howard Zlotoff, DPM, Camp Hill, PA


 


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01/31/2017    

CODINGLINE CORNER


Query: Billing Injections with Office Visits


 


If an established patient is seen for a painful condition and is given an injection and no other chief complaint is stated, can the patient be billed for an office visit as well? If so, is it a level 2 or level 3 visit?


 


Danielle LaLonde, Belvidere, NJ


 


Response: The answer is, it depends. If an established patient presents with a new complaint that ultimately results in the patient receiving an injection as treatment, presuming the documentation is supportive (“significant, separately identifiable evaluation and management”), the doctor deserves to be reimbursed for both the work-up and the treatment.


 


If, however, the patient is returning for a subsequent injection (not unexpected), and there is little significant new E/M findings (i.e., no new interval key elements) – the doctor expected to give that 2nd or 3rd injection (previous medical decision-making) – then only the injection and therapeutic medication are reimbursable. The level of E/M is based on significant, separately identifiable new findings (from the previous encounters). One would think a new condition would have a greater need for history, exam, and/or medical decision-making than an established condition that has minimal new information that impacts the evaluation prior to injection performance. Ultimately, the level of the E/M service would depend on medical necessity, interval change from the previous encounters, and the documentation.


 


Tony Poggio, DPM, Alameda, CA


 


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01/28/2017    

CODINGLINE CORNER


Query: New Bunionectomy with Implant Coding


 


Now that CPT has revised the bunionectomy codes for 2017, deleting CPT 28293 (correction, hallux valgus [bunion], with or without sesamoidectomy; resection of joint with implant), what is the new code for insertion of a total 1st metatarsal-phalangeal joint implant? There seems to be some confusion.


 


Mike King, DPM, Alpharetta, GA


 


Response: If the 1st metatarsal-phalangeal joint implant is inserted as part of a hallux rigidus repair, the appropriate code for 2017 is CPT 28291 (hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant).


 


Jeffrey Lehrman, DPM, Springfield, PA


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01/24/2017    

CODINGLINE CORNER


Query: Billing Injections with Office Visits


 


If an established patient is seen for a painful condition and is given an injection and no other chief complaint is stated, can the patient be billed for an office visit as well? If so, level 2 or level 3 visit?


 


Danielle LaLonde, Belvidere, NJ


 


Response: The answer is, it depends.


 


If an established patient presents with a new complaint that ultimately results in the patient receiving an injection as treatment, presuming the documentation is supportive (“significant, separately identifiable evaluation and management”), the doctor deserves to be reimbursed for both the work-up and the treatment.


 


If, however, the patient is returning for a subsequent injection (not unexpected), and there is little significant new E/M findings (i.e., no new interval key elements) – the doctor expected to give that 2nd or 3rd injection (previous medical decision-making) – then only the injection and therapeutic medication are reimbursable. The level of E/M is based on significant, separately identifiable new findings (from the previous encounters). One would think a new condition would have a greater need for history, exam, and/or medical decision-making than an established condition that has minimal new information that impacts the evaluation prior to injection performance. Ultimately, the level of the E/M service would depend on medical necessity, interval change from the previous encounters, and the documentation.


 


Tony Poggio, DPM, Alameda, CA


 


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01/20/2017    

CODINGLINE CORNER


Query: Nerve Biopsies


 


Can anyone please tell me what diagnosis you are using for Medicare patients who have a nerve biopsy done?


 


Danielle LaLonde, Belvidere, NJ


 


Response: We have used peripheral neuropathy as the diagnosis in the past. Of course, with ICD-9, we could use ICD-9 356.9, but that crosswalks to G60.9 which is an unspecified code in ICD-10. I would look at the range G57-G60 and pick the most appropriate code that describes the patient’s condition.


 


You could also check in the APMA Coding Resource Center by entering the CPT code, and looking to see what is offered under CPT to ICD-10 suggested links. There will be suggestions for diagnosis coding for most procedure CPT codes. Unfortunately, if you are using CPT 94795 for your biopsy of nerve code, there are no suggested diagnosis codes.


 


Katherine Sharp, Woodbury, TN


 


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01/18/2017    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Tom Silver, DPM


 


We finally addressed this problem of unmet deductibles last January when we started asking patients for their credit card, to keep it "temporarily" on file.  Our policy states that once we know what their insurance allows, we will notify the patient of their balance by phone as to the amount we will be applying to their credit card (unless they want to make other arrangements).  


 


Since some patients refuse to give us their credit card, I need to decide if we should start asking for a percent of their charges at the time of service, since they will have to pay a certain amount out of pocket anyways when their deductible isn't met.


 


Tom Silver, DPM, Minneapolis, MN

01/17/2017    

CODINGLINE CORNER


Query: PQRS for 2017


 


Has PQRS been completely eliminated for 2017 in lieu of CMS’s implementation of the Quality Payment Program and MIPS? For 2017, do we need to still track the PQRS measures using the “G” codes and other codes established for PQRS in the past?


 


Joseph Borreggine, DPM, Charleston, IL


 


Response: PQRS no longer exists in 2017. MACRA began January 1, 2017. PQRS and Meaningful Use are over. One way to participate in MACRA is through the Merit-Based Incentive Payment System (MIPS).


 


One of the three reporting categories of MIPS in 2017 is “Quality”. Full MIPS participation requires reporting on 6 quality measures. These quality measures are very similar or identical to the PQRS measures that you are referring to, some of which are reported using “G” codes.


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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01/16/2017    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Charles Morelli, DPM


 


My opinion on this practice is a simple one. CHARGE YOUR PATIENTS FOR THEIR DEDUCTIBLES. Most of use have EMR software that connects directly with Medicare and many commercial carriers, and lets you know exactly what a patient's deductible is. You can tell your patient this information prior to their appointment, assuming you call patients to remind them of their appointments, or they can be told when they arrive and let them know that their deductible needs to be paid BEFORE they are seen (as well as their co-pays).


 


When we see patients in November/December and they make a follow-up appointment for the new year, we tell them at that time that they will be paying for their next visit (assuming that the deductible has not been met previously or they do not have a secondary carrier that picks up that amount). Stop working for free and stop being afraid to ask (or tell) your patients that they need to pay for their treatments. 


 


Charles Morelli, DPM, Mamaroneck, NY

01/13/2017    

CODINGLINE CORNER


Query: Holding Billing at the Beginning of the Year


 


I have read in the past, opinions on the pros and cons of holding your billing for the first 1-2 months of a new year to avoid hitting everyone’s deductible. Do readers on this forum have an opinion on this practice?


 


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


 


Response: You should check with your payers because I have found that this actually may be against your contract in many cases.


 


Anna Sanders, Clarksville, TN


 


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01/10/2017    

CODINGLINE CORNER


Query: Bunionectomy with Implant Coding


 


Now that CPT has revised the bunionectomy codes for 2017, deleting CPT 28293 (correction, hallux valgus [bunion], with or without sesamoidectomy; resection of joint with implant), what is the new code for insertion of a total 1st metatarsal-phalangeal joint implant?


 


Mike King, DPM, Alpharetta, GA


 


Response: If the 1st metatarsal-phalangeal joint implant is inserted as part of a hallux rigidus repair, the appropriate code for 2017 is CPT 28291 (hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant).


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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01/09/2017    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Jerry Peterson, DPM


 


Before you go calling the State Board, I suggest that you contact your state association’s representative on legislative activities. I am sure they have a committee and chairperson on this. If not, ask the component president. Going to the state could cause the opening of a can of worms when you don’t ask the right people the correct question.


 


When you deal with government or any regulatory agency, you always want to know the answer BEFORE you ask the question! There may be better people to ask.


 


Jerry Peterson, DPM, West Linn, OR

01/06/2017    

CODINGLINE CORNER


Query: Staff Performing CPT 17110


 


Can the office staff perform 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 to 14 lesions) and bill this code without the doctor being in the office?


 


Anna Sanders, Clarksville, TN


 


Response: In my opinion, the answer would be a resounding “no.” In the State of Illinois, if an unlicensed staff member provides procedural or surgical treatment as described in the post, it would be practicing medicine without a license. Not only would it be illegal to perform said treatment, but also to bill an insurance carrier for the surgical services performed by an unlicensed member of the doctor’s staff.


 


I recommend you check with your state licensing board (my response may not be the same for your state). If you do check with your licensing board and get a response, I would appreciate you sharing it with us.


 


Joseph Borreggine, DPM, Charleston, IL


 


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