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Query: Billing Lapidus/Akin

The doctor performed a Lapidus-type bunionectomy (CPT 28297) and an Akin-type osteotomy (CPT 28310) on a patient. CPT 28310 was denied as inclusive to the Lapidus-type procedure. Does anyone have any suggestions on how I should have billed the procedures? Or how I should appeal the denial?

Sarah Avilleira, Office of Peter A. Wishnie, DPM, Piscataway, NJ

Response: The correct billing for a Lapidus-type bunionectomy and an Akin-type osteotomy is:

#1 CPT 28297 (correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus type procedure); and CPT 28310-59 (osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe). or

#2 CPT 28740 (arthrodesis, midtarsal or tarsometatarsal, single joint); and CPT 28298-59 (correction, hallux valgus (bunion), with or without sesamoidectomy; by phalangeal osteotomy).

Both coding methods are correct. By the way, the value of coding example #2 is higher than #1. The payer was incorrect in denying CPT 28310 as inclusive (unless you did not add a "-59" modifier to the code). I recommend you appeal with submission of a corrected claim with either one of the coding examples listed above.

It should be noted that CPT 28310 is a designated "separate procedure" code. Separate procedure means that in order to be independently reimbursed, the procedure must not be an integral part of a comprehensive procedure being billed. CPT 28310 needs to be distinct, and in coding example #1, it is.

Harry Goldsmith, DPM, Cerritos, CA

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Other messages in this thread:



Query: Frequency for Billing CPT 17110


I was under the impression that last year Medicare (Noridian) limited the billing of CPT 17110 to once every 6 months. The reasoning was that if the lesion was destroyed, why would you need to repeat the procedure? We have been billing the first procedure to insurance and if the patient needs to have it repeated, it has been self-pay. I need clarification on this information. Can we bill CPT 17110 more frequently than once in a 6-month period if needed? 


Lani Smith, Office Manager, Office of Kash Siepert, DPM, Roseburg, OR 


Response: You did the right thing by first going to the LCD for your particular area or MAC - but then you also need to check the NCD as well. 


NCD 54602 Removal of Benign Skin Lesions, found on CMS' website covers this code as well - but it also does not have a limitation of "once every six months" that you've asked about. In fact, I do not see anything LCD 33979 in Oregon that limits this to once every six months either. 


Don Self, Don Self & Associates, Whitehouse, TX 


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Query: Accessory Navicular ICD-10 Code


I cannot find a code close enough to the accessory navicular or the os tibiale externum. Can someone make some suggestions? The closest I can find is M21.0 (valgus deformity not elsewhere classfied) or Q66.6 (other congenital valgus deformity of the foot). 


Wendy Siegel, DPM, Smithtown, NY


Response: If you look up "accessory navicular" in the ICD-10 Tabular Index, you won't specifically find it, but you will find Accessory bone NEC Q79.8, Accessory tarsal bones Q74.2. When you check the Tabular List, you will find that Q79.8 is described as "other congenital malformations of musculoskeletal system." 74.2 is described as "other congenital malformations of lower limb(s), including pelvic girdle." 


Both present as congenital malformations. Of the two, obviously, Q74.2 is more specific. However, if you go to the CMS site and look at the 2016 GEMs (General Equivalent Mappings) crosswalks from ICD-9 to ICD-10, ICD-9 755.67 (accessory bone foot) crosswalks to ICD-10 Q66.89 - other specified deformities of foot. If you go to the APMA Coding Resource Center ICD-10 Quick Index, the AAPC crosswalk site,, etc., all point you to Q66.89, which is my recommendation. 


Harry Goldsmith, DPM, Cerritos, CA 


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From: Don R Blum, DPM


There might be a better ICD 10 code than this, but this is the one I found.


V84.7 Person on outside of special agricultural vehicle injured in non-traffic accident

V84.7XXA is a specific ICD-10-CM diagnosis code V84.7XXA …… initial encounter

V84.7XXD is a specific ICD-10-CM diagnosis code V84.7XXD …… subsequent encounter

V84.7XXS is a specific ICD-10-CM diagnosis code V84.7XXS …… sequela


From: Don R Blum, DPM, Dallas, TX



Query: ICD-10 Trauma Case


I have a 21 year old patient who had a farm implement wheel fall horizontally on the right foot causing a traumatic contusion to the great toe including nail plate disturbance with a displaced fracture of the distal tuft of the distal phalanx. There was the presence of a subungual and digital hematoma with pain in the great toe. What would the ICD-10 codes be for the above? 


Joseph Borreggine, DPM, Charleston, IL


Response: I recommend M79.674 (pain in right toe), S90.211A (contusion of right great toe with damage to nail; initial encounter), S92.421A (displaced fracture of distal phalanx of right great toe; initial encounter), and last, but not least, W30.81A (contact with agricultural transport vehicle in stationary use; initial encounter) 


Erica D., Biller The Office of James Hirt, DPM, Fenton Foot Care, Fenton, MI 


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Query: Meaningful Use Measure 10


Our specialty registry is telling us that we have to upload information on EVERY patient that we treat in 2016. This seems a bit excessive. Is anyone else hearing this? 


Michael Giordano, DPM, Mt Kisco, NY


Response: It depends upon what information the registry is collecting. Off the top of my head, I cannot think of any single measure that would require data on every patient. Typically, a registry is collecting data on a specific clinical condition. In that case, they only should be requesting information on patients who fit the specific cohort. 


Your registry SHOULD NOT be requesting patient data that is NOT related to the specific measure that they are collecting data for. To request that you send in more information than is needed has a number of ramifications in relation to HIPAA and Patient Privacy. 


Michael L. Brody, DPM, Commack, NY 


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Query: Medicare Denial for Neuropathy


We have recently been getting Medicare denials for CPT 64450 with G60.9 (hereditary and idiopathic neuropathy, unspecified) for non-diabetic neuropathy. Is there a better injection code or diagnosis code to use for neuropathy? 


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


Response: First, check to see if your MAC has an LCD for CPT 64450 which would list the allowable codes. Regardless, the doctor should avoid unspecified codes, if possible. The second consideration centers on medical necessity. Why are the injections performed? Is the anesthetic injection for pain management or some type of therapeutic injection to treat a systemic, not local "neuropathy"? Is this injection curative or palliative? Are there studies that prove this injection to be effective in the long run (especially in an audit or malpractice situation)? Is there a proximal nerve entrapment resulting in local symptoms or a local problem such as a neuroma? 


Many payers have policies regarding peripheral nerve blocks for neuropathy or nerve pains. It is not unusual to have them label the injections investigational. 


Tony Poggio, DPM, Alameda, CA 


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Query: Evaluation & Treatment of the Same Condition on the Same Day


An established patient presents with a new complaint. I do a thorough evaluation, including history of present illness (NLDOCAT) and physical exam (4 systems). The patient is educated on her diagnosis, and the condition is treated the same day with a steroid injection. My understanding has been that I bill for either E/M or injection. My office manager is not in agreement, since a separately identifiable evaluation and management service was provided, even though it was for the same condition. Please advise. 


Richard Wolff, DPM, Oregon, OH


Response: Your office manager is correct. If the E/M service is separately identifiable from the procedure performed, you may bill for that E/M service in addition to the procedure. This is true if the E/M and procedure are for the same problem and also true for an established patient. 


It is important that the documentation for this encounter supports the fact that a separately identifiable E/M service was performed and that it was necessary. 


Jeffrey Lehrman, DPM, Springfield, PA



Query: Debriding a Cutaneous Horn


Is debridement of a cutaneous horn-type hyperkeratosis that protrudes from the tip of the toe about 6 mm on a diabetic who's on Medicare covered? How about if the patient has qualifying diagnoses and class findings? The gentleman has a rigid hammertoe which has caused this callus on the tip of the toe about 5 mm from the nail. Can I bill for the nail debridement as well? 


Joseph Borreggine, DPM, Charleston, IL


Response: This is a covered service, CPT 11055, if the patient meets the criteria for callus debridement under your routine foot care LCD. Same rules apply with the diagnosis and class findings. 


Jeffrey Lehrman, DPM, Springfield, PA 



Query: ICD-10 for Plantar Fibroma


What is the ICD-10 code everyone is using for plantar fibroma? 


Monica Link, DPM, Houston, TX


Response: I believe the code you are looking for is M72.2 (plantar fascial fibromatosis), which is the same code you would use for plantar fasciitis. 


Paul Kinberg, DPM, Dallas, TX



Query: Removal of Benign Cyst


What CPT code is most appropriate for removal of a benign lesion/cyst such as a ganglion cyst? 


Monica Link, DPM, Houston, TX


Response: The location of the cyst would determine which CPT code is best. 


A cyst excised from the toe would be coded using CPT 28092. 

A cyst excised from the foot would be coded using CPT 28090. 


Howard Zlotoff DPM , Camp Hill, PA 



Query: Post-Op ORIF Care for Another Surgeon


I saw a new patient yesterday who had open reduction internal fixation (ORIF), left ankle, 2 weeks ago while on vacation up north. She was referred by her primary care physician to me for "post-op care." She was a new patient to my practice, and required x-rays, removal of sutures, and a walking cast application. She will need follow-up and subsequent office visits, cast changes, x-rays, and other post-op care. Needless to say, I am assuming care. 


Do I bill an office visit, cast application, x-ray study, or do I use the ORIF procedure code with modifier "-55" (post-op management only)? What do I bill for subsequent care if I use the ORIF code? 


Jeffrey Klein, DPM, Waterford, MI


Response: Keep life easy and bill a new patient office visit along with whatever else you did. Don't bother with the post-op management coding. 


Don Self, Don Self & Associates, Whitehouse, TX 



Query: Coding J3301 Units


The medical records note that 0.5cc of 0.5% Marcaine and 1.0 cc of Kenalog 10 were injected. The Kenalog bottle says 50 mg per 5 ml. 10 mg per ml. I need to report units on the claim. How many units? The product code for Kenalog 10 is J3301. Is the Marcaine included with the J3301? 


Laurie, Office of John Arsen, DPM, Lake Orion, MI


Response: J3301 is described in HCPCS as: "Injection, triamcinolone acetonide, not otherwise specified, 10 mg." The product description 10 mg triamcinolone acetonide per ml.  If you inject 1.0 ml of Kenalog 10, you would be injecting 10 mg, and billing 1 unit. If you inject 1.5 ml (10 mg), you would be billing 2 units, 2.0 ml, 3 units. And so forth.. 


The local anesthetic, be it Marcaine, lidocaine, etc., is incidental and not separately billable. 


Paul Kesselman, DPM, Woodside, NY 



From: Robert Scott Steinberg, DPM


Your exam, and then your plaster-of-Paris cast, should capture the forefoot varus or valgus. If you use a quality lab and order internal or external forefoot post correction, it should be included in L3000. Be very careful of any "creative" coding. I  also recommend using an orthotic lab that supports podiatry and is not a retail operation.


Robert S. Steinberg, DPM, Schaumburg, IL



Query: L2275 Billed with Orthotic Forefoot Posting


Does anyone have experience billing L2275 (addition to lower extremity, valgus or varus correction) when the orthotic needs forefoot posting at the time of billing L3000? Our local pedorthic lab does this and suggested that we do as well. 


Saera Arain-Saleem, DPM, Elmhurst, IL


Response: L2275 (addition to lower extremity, valgus or varus correction; plastic modification, padded/lined) can be found in the "Additions to Lower Extremity Orthosis - Shoe-Ankle-Shin-Knee" HCPCS section. 


This is separate, preceding the foot orthosis coding which resides in the section headed by "Foot (Orthopedic Shoes) - Insert, Removable, Molded to Patient Model" beginning with L3000. It would be inappropriate to choose a code for an AFO addition item and apply it as an addition to a foot orthosis device code. 


Harry Goldsmith, DPM, Cerritos, CA



Query: HIV and Qualified Routine Care


Is HIV positive status still a covered criteria for routine footcare in New York? If so, what ICD-10 code would be acceptable? Does the person need to be vascularly compromised? 


Stephen Bennett, DPM, NY, NY


Response: I checked your LCD on routine foot care. There is no listed approved coverage for HIV (B20) present. 


Jeffrey Lehrman, DPM, Springfield, PA 



Query: Diabetic Shoes in Assisted Living Facility


I was asked to order shoes for a diabetic patient (Medicare and ward of the state) who presently lives in an assisted living facility (POS = 13). Besides the necessary paperwork to be filled out by the primary MD/DO, are there any different requirements for reimbursement as there are when a patient is in a nursing home?  Do you need to have an agreement with the facility or an ABN from the family prior to fitting the shoes because the patient does not have the capacity to make decisions? 


Debra Manheim, DPM, Parsippany, NJ


Response: Before proceeding any further, be perfectly sure that this patient is eligible for Part B fee-for-service Medicare. Because she is a "ward of the state", you want to be certain that she is not enrolled in a mandated managed dual eligible plan. This would be considered a Part C Medicare plan and could carve out DMEPOS to only large commercial suppliers. If she is confirmed as Part B Medicare, then the same rules apply to a patient living at home. Assisted living (POS 13) is not the same as Part A Medicare (which would cover the patient in a skilled nursing facility - POS 31) where consolidated billing regulations should apply. 


In my opinion, no separate agreement with the assisted living facility should be required. It would be the same scenario as a patient living in a nursing home (POS=33) but not in a skilled nursing bed. 


Paul Kesselman, DPM , Woodside, NY 



Query: Tier 1 and Tier2


Recently, insurance companies are designating our practices into Tier 1 or Tier 2 according to our utilization of certain services. Patients who seek a Tier 2 doctor generally have to pay a higher co-pay than if they choose a Tier 1 provider. How can we, as providers, find out what Tier we are in with the various insurance companies? 


Sandy, Office of Allan Hetelson, DPM, Bensalem, PA 


Response: We currently have two plans that our office deals with which have the tier system. The first plan is pretty simple and has guidelines that we have to follow in order to be a tier 1 (lower co-pay) for patients who present in our office. With this said, we have to provide MU and PQRS to them on a regular basis as well. They put a tracking system in our software to assist in gathering the MU/PQRS data. The second plan is a Highmark plan in the state of Pennsylvania. This plan is specifically a marketplace plan. With this Flex Blue PPO plan, we are also told that we are in the higher co-pay bracket. When I called the insurance company and our insurance rep, all I was told was that we are not enhanced because our doctor is not affiliated with Penn State Health or Pinnacle Health System. As a result, we have new patients presenting with this marketplace plan showing a $120 co-pay. 


When I dug as deep as I could to find out how we could be considered part of the Penn State Health plan/Pinnacle, I got no where. All I was told was that they are not adding new doctors to their preferred network at this time. Our doctor is also on staff at our local Penn State Hospital and sees patients at their clinic. Apparently, seeing patients at the Penn State Clinic doesn't grant you the ability to be in the lower co-pay tier. It is important to note that this marketplace plan was tiered this way in 2016 to allow for a lower monthly premium. As a result, patients are finding out that it comes with some restrictions on which doctors they can and can not see. We have encountered many patients who felt that they were misled on this Flex Blue Highmark plan. 


Jennifer Fields, Office Manager, Office of Paul LaFata, DPM, West Lawn, PA 



Query: Senior Housing POS & Coding


Has anyone had any experience with coding podiatry services to residents of senior housing? The place of service is not assisted living in any way. These are just apartments for seniors. The facility contacted our office about coming there and treating the residents. Would this be considered "home care", and is it covered? 


Nancy, Biller, Podiatry Associates of Rocheser, Office of Michael Giordano, DPM, Mt Kisco, NY


Response: Place of service would be "12" which is "home." The scenario you presented is not "assisted living."


Joseph Borreggine, DPM, Charleston, IL



Query: CPT 20600 Injection


I am looking for the code to use for an injection of an arthritic joint. I am proposing CPT 20600, however, no LCD exists for the code. Any thoughts? 


Donald Carlson, DPM, Hermiston, OR


Response: For injection of an arthritic interphalangeal joint or metatarsal-phalangeal joint, I suggest CPT 20600. For injection of a midtarsal, subtlalar, or ankle joint, I suggest CPT 20605. 


Pick the diagnosis code(s) that best describes the pathology and qualifies the therapeutic injection. 


Jeffrey Lehrman, DPM, Springfield, PA



Query: Coding Skin Substitute Graft Application


What is the proper way to bill skin graft substitute for bilateral extremities? Does the code, CPT 15275 or CPT 15271 include the application of graft to both extremities if the total square centimeters is less than 25? Are you able to bill for the product code individually if there are two separate product units? 


Anthony Fiorilli, DPM, Howell, NJ


Response: Yes, exactly as you stated: 1 unit of CPT 15275 includes applications to multiple areas within an anatomic category if the total wound area combined in that category is less than 25 sq cm. That does include both feet. If you applied graft to foot and leg wounds, then you would be able to use both the foot and leg codes with the exact code dependent on the total square cm of each. 


As for the product, you can code for as many units as you purchased for that encounter. If you cut one piece of product X in half and apply it to two wounds, you can only bill for one piece of product X. If you bought two of them and applied one to each wound, then you can bill for two of them. The number and sizes you purchase should be appropriate based on the size of the wound(s). 


Jeffrey Lehrman, DPM, Springfield, PA 



From: Joseph Borreggine, DPM


Regarding what Dr. Hultman stated in a recent Codingline interview, I must disagree because podiatry does not have the same credible education according to our medical colleagues. The fact is that the curriculums at the podiatry colleges change every couple of years, and hence, there is no standardization in education at all. 


The actual way to an MD degree is in a conjoint venture with a medical school. Most, if not all, physicians assistants, nurse practitioners, and osteopaths are trained in medical teaching hospitals. If that were the case with podiatry, that would solve part of the problem , but alas...


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



Query:  Dehisence of Surgical Wound Diagnosis Code


I had a patient with a dehiscence of surgical wound that required repair. At the time of the procedure, I coded the dehiscence as T81.31S (disruption of external operation (surgical) wound, not elsewhere classified).  My clearinghouse is returning the claim as "T81.31S is not a valid diagnosis code". I also tried T81.31A and T81.31D with the same results. Comments?


Lawrence Tamburino, DPM, Brandon, MS


Response: I recommend ICD-10 code, T84.32XA: "active treatment" of disruption of internal operation (surgical) wound, not elsewhere classified. In your example, you only have 5 characters of a code that requires 7 characters. In those cases, you add an "X" placeholder in the 6th character position, and then choose the appropriate "A, D, and S" 7th character. 


Joseph Borreggine, DPM, Charleston, IL


Just one more point... surgical complications are not eligible for the 7th character "S" (sequela) use. Sequela character use is limited to complication(s) after the acute phase of the injury or illness. 


Harry Goldsmith, DPM, Cerritos, CA



RE: Metatarsal Osteotomy & Plantar Plate Repair (Howard Zlotoff, DPM)

From Michael G. Warshaw, DPM, CPC


After reading the posts on this topic by Dr. Zlotoff and Dr. Mullen, I felt the need to comment. I respectfully disagree with Dr. Zlotoff that the most appropriate way to code for a plantar plate repair is either using CPT 28200 (repair, flexor tendon, foot, single) in conjunction with CPT 28308 (osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each) or CPT 28899 (unlisted procedure, foot or toes). The question at hand is what is a plantar plate tear? I agree with Dr. Mullen that this is, in effect, a dislocation of the lesser metatarsal-phalangeal joint resulting in metatarsal-phalangeal joint destabilization, incongruity, and joint wear and tear. This is not a dislocation in the true sense of the word. There is no acute injury. This is a process over time.


I agree with Dr. Mullen that the most appropriate CPT code for the repair of a plantar plate tear would be CPT 28645 (open treatment of metatarsal-phalangeal joint dislocation, includes internal fixation when performed). The question now becomes, what ICD-10 code(s) would be most appropriate to define a plantar plate tear? Since this is not an acute injury, it would be incorrect to use the S93.12_ series with a 7th character. I feel that the most appropriate ICD-10 codes would be either M24.374 or M24.375 (pathological dislocation of right foot/left foot, not elsewhere classified). 


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



From: Steven J. Kaniadakis, DPM


These are the types of posts that the profession reads which lead to so-called illegal "unbundling" acts of the CPT-related codes. Is there a global code for these two procedures? What is the authoritative source which truly provides the answer, and not just a response to these related type questions? Why wait to find out until a federal court and another paid expert tell you that the answers are not so clear, or until you are the one "sitting in the hot seat". 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



Query: Met Osteotomy & Plantar Plate Repair


Can someone please advise me of the appropriate CPT for a plantar plate repair? I will be doing this procedure in conjunction with a Weil-type osteotomy. 


Harry Cotler, DPM, Soldotna, AK


Response: There is no specific code for plantar plate repair of the lesser metatarsal joints. I recommend using CPT 28200 (repair, flexor tendon, foot, single), and recommend also billing for the Weil osteotomy using code CPT 28308. 


Your other coding option for the flexor plate repair would be to bill CPT 28899 (unlisted foot/toe procedure). If you choose this, you would need to submit an operative report with a manual claim and request peer review. 


Howard Zlotoff, DPM, Camp Hill, PA