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02/27/2010    

CODINGLINE CORNER

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:


05/24/2015    

CODINGLINE CORNER


Query: Coding a Drop Foot AFO


 


What is the proper code for a pre-molded AFO drop foot brace? Is it covered by Medicare? Must it be custom made? 


 


Jay Lifshen, DPM, Irving, TX


 


Response: HCPCS L1930: Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment 


 


HCPCS L1940: Ankle foot orthosis, plastic or other material, custom-fabricated 


 


You must indicate side "RT" or "LT", and it may need a "KX" modifier. Modifier KX is defined as "requirements specified in the medical policy have been met." It is appropriately used when additional documentation is available to support the medical necessary service under a medical policy. 


 


Joseph Borreggine, DPM, Charleston, IL 


 



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05/15/2015    

CODINGLINE CORNER


Query: Multiple Foreign Bodies


 


My patient stepped on a sea urchin receiving 20 spines (subcutaneous) in the forefoot. Do I bill CPT 28190 x 20? 


 


Mark Stempler, DPM, Staten Island, NY


 


Response: If these were not sticking out of the skin, leading to you just pulling them out, but rather you did 20 separate procedures to remove them, then you can bill as you described as a single line item x 20 units, or you could bill CPT 28190 on 20 different lines with a "-59" modifier on 19 of them. I would expect either of these options to be met with resistance by the payer, and suggest submitting a report and maybe even photos along with your claim if you try either of these. 


 


The other option would be to bill CPT 28190 with a "-22" modifier, which indicates that the work performed was substantially greater than typically required for that code. 


 


Jeffrey Lehrman, DPM, Springfield, PA



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05/12/2015    

CODINGLINE CORNER


Query: Medicare Denial of CPT 29515


 


Why is Medicare denying CPT 29515? The EOB says, CO-4, "The procedure code is inconsistent with modifier used."  We are using the appropriate right or left foot modifier. We are not bundling this service with anything else. 


 


Lina Diaz, DPM, Englewood, NJ


 


Response: There may be other codes on the EOB that are prompting this to appear. CO-4 is a reason code. Please look at the EOB for the Remark codes (to the left under the patient's name) and see if there is another comment. 


 


You are correct - "RT" or "LT" - is appropriate for this CPT code, but I believe something else on the EOB has more information. 


 


Karen Hurley, CMM, CPC, Lakewood Ranch, FL


 



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05/09/2015    

CODINGLINE CORNER


Query: SmartSkan - CPT 95923


 


I am considering purchasing a nerve testing unit, SmartSkan CPT 95923. I was wondering and hoping that I can get some feedback on whether or not we, as podiatrists, are eligible to use this (involves placing both hands and feet on plates for measurements).  Any other info regarding reimbursement and usage would be appreciated. 


 


Michael Rosenblum, DPM, Fair Lawn, NJ


 


Response: First check with your state regs whether this testing is covered under your scope of practice. Then, I would check with your major insurance companies about coverage issues, and specifically the appropriate use of CPT 95923 or other coding for the testing. Many plans do not cover this type of testing or this unit, or they do so in very limited scenarios. Be very clear when asking about coverage issues to make sure that you are being given accurate information. Many carriers deem this testing/unit investigational. Do not rely on what the company reps tell you about coverage and potential income revenue. 


 


Tony Poggio, DPM, Alameda, CA


 



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05/06/2015    

CODINGLINE CORNER


Query: Skin Graft for Closure


 


How would you properly code for advancement of skin graft to allow for the skin to approximate upon one another? The skin was advanced and closure was accomplished with 4-0 nylon in simple interrupted sutures. This was for an arthrodesis of the proximal interphalangeal joint, 2nd digit, left. 


 


Susie A, Office of Jan Tepper, DPM, Upland, CA.


 


Response: I am not sure what you mean by a skin graft that was advanced. There is a code series for tissue rearrangement or transfer (versus skin graft) which includes CPT 14000-14350. That said, your operative report needs to clearly document what was performed. Usually with a fusion procedure, there is redundant tissue. Suturing the tissue to address the redundancy to make it align better is part of the overall hammertoe correction procedure and not payable separately. 


 


Tony Poggio, DPM, Alameda, CA 



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05/02/2015    

CODINGLINE CORNER


Query: Walking Boot & Night Splint Coding


 


Has anyone heard about the new codes for walking boots and night splints? 


 


Instead of L4360 and L4396, it they would be L4361 and L4397, respectively, if you use the kind of devices that do not require substantial modifications. Any additional information would be appreciated. 


 


Gina Garza, College Station, TX


 



Response: I had a meeting with our DME contractor about this very issue. The coding selection has to do with how much modifications are required. The key is whether "significant modification" was performed. The fitting and maybe adding a wedge or an off-loading accommodation does not seem to be enough to validate the term "significant". Dr. Kesselman, I believe, in previous posts on Codingline explains some of the expectations regarding the new and old codes. 


 


The good news is that there is no reimbursement differences between the two codes at this time. That may change though in the future. 


 


Tony Poggio, DPM, Alameda, CA


 



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04/29/2015    

CODINGLINE CORNER


Query: Medicare Penalties


 


During negotiations of the "doc fix", I thought I saw that they were ending all of the PQRS and meaningful use penalties and replacing them instead with an incentive. Is this true? 


 


Gary S Smith, DPM, Bradford,PA


 


Response: There are some changes coming as a result of the SGR bill that passed. Here is a brief summary of what happens to meaningful use (MU) and PQRS: 


 


The provision would create a new incentive payment system while sun setting several existing programs on the last day of 2018: (1) the meaningful use incentive program for certified electronic health record (EHR) technology, (2) the quality reporting incentive program currently called PQRS, and (3) the value–based payment modifier (VM). The Secretary would establish a replacement program, the merit–based incentive payment system (MIPS) that would accomplish the following: 


1. Develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards described below; 


2. Using the methodology above, provide for a composite performance score as specified below for each professional for each performance period; and 


3. Use the composite performance score of the MIPS eligible professional to make MIPS program incentive payments (as described below) to the professional for the year. 


 


The MIPS program would apply to payments for items and services furnished on or after January 1, 2019. So PQRS, VM and MU will sunset at the end of 2018 and be replaced with the merit-based incentive payment system (MIPS). This program will have winners and losers, so you could in theory earn an incentive or be penalized or be neutral. 


 


Jim Christina, DPM, Bethesda, MD 


 



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04/25/2015    

CODINGLINE CORNER


Query: Arthroereisis Coding


 


What is the best current billing code for subtalar arthroereisis? 


 


Louis Cappa, DPM, New Windsor, NY


 


Response: Most carriers still don't recognize any code for this. I suggest billing CPT 28899 (unlisted procedure) and also sending an op report, along with a letter noting a CPT code that you feel is comparable to the work that was done for this surgery. 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 



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04/22/2015    

CODINGLINE CORNER


Query: Screw Removal and Replacement


 


My patient walked extensively on her foot after an Austin/Akin-type bunionectomy performed with screw fixation. This resulted in the distal screw moving considerably. I will be taking her back to the operating room to remove the screw from the hallux and replace it with a staple. How would I code this? Since I already created the osteotomy and billed for it the first time, all I am doing is re-fixating the same osteotomy, so it seems counter-intuitive to bill the Akin again with a "-78" modifier. 


 


Wendy Siegel, DPM, Smithtown, NY


 


Response: Basically, the surgery involves removal of one fixation device for another at the same anatomical location. I recommend billing CPT 20680 (removal buried pin, screw, plate, etc.; deep). I don't think you should bill for replacing with a staple since you already were compensated once for that when you billed the original surgery. 


 


Howard Zlotoff, DPM, Camp Hill, PA



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04/17/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Ron Freireich, DPM


 


Thank you, Dr. Lehrman! I now know there is at least one other physician in this country who gets it. Not only shame on HHS, but shame on the leaders (whoever they are) of our medical system for allowing this to go on un-checked. Who plays a game when the people making the rules change the rules in the middle of the game? You can’t possibly win. It is a disgrace. The game should be stopped and all players involved come to an agreement on what is reasonable, manageable, and good for the patient. The current system is not.


 


Once again the government is reforming a system because they couldn’t get it right the first time. I understand this change might ease the burden this year, but what about next year and the year after. This system is a failure and the people making these rules are failing us and our patients.


 


Ron Freireich, DPM, Cleveland, OH

04/15/2015    

CODINGLINE CORNER


Query: Stage II MU Attestation


 


Does anyone know if the 90-day attestation (annual quarter) for Stage II meaningful use is in effect, or will it be for an entire year as was required for 2015 calendar year? 


 


Joseph Borreggine, DPM, Charleston, IL


 


Response: On April 10, 2015, CMS issued a new proposed rule for the EHR incentive program. Part of the proposed rule includes a 90-day reporting period for 2015. 


 


The other big news in this announcement is that CMS is proposing that the number of patients in a physician's practice who must access their records electronically be lowered from 5% of all patients to just 1 single patient for stage 2. The proposed changes are subject to a 60-day comment period and a final rule will evidently be drafted after that. 


 


My unsolicited opinion:  Regardless of how you feel about the content of the announcement, it is shameful that this comes out on April 10, 2015. MEMO TO HHS: 2015 started over 3 months ago! We're not going to find out what we actually have to do for 2015 until over HALF of the year is over. What a disgrace. Shame on you, HHS. Finally, nice job burying this by announcing late on a Friday afternoon. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 



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04/11/2015    

CODINGLINE CORNER


Query: Registering Intent for Public Health Measure


 


Should my office be registering my intent for any specialized registry submission? My folks and I are not aware of any, however, I wanted to ensure that we are complying with Meaningful Use. My practice has already registered for the Cancer Registry. We are exempt from the Immunization Registry. And, in Pennsylvania (according to our EMR), we are able to claim an exemption for the Syndromic Surveillance Measure due to cost. 


 


Gary Raymond, DPM, Altoona, PA


 


Response: You must register for: 


- Immunization Registries 


- Syndromic Surveillance Registries 


- Cancer Registries 


 


To register, contact your State Department of Health. You do not have to register for a specialty registry at this point in time. 


 


Michael L. Brody, DPM, Commack, NY



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04/08/2015    

CODINGLINE CORNER


Query: Excision of Mass Coding


 


How do I code for an "excision of soft tissue mass, foot" when the path report states it is a capillary hemangioma? 


 


Jane Koch, DPM, Evansville, IN


 


Response: Consider using one of these codes, based on anatomic location, depth of mass: 


 


CPT 28043 - excision tumor, foot, subcutaneous tissue 


CPT 28045 - deep, subfascial, intramuscular 


 


Howard Zlotoff, DPM, Camp Hill, PA 


 



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04/04/2015    

CODINGLINE CORNER


Query: Two Sets of X-Rays Done Same Day


 


A patient had two sets of x-ray studies done in the same visit. The second one was done post-reduction of a dislocated joint. How can I bill the second set of x-rays? 


 


Kelly Malinoski, DPM, Naples, FL


 


Response: Append a "-76" modifier on the second x-ray study. This modifier is used when there is a repeat procedure by the same physician. The "-59" modifier would be inappropriate to apply to the second x-ray code. 


 


Tony Poggio, DPM, Alameda, CA


 



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04/01/2015    

CODINGLINE CORNER


Query: Ultrasound-Guided Injection Code


 


Can someone please tell me the correct code for ultrasound-guided injections for plantar fasciitis?  


 


Kenneth T. Goldstein, DPM, Williamsville, NY


 


Response: CPT 76942 - Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation 


 


Your documentation would have to clearly note why you required (i.e., the medical necessity for) ultrasound guidance to administer what is a commonly performed infiltrative injection around the plantar fascia. Additionally, be prepared to offer peer-to-peer published studies that back the medical necessity for imaging to significantly impact therapeutic improvement of the injection over not using imaging to place your needle. 


 


Tony Poggio, DPM, Alameda, CA 


 



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03/31/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Michael M. Rosenblatt, DPM


 


Sometimes, "high risk" routine foot care treatment is also "high risk" for the podiatrist. Daniel C Albertson, APRN wrote a coding/treatment question for a high-risk patient in an extended care facility who had no obvious care by a medical doctor. The concern was for proper coding of RFC in the absence of a treatment plan. 


 


This situation goes considerably beyond coding and Medicare. Whenever there is a bad result, say an amputation after podiatric care, family members and other providers tend to look at the (recent) DPM care as primarily responsible for ...


 


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

03/28/2015    

CODINGLINE CORNER


Query: No PCP with High Risk Foot Care Patient


 


A doctor in our office recently evaluated and treated a patient at an assisted living facility for high risk foot care. The patient qualified for palliative services with absent pedal pulses and pain. The patient reported not having a primary care provider and has not seen one in over 3 years. I believe that we are required to indicate an active treatment plan to Medicare (by submitting last date of visit to a primary care physician) when treating for high risk foot care. Is this correct? How would we handle this case, as the patient has not been treated for such a long period of time and states that he is not under a primary care provider's care? 


 


Daniel C Albertson, APRN; President, Office of Paul Krestik, DPM,  London, KY


 


Response: Most routine foot care LCDs require that you submit the date the patient was last seen, NPI number, and the name of the MD/DO managing the patient's systemic condition, IF the qualifying diagnosis has an asterisk (*) next to it. Peripheral vascular disease conditions, with few exceptions, have no asterisk designation. I don't think you have to worry about it in the case you describe. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 



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03/25/2015    

CODINGLINE CORNER


Query: Proper Place of Service Code


 


We provide podiatric services to mentally and physically disabled patients at a sheltered workshop and an activity meeting place. We have seen some indications that you cannot use the place of service code "11" (office) for these places. I have contacted Medicare previously and they could not answer our question. What is the correct place of service code for billing? 


 


Linda Stevens, Office Assistant, Office of Jeff Chism, DPM, Merrill, WI


 


Response: Place of service 99. 


 


Unless you're paying rent, etc. for the use of the space you're using to see these individuals, it cannot be considered an office. Since the type of location where the services are rendered is not one currently defined, POS 99 is the correct code to report. 


 


Joan Gilhooly, CPC, CPCO, Lebanon, OH


 



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03/21/2015    

CODINGLINE CORNER


Query:  Nail Avulsion with Nail Bed Repair


 


Does anyone have a code and diagnosis for total avulsion with nail bed repair? 


 


Craig Sapenoff, DPM, West Palm Beach, FL


 


Response: The code you are looking for is CPT 11760 (repair of nail bed). The avulsion on the nail would be "incident to" the repair procedure and not separately billable. 


 


The diagnosis most probably would be ICD-9 892.0 (open wound of toe), but other diagnoses might be used if there are other issues that you did not mention in the nail bed laceration . 


 


Paul Kinberg, DPM, Dallas, TX 


 



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03/18/2015    

CODINGLINE CORNER


Query: Routine Foot Care Coding Scenario


 


The patient presented with 3 thickened, mycotic, dystrophic, and elongated nails. The other 7 nails are normal (only elongated). The treatment consisted of debridement of 2 of the thickened (mycotic) nails and trimming of the other nails. Assuming they meet "Q8" vascular risk, would this be coded: CPT 11720-Q8 G0127-Q8-59 or CPT 11719.-Q8 CPT 11720-Q8-59? 


 


Barry Feinstein, DPM, North Hollywood, CA 


 


Response: The coding in both sets is "correct" regarding use of modifiers. 


 


The selection of option 1 versus 2 depends on the description of the nails. If the nails not debrided are "normal", but long and in need a trim, then option 2 is correct. 


 


If the nails not debrided are "dystrophic" (but not thick requiring debridement), and long in need of a trim, then option 1 is correct. 


 


Tony Poggio, DPM, Alameda, CA 


 



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03/14/2015    

CODINGLINE CORNER


Query: Long-Term Care Coding


 


We see patients at a long-term care facility - the rehabilitation institute (place of service, 61), that is associated with a hospital. Patients are inpatient, recovering from different conditions. 


What E/M codes should we use for a new/established patient? Also, recently, our biller told us that CPT 11042 and CPT 10061 are not being paid when performed at this facility. The reason code was N428 (not covered when performed at this place of service). My question is why? If these codes aren't acceptable at that type of facility, what else could we use? 


 


Pam Eernisse, DPM, Chicago, IL


 


Response: I would change the place of service to either "31" or "32". If you check the description, it's actually more appropriate because your patient will recover. POS 61 is for patients with physical disabilities. 


 


POS 32 - A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. 


 


POS 61 - A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. 


 


Both codes are probably applicable to the facility, however you want to get paid. Just use "31" (skilled nursing) or "32" (nursing). I've always found the description odd because, of course, nursing home patients are still under the supervision of a physician. E/M codes for new patients are CPT 99304-99306, for established patients are CPT 99307-99310.


 


Lisa Merkow, CPC, Largo, FL


 



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03/11/2015    

CODINGLINE CORNER


Query: Ultrasound-Guided Injection


 


Would the following dictation warrant the “medical necessity” for an ultrasound guided injection? “Ultrasound guided injection was utilized today to avoid infiltration into the fat pad, which could cause a thinning of the pad and additional complications.” If this wording does not appear to justify the use of ultrasound, can someone provide a few acceptable examples? 


 


Kelly Bruce, Kingston, NY


 


Response: You are correct that this issue was discussed before, and unfortunately, the clarification that you seek does not exist. It also appears by your second question that your office is seeking a set of "magic words" that will validate this procedure as medically necessary. Your question can only be answered with opinions; the same opinions that have already been offered. Some payers issue written statements in LCDs and medical policies regarding medical necessity of certain procedures. To me, it sounds like the routine use of the wording offered does not justify medical necessity; it offers 'billing justification necessity.' 


 


Richard Rettig, DPM, Philadelphia, PA 


 



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03/09/2015    

CODINGLINE CORNER


Query: Post Office Box Break-In


 


My medical office post office box was broken into. I have no idea if any mail was stolen or not. I just found out about it today when our key would not open the box. What, if any, obligations do I have under HIPAA? 


 


Name Withheld by Moderator


 


Response: Your obligation under HIPAA is to do a careful investigation to determine if any patient information was compromised. If you determine that no health information was compromised, document that fact and you are done. If you find the contrary to be true, you will need to follow the rules on breach notification for the affected patients. The details for doing this are too extensive for this post, but I recommend that you consult with a healthcare attorney. You want to make sure you respond properly to this event so that you neither over-react or under-react. And don't wait-- you generally have 30 days to do breach notifications. 


 


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


 



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03/04/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Jack Ressler, DPM


 


I can't tell you the countless number of times this has happened in our office. The major problem arises when we tell our patients to call Medicare to verify. 90% of the time Medicare tells the patient erroneously to just have your doctor re-submit the claim. 


 


Jack Ressler, DPM, Tamarac, FL 

03/04/2015    

CODINGLINE CORNER


Query: Follow-up Hospital Consults


 


Can a specialist continue to bill for follow-up E/M visits to a hospitalized patient, whether or not any procedure was performed? Would these be CPT 9923x? I've heard that a specialist may only have one E/M charge per admission. 


 


James Hatfield, DPM, Encinitas, CA


 


Response: You absolutely may bill for follow-up E/M visits as long as the visit is not during the global period for a related procedure you performed. There are no other limits. Bill it at the appropriate level, of course. 


 


Richard Papperman, MBA, CHBME, Cape May Court House, NJ 


 



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