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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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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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02/28/2015    

CODINGLINE CORNER


Query: Modifier -25 vs -57 Use


 


If you have a new patient who presents with pain in a toe, you examine the patient to find out he/she has a paronychia. You decide to perform a nail surgery at the same time of the initial visit. Should one use new office visit with modifier "-25" or "-57" with pain in foot as the diagnosis and then CPT 11730 or CPT 11750 with the paronychia diagnosis along with the location? This question comes up in order to determine if the insurance company will pay for the initial visit in addition to the surgery. 


 


David Hamilos, DPM, Johnson City, TN


 


Response: These modifiers both alert the payer that the E/M service performed was significant and separately identifiable and not included in the surgical service allowance. The distinction between these two modifiers is that the "-25" modifier is used to amend the E/M code only when the surgical procedure has a 0 or 10 day global. The "-57" modifier is used to amend the E/M code when the surgical procedure has a 90-day global and a decision for surgery was made through the E/M service for a procedure that will be performed within 24 hours. 


 


Paul Kesselman, DPM, Woodside, NY


 



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02/26/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B



From: Michael M. Rosenblatt, DPM


 


I must respectfully disagree with Dr. Richard Rettig, regarding his advice to a DPM who was "saddled" with a Medicare deductible because an internist waited to turn in his billing, but directly billed the patient, who (allegedly) paid at time of that treatment. (Dr. Rettig suggested that the DPM contact the MD to "work out" the payment issue.) 



 


This is actually a fairly common occurrence. Most physicians wait to turn in their Medicare billings, hoping that someone else will absorb the deductible. So, even if you wait, there is still a good chance that...


 


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


02/25/2015    

CODINGLINE CORNER


Query: Patients and Medicare Deductibles


 


A new patient was evaluated and treated for plantar fasciitis. She informed my front office that she had gone to her internist 10 days before and paid him $147 dollars, meeting her annual Medicare deductible. I billed Medicare for a new patient visit and a strapping. About one week later, I got an EOB from Medicare stating that the patient did not meet her deductible and is responsible for $105. She has no Medicare supplement. Obviously, the internist did not submit his claim until after I did, so I got stuck being owed the deductible. My question is, how do other offices handle this situation? Any advice would be greatly appreciated. 


 


Ronald Oberman, DPM, Deerfield Beach, FL


 


Response: One solution is to call the internists office, explain the situation, and try to work it out either between you two, or facilitating the overcharge refund to the patient, then getting it from the patient. That is the cleanest way to patch this up. 


 


A second way is to have the patient call 1-800-Medicare in your office, and clearing it up with your input if necessary. Since you say you have a lot of problems with this, then I suggest that you avoid this in the future, either for specific patients or across the board, by holding your claims until other doctors eat the deductible for you. 


 


Richard Rettig, DPM, Philadelphia, PA 


 



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02/21/2015    

CODINGLINE CORNER


RE: Billing CPT 96372 By a Podiatrist


 


Are there any circumstances/medications etc. when a podiatrist can bill for CPT 96372 (therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). If so, what would be the circumstances (i.e., when would it be appropriate, what medications, etc.)? Is it allowable by Medicare and/or commercial payers to bill the code in addition to other CPT injection codes or, conversely, when the code not be billed with/bundled to other injection codes or medications? 


 


Terry Boykoff, DPM, Santa Monica, CA


 


Response: I don't know of any podiatrists who administer IM injections of antibiotics within their offices. However, I could easily foresee injection of tetanus toxoid or antitoxin as long as it is within the state scope of practice. You can bill any payer for the injection administration, as well as the therapeutic supply 


 


Rick Horsman, DPM, Olympia, WA 


 



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02/18/2015    

CODINGLINE CORNER


Query: PQRS #317: Screening for High Blood Pressure


 


Patients 18 years and older are considered "not eligible" for this measure if they have an active diagnosis of hypertension. So, if a patient has a diagnosis of hypertension AND has a pre-hypertensive or hypertensive blood pressure reading (systolic > or = 120 OR diastolic > or = 80) at their visit, they would be coded as G8951 ("pre-hypertensive or hypertensive blood pressure reading documented, indicated follow-up NOT documented, patient NOT eligible"). But if the patient has a diagnosis of hypertension and their blood pressure is controlled on medication resulting in a normal blood pressure (systolic <120 AND diastolic <80), which code would be used: G8783: "Normal blood pressure reading documented, follow-up NOT required" or G8784: "Blood pressure reading NOT documented, patient NOT eligible"? 


 


Nancy Hayata, DPM, Huntington Beach, CA


 


Response: If a patient has an active diagnosis of hypertension, you report the G8784 no matter what their blood pressure reading is when taken. Technically, you do not have to take their blood pressure since this is a screening for high blood pressure measure, but for good medical care, it makes sense to take their blood pressure if they have an active diagnosis of hypertension and advise them to follow up with the provider treating their blood pressure if it is elevated. Either way, you report G8784 and this is excluded from calculating your performance on the measure but meets the reporting requirement. 


 


Jim Christina, DPM, Bethesda, MD 


 



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02/14/2015    

CODINGLINE CORNER


Query: CAM Walker and Night Splint Coding


 


Our DME vendor tells us that the “new” HCPCS code we should use for CAM walking boots is L4361, and L4397 for night splints. These new codes describe pre-fabricated devices with minimal adjustments. The codes we previously used were L4360 for CAM walking boots and L4396 for night splints. These are now described as “pre-fabricated devices that require substantial modification by a certified orthotist or an individual with equivalent expertise.” We are looking for feedback from others as to how they are now billing for these DME products. 


 


Kelly Bruce, Kingston, NY


 


Response: In 2014, CMS initiated many HCPCS changes which, as usual, created lots of confusion for orthotics and prosthetic providers. Instead of adding new codes with new definitions, CMS created new HCPCS codes using the existing definitions and also provided new definitions to existing codes. The key to your (and others' queries on this) is to look at the last portion of the definition and decide: 


 


1) What CMS meant by substantial modification and did you do so? 


2) Are you an individual with the expertise required to make the substantial modification? 


 


A DPM should be able to meet the qualifications to substantially modify (devices). And one would need to document what was done and why an OTS (off-the-shelf) device was inappropriate. "Substantially modify" is not implied by simply adjusting a strap or adding a Velcro pad from a package to the strap or boot. The new codes are appropriate for most CAM boots and night braces


 


Paul Kesselman, DPM, Woodside, NY 


 



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02/11/2015    

CODINGLINE CORNER


Query: Digital Block for Corn Debridement


 


A patient presented to the office with a painful dorsolateral corn on her right 5th digit. I attempted to debride it, however, it was so tender, she required a digital block prior to debridement. I was considering using CPT 64450 (injection anesthetic agent, other peripheral nerve or branch), but when reviewing the Medicare LCD, I didn't find an appropriate ICD-9 code to justify the injection. 


 


Jay Seidel, DPM, Baltimore, MD


 


Response: Performance of a procedure (e.g., CPT 11055) that usually does not require local anesthesia in rare cases, like you stated, may require administration of local anesthesia. In those relatively rare cases, the anesthesia would be included in the procedure. I do not recommend billing the injection as CPT 64450. 


 


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


 



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02/10/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Carla Poma


 


You have been given good advice to contact your Medicare carrier and find out when claims were submitted and if they are pending, rejected, or on the payment floor. Two months (delay) hints to bigger issues beginning with the billing service. Ask your office how often they are submitting claims for billing. Are you getting paid on claims other than Medicare? Ask for reports from your billing service, and/or schedule a conference to go over your billing and look at your outstanding claims report. Doctors need to be proactive with their billing nowadays more than ever and know what is going on with their practice. Time is of the essence. 


 


Carla-Ruth Poma, Michigan Medical Billing Specialists,LLC

02/09/2015    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: John Scholl, DPM


 


With traditional Medicare (not Medicare replacement policies or Medicare HMOs), the vast majority of the patients you are seeing this year have yet to meet their Medicare deductible. Medicare must process the claims and then send the claims to the secondary insurance, which takes time. You should be getting paid little by little from the secondary insurance companies until the patients meet their deductible. When deductibles are met, you should start receiving the Medicare payments.


 


John Scholl, DPM, Lady Lake, FL

02/07/2015    

CODINGLINE CORNER


Query: Medicare "Dark" Days


 


I have not gotten paid in about two months from Medicare, and my billing service keeps telling me about these "dark" days that Medicare has. Can someone please explain this to me in plain English? This has happened a couple of times before. How can I run my practice not having gotten paid in two months? 


 


Jahangir Habib, DPM, Pottsville, PA


 


Response: Because of fee scheduling issues, CMS instituted a hold on all payments for services rendered during the first two weeks of January. However, payments should have been re-started after January 15th. The term "dark days" are otherwise used by carriers during times when they are updating their systems. Usually, these occur during the weekend or non-business hours. Since you are continually getting the same answer from your biller and you are having significant payment issues, you might want to call your carrier yourself and be sure that there is not some other issue(s) going on. 


 


Paul Kesselman, DPM, Woodside, NY


 



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02/04/2015    

CODINGLINE CORNER


Query: Denial for Excision of Benign Lesion


 


I have a patient who had a bleeding growth on the bottom of his hallux that I excised and utilized primary closure. I billed it as CPT 11422 (excision of a benign skin lesion), utilizing ICD-9 729.5 and ICD-9 216.9 (benign neoplasm of skin, site unspecified). This was denied by my Medicare carrier. The pathology report later revealed the lesion to be an "acral fibrokeratoma." What would be the correct way to bill this? 


 


Jack Reingold, DPM, Solana Beach, CA


 


Response:  I think your mistake was in coding it as "benign". The payer probably thinks, if you know it's benign, why should we pay you to remove it? In the remote past, I would have submitted the claim with a diagnosis of neoplasm of skin of uncertain behavior. But my good friend Harry Goldsmith recently clarified to me that lesions of "uncertain behavior" are instances when the pathologist has to determine what it is. That is to say, it's a pathologist's diagnosis- not a surgeon's. 


 


The correct diagnosis code is neoplasm of skin of "unspecified behavior." That diagnosis implies you aren't really sure what it is, and it bothers the patient, so you removed it and submitted it for pathology. I don't see any problem with your procedural coding at all. Resubmit the claim with the revised diagnosis coding. 


 


Rick Horsman, DPM, Olympia, WA

 



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01/31/2015    

CODINGLINE CORNER


Query: Nursing Facility vs. Group Home Setting E/M


 


I was asked to see patients in a group home setting. In looking at the E/M categories, I believe that a group home is in the nursing facility category. I have not seen patients in a nursing home/facility for a number of years. Are there requirements such as having an order from the attending or primary care physician to see the patient? I also remember something about not being able to bill for an initial E/M, as only the admitting PCP can bill for that type of visit in the facility. Is that correct? 


 


Louis Scotti, DPM, Nesconset, NY


 


Response:  I recommend looking at the Domiciliary, Rest Home, (e.g. Boarding Home), or Custodial Care Services codes: CPT 99324-99337. The place of service code is 14 for Group Home and 33 for Custodial Care. These CPT codes do not have a medical care component. They are distinguished by new or established patients. It is best to contact the facility and ask how they are designated before seeing patients. Even if you are provided a room to use for your work, please do not bill place of service 'office', as in order to do that, one would have to bear the expense for the office setting. 


 


There must be an initial order on record from the patient's PCP for podiatry care. I recommend asking whomever contacts you if the order is written for each patient. I have not seen any guidance that this order must be renewed in a certain period of time. The new patient codes for Domiciliary, Rest Home, Boarding, or Custodial Care will closely fall into the same realm as office visit coding. The Initial E/Ms for nursing home patients (which do not distinguish new vs. established) would not, as they are designed for the first visit by the PCP for a detailed/comprehensive evaluation for the entire care of the patient. This may or may not include the written order for podiatry care. 


 


Karen Hurley, CMM, CPC, Lakewood Ranch, FL


 



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01/28/2015    

CODINGLINE CORNER


Query: Hardware Removal


 


Our doctor removed a pin and an external fixator under fluoroscopy in the ASC. The patient was under IV sedation (not general anesthesia) with the soft tissue locally anesthetized. Can we code both procedures, CPT 20680 and CPT 20694-52 (reduced because no general was administered)? 


 


Codingline Archive Question


 


Response: If the pin is buried (not protruding above the skin), and it requires an incision to remove it, you can bill CPT 20680 (if deep - at level of bone) or CPT 20670 (if superficial, buried in the subcutaneous tissue). 


 


You cannot bill CPT 20694 if you remove it under a local with sedation. "CPT Assistant" (July 2000) notes: "CPT code 20694, Removal, under anesthesia, of external fixation system, may be reported if the removal procedure is performed under general anesthesia. General anesthesia is not usually required to remove an external fixation system, therefore, removal not requiring anesthesia is not a separately reportable service." You cannot alternatively add a "-52" reduced service modifier since the value assigned the application includes removal without general anesthesia. 


 


Harry Goldsmith, DPM, Cerritos, CA 


 



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01/24/2015    

CODINGLINE CORNER


Query: GraftJacket Plantar Fat Pad Augmentation


 


How would you code placement of an acellular matrix (using the parachute technique) for augmentation of the fat pad underlying a lesser metatarsal head? Or more than one? I was thinking of using CPT 15002 wound bed preparation with CPT 15777 (implantation of biologic implant [e.g., acellular dermal matrix] for soft tissue reinforcement [e.g., breast, trunk]) for graft placement, as it is not a stand-alone code. Or does this fall in the unlisted procedure box? 


 


Wendy Winckelbach, DPM, Greenwood, IN


 


Response: There is no code for this. I believe the most appropriate code is CPT 28899 (unlisted procedure, foot or toes). CPT 15002 is not appropriate because there was no wound bed preparation performed. I suggest you pre-certify or check with the payer before performing this procedure as some may consider this "experimental" and not reimburse it. 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 



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Sorbothane