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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:


07/26/2016    

CODINGLINE CORNER


Query: CPT Coding for Hallux Varus Repair


 


I have a patient with hallux varus. She does not have an unusually low intermetatarsal angle, and the abductor hallucis is not really unusually tight - but one could argue that. My operative plan is a release of the insertion of the abductor hallucis, and use of an Arthrex Mini-TightRope device to reconstruct the lateral collateral ligaments. The patient clearly and obviously does not require a reverse metatarsal osteotomy. Any suggestions on most applicable CPT coding would be appreciated. 


 


Rick Horsman, DPM, Olympia, WA


 


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 (2009) via Joseph Borreggine, DPM


 


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07/22/2016    

CODINGLINE CORNER


Query: Surgery Denial Question


 


Our doctor saw a patient a day BEFORE his surgery for routine foot care (billed CPT 11056, CPT 11721). We billed the surgery CPT 28293-79-RT and CPT 28293-79-59-LT. We are getting a CO-151 (payment adjusted because the payer deems the information submitted does not support this many/frequency of service denials. 


 


Staff, Neil Kelley, DPM, Fortuna, CA


 


Response: The performance of routine foot care the day before surgery should not impact the surgical coding. The problem, as I see it, is your coding. I  suggest CPT 28293-50 at 1 unit.  


 


CPT 28293 is designated bilateral coding by Medicare, which does not allow for separate line billing of bunionectomy codes. Also, you do need need the "-79" modifier, unless you are in a separate global period for a surgery previously done. 


 


Harry Goldsmith, DPM, Cerritos, CA 


 


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07/19/2016    

CODINGLINE CORNER


Query: Nursing Home Nail Care


 


As I understand it, a nursing home patient or the family may request foot care without an order from the primary physician. Does the patient or family have to request foot care in writing every time? 


 


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


 


Response: That is correct, although most providers forget this. Note, though, that is true for a nursing home patient, but not a skilled nursing bed (SNF) patient (Medicare Part A stay). 


 


An SNF patient is like an inpatient hospital patient - they cannot request their own care. And, no, to question 2, as in a regularly ordered patient, once you see a patient, you have a doctor-patient relationship, and may see the patient as you see fit for medical necessity. There has never been any rule that each separate visit must be ordered by an MD/DO. 


 


Richard Rettig, DPM, Philadelphia, PA 


 


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07/15/2016    

CODINGLINE CORNER


Query: Minor Procedure Identification 



 


Where can I find a list of what Medicare Part B (Indiana) considers a minor procedure? Humana Medicare is trying to take back (payment) on a consult that was done the same day as a procedure, stating that the procedure is a minor procedure. 


 


Michael Carroll, DPM, Greenwood, IN


 


Response: Medicare defines a "minor procedure" as a procedure that has 0 to 10 global days. A major procedure has a 90-day global period. You can review Medicare's designation of global days per procedure codes in the APMA Coding Resource Center or the CMS site under Medicare Physician Fee Schedule search (per code). 


 


Tony Poggio, DPM, Alameda, CA 



 


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07/08/2016    

CODINGLINE CORNER


Query: CPT 20550 Denials


 


Recently, my office has been getting random denials on cortisone injection code CPT 20550, from private insurance carriers. We bill a diagnosis code of plantar fasciitis (M72.2). Most of the time, it pays just fine, but occasionally, it will get denied and when we call the payer, they say that it is not in the policy. When I checked the LCD for Ohio, plantar fasciitis appears to be one of the approved codes to bill for CPT 20550. Any ideas? 


 


Susan Yu, DPM, Urbana, OH


 


Response: I had the same problem and just used a similar diagnosis that represented the complaint that was listed in the LCD. The code that I used in this case was ICD-10 M77.51 (or M77.52) - enthesopathy (right and left foot, respectively). 


 


Joseph Borreggine, DPM, Charleston, IL 


 


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06/29/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: John Moglia, DPM


 


Thanks to Dr. Kinberg for his reply regarding LCD for CPT code 29540. Similarly, I have been denied payment for office visits using CPT codes 99212/99213 using ICD-10 codes for paronychia/infection toe L03.031, foot L02.611 when treating patients with infected ingrown toenails or cellulitis of the foot without performing an I&D or excision of toenail. Is there an exclusion or LCD against using office evaluation codes for infection without surgery?


 


John Moglia, DPM, Berkeley Hts, NJ

06/28/2016    

CODINGLINE CORNER


Query:  CPT 29540 Denial


 


My billing manager has brought to my attention that CPT 29540 (strapping ankle/foot) is being denied by New Jersey Medicare (Novitas) when billed with an office visit, CPT 99213-25 with diagnosis codes for sprain, tendinitis, or fasciitis. The EOB explanation given was "These are non-covered services because this is not deemed medically necessary by the payer." Is this a new CMS/Novitas policy? I can't find any reason online. 


 


PM News Subscriber


 


Response: Novitas put the "Strapping" (L36423) LCD into place, effective April 7, 2016. The qualifying diagnoses codes for CPT 29540 and CPT 29550 can be found in the Group 7 series. There was nothing in a quick reading of the LCD that speaks to a separate E/M with a "-25" modifier or any rationale for denial of same. You also have to be sure you are not taping, but are truly strapping; and, yes, there is a difference based on the LCD. Just be sure you have documented the strapping as such (and how it was accomplished) while documenting all the elements needed to evidence a separately identifiable E/M service so you can request a redetermination from Novitas. 


 


There is a 120-day time limit to file this redetermination. There is also a special form you will need to download and fill-out. Be sure you have all the appropriate required information. As this is a newly created LCD, please be sure to let your New Jersey CAC rep know how this review turns out. We may need to get clarification from and have Novitas update the LCD if there are problems and this become widespread. 


 


Paul Kinberg, DPM, Dallas, TX


 


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06/21/2016    

CODINGLINE CORNER


Query: 2016 PQRS and Value-Based Modifier


 


Is it true that there is a possible 2% penalty for PQRS for 2016? Is there a 2% penalty for the Value-Based Modifier for 2016? Is there a possible incentive for the Value-Based Modifier for 2016? What is suggested in order to meet these programs? 


 


Gina Garza, College Station, TX


 


Response: If you DO NOT report PQRS you will be subject to: 


 


- 2% reporting penalty 


- up to 2% performance penalty 


 


If you DO report PQRS: 


 


- you will NOT be subject to the reporting penalty. 


- you may be subject to a performance penalty of up to 2% if your performance is poor. 


- you may be eligible for a performance bonus of up to 2% if your performance is excellent.


- if your performance is average, you may not get any penalty or bonus. 


 


The performance bonus/penalty is also known as the Value-Based Modifier.


 


Michael Brody, DPM, Commack, NY 


 


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06/17/2016    

CODINGLINE CORNER


Query: Needling Technique: Achilles Tendon Calcification


 


What are the recommended CPT codes for an ultrasound-guided needling of the Achilles tendon for calcification - performed in office under local anesthesia? The physician states he will inject saline into the calcification; he is not dry needling. 


 


Terri Phillips, CPC, Tulsa, OK


 


Response: CPT 76942 is defined as ultrasound-guided needle placement for an aspiration or an injection (used for tendon/fascial/muscle injections). CPT 20550, CPT 20551 is the procedure code for injection of tendon sheath, tendon insertion, respectively. 


 


Supportive documentation must be present in the medical record when using CPT 76942. Some insurance carriers are now not paying for CPT 76942 separately when used in combination with the above injection CPT codes. 


 


Joseph Borreggine, DPM, Charleston, IL


 


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06/14/2016    

CODINGLINE CORNER


Query: Out-of-Network Provider Question


 


I give the patient the diagnosis codes, procedure code, and invoice amount so she can file a claim. Must I also include an E/M code? 


 


Troy Harris, DPM, Swansboro, NC


 


Response: Bill your usual and customary fees. List all of the services you performed. If you performed an E/M service, bill it. If you did not perform a qualified E/M service, then obviously, it would be inappropriate to bill it. The reimbursement for out-of-network may vary as to the amount paid as well as the deductible depending on the plan. Some plans have a separate out-of-network deductible. 


 


As long as the patient knows that you do not participate in that plan and agrees to be seen, you should be fine. What they get reimbursed for is based upon the contract THEY signed with the insurance company. 


 


Tony Poggio, DPM, Alameda, CA 


 


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06/14/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Steven J. Kanidakis, DPM


 


If it were my practice, then there would be no question. I would not take this risk. I remember the case where the written informed consent was not translated to the Latin patient in Miami. When they were at trial, the patient suddenly did not understand a word of English. Yet, the patient knew enough "legalese" to know she had a case, without the translator.


 


In a case where the patient is remotely reluctant, I would not elect to perform the surgery or procedure. Your post said enough for it to be crystal clear to me. If you're worried about the patient's hearing, then do not take the chance. Otherwise, you may end up in a "hearing". Do not feel obligated to take and help every patient. I am here to say that doctors cannot always be the heroes for patients anymore.


 


Steven J. Kanidakis, DPM, Saint Petersburg, FL

06/13/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER))



From: Paul Busman, DPM, RN


 


I don't know the legal acceptability of this, but there are many app-based translators which can translate from one language to another in both directions. One that I've used is Google Translate, available for Android and iOS.


 


Users can type or write into the app, and the app also understands spoken language. It's not perfect, but it's quite good. The Hispanic patients I've used it with in my OR nurse role have found it useful and even got a kick out of it. This app can even recognize printed words (as long as they're in a conventional typeface) and translate them instantly in realtime!


 


Paul Busman, DPM, RN, Clifton Park, NY

06/10/2016    

CODINGLINE CORNER


Query: Hearing Impaired Patient


 


I have a patient who is hearing impaired. She has "requested" that I provide an interpreter. All the services in my area are around $70/hour with a 2-hour minimum. I know I am legally obligated to this service, but it was my understanding that I must provide a "meaningful way of communication." I offered the patient more than one time slot in my schedule for writing and notes, etc. She refused. Am I right in that every time she comes in, I would be required to provide the interpreter? Do I have any legally acceptable alternatives that I can present to the patient? I am all for being ADA compliant, but I am losing money on this patient and am not in the situation where I can or want to do so. 


 


Jeffrey Worman, DPM, Largo, FL 


 


Response: I have the perfect solution. It hurts me to see our profession being "shaken down" by this exploitative situation. I have found a company that performs interpretive services online. It is like Skype or Apple Facetime. You take your laptop and sit it in front of the patient (I place it on a chair facing the patient). The patient sees the interpreter and the interpreter sees the patient. The interpreter speaks with the doctor over the laptop built-in speakerphone. The amazing thing is they hook you up with a certified interpreter through an Uber-like system. It is best to put in a request maybe a week ahead. It costs roughly $15 for 15 minutes, more or less. Since the interpreter is certified, your patient has no grounds to object. The link to the company is http://govineya.com/interpreter/ 


 


Disclosure: I have no connection to this company. 


 


Richard Rettig, DPM, Philadelphia, PA


 


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06/08/2016    

CODINGLINE CORNER


Query: Claims for Therapeutic Shoes


 


When dispensing therapeutic shoes, which doctor's name goes into box 17? 


 


Craig Sapenoff, DPM, West Palm Beach, FL


 


Responses: Block 17 is one of the more interesting of the changes to the "new" CMS 1500 claim form and its electronic counterpart that came about due to ICD-10. There is a left-hand block for a qualifier to be used with the "Name of Referring Provider or Other Source". Those qualifiers are: 


 


DN - Referring Provider 


DK - Ordering Provider 


DQ - Supervising Provider. 


 


If there are multiple physicians involved, enter the names in the rank-order given above. So it would be my recommendation that the ordering/dispensing podiatrist's name go in Block 17 with the qualifier "DQ". 


 


Paul Kinberg, DPM, Dallas, TX 


 


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06/03/2016    

CODINGLINE CORNER


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? I can't find anywhere in the Noridian LCDs where it states that this procedure is limited to once every 6 months. Any help would be appreciated. 


 


Lani Smith, Office Manager, 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 in LCD 33979 in Oregon that limits this to once every six months either. 


 


Don Self, Don Self & Associates, Whitehouse, TX 


 


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05/28/2016    

CODINGLINE CORNER


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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05/24/2016    

CODINGLINE CORNER


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, ICD10Data.com, etc., all point you to Q66.89, which is my recommendation. 


 


Harry Goldsmith, DPM, Cerritos, CA 


 


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05/23/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



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

05/20/2016    

CODINGLINE CORNER


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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05/17/2016    

CODINGLINE CORNER


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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05/14/2016    

CODINGLINE CORNER


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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05/03/2016    

CODINGLINE CORNER


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

04/29/2016    

CODINGLINE CORNER


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 

04/26/2016    

CODINGLINE CORNER


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

04/22/2016    

CODINGLINE CORNER


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 
Ossur