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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:


08/19/2017    

CODINGLINE CORNER



Query: Roll-A-Bout Knee Scooter Rental


 


Is our practice allowed to rent out a Roll-A-Bout Knee Walker (scooter) to our patients if those scooters aren’t directly purchased by the practice? For example, if a patient drops off a used scooter (they don’t need it anymore), can I rent it out or sell that to my patients at a discount?


 


Name Withheld by Moderator


 


Response: Renting out equipment is a ‘slippery slope’. There are rules about renting and even loaning (for free) durable medical equipment. There is liability if the patient injures his/herself because of defect or improper instruction. You most likely need a technician (certified) to inspect the device and certify that it is in working order (again, even if it is loaned out at no cost), and you need to make sure the patient is instructed properly in the use of this device.


 


Your medical malpractice insurance might not insure you or your practice on the rental of the device, so check with your liability insurance company. Most doctors who rent out equipment do it as a separate company, but remember there could be Stark rules or state laws to follow.  


 


Donald R Blum, DPM, JD  Dallas, TX



 


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08/15/2017    

CODINGLINE CORNER



Query: Decubitus Ulcer Coding with CPT 97597


 


We are having rejections from Medicare when submitting CPT 97597 (selective debridement) along with L89.623 (pressure ulcer of left heel, stage 3). Are we to use a 7th character at the end representing initial, subsequent, etc.?


 


Edwin S. Hart, DPM, Bethlehem, PA


 


Response: L89.623 (pressure ulcer of left heel, stage 3) is a complete code and does not require a 7th character. A stage 3 pressure ulcer is “full thickness skin loss involving damage or necrosis of subcutaneous tissue, left heel“. If this is what your patient has and you only did selective (superficial) debridement, I believe L89.623 and CPT 97597 would be the appropriate codes.


 


Jeffrey D Lehrman, DPM, Springfield, PA



 


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08/12/2017    

CODINGLINE CORNER



Query: Medicare Billing for X-Rays


 


We have a CR digital x-ray system. The new ones are DR. It is my understanding that Medicare is going to be cutting x-ray reimbursement by 2-10% for non-DR x-rays. I also understand there is an “FX” modifier. What is the correct way for us to bill given we have a CR digital system? Do we use the “FX” modifier?


 


Office of Mark M. Goldberg, DPM, Chestertown, MD


 


Response: CR-based x-rays are scheduled to be reduced by 7% beginning next year and then reduced by 10% beginning 2023. As of now, I do not believe that the “FX” modifier applies to CR-based x-rays. I suspect that a new modifier would be available for CR-based x-rays effective 2018.


 


Paul W Kim, JD, MPH, Baltimore, MD



 


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08/08/2017    

CODINGLINE CORNER



Query: Core Needle Biopsy of 4th Metatarsal


 


My patient has a tumor/lesion on the 4th metatarsal, with possibility of a giant cell tumor or enchondroma. I discussed the case with an ortho-oncologist, and he recommended a core needle biopsy. The problem is that I cannot find the appropriate code for a bone biopsy. Can I use partial excision of bone code (CPT 28122 – partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [e.g., osteomyelitis or bossing]; tarsal or metatarsal bone, except talus or calcaneus) or an arthrotomy of tarsal-metatarsal joint code (CPT 28050 – arthrotomy with biopsy; intertarsal or tarsometatarsal joint)?


 


Michael Downey, DPM, Fort Worth, TX


 


Response: I am picturing this biopsy as a stab incision over the 4th metatarsal and the core needle going into the 4th metatarsal. If that is the case, the only code I suggest you consider is CPT 20220 – biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous process, ribs).


 


Jeffrey D Lehrman, DPM, Springfield, PA



 


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08/05/2017    

CODINGLINE CORNER



Query: CPT 11043 Denial


 


I have a patient with a traumatic wound requiring debridement. I billed CPT 11043 (debridement, muscle and/or fascia [includes epidermis, dermis, and subcutaneous tissue, if performed]; first 20 sq cm or less)  with a diagnosis of  S97.81xD (crushing injury of right foot; subsequent encounter)  The insurance plan denied as diagnosis invalid for the procedure. I also tried diagnosis T79.8xxA (other early complications of trauma; initial encounter) with the same denial.


 


Charles Chapel, DPM  Brooksville, FL“


 


Response: CPT 11043 (debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less) is for the excisional debridement of necrotic muscle and/or fascia from within a wound or ulcer. The CPT manual states that wound debridement “services may be reported for injuries, infections, wounds, and chronic ulcers.”


 


Clearly, ICD-10-CM code, S97.81xD (crushing injury of right foot; subsequent encounter) indicates that an injury occurred, but without a secondary diagnosis that demonstrates that as a result of the injury, a wound manifested necessitating the debridement of necrotic tissue, the billing of CPT 11043 will not be reimbursed as was the case above.


 


I suggest using the secondary ICD-10-CM code S91.301A (unspecified open wound, right foot, initial encounter) or S91.301D (unspecified open wound, right foot, subsequent encounter) as appropriate.


 


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



 


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08/01/2017    

CODINGLINE CORNER



Query: Coding Two Nail Unit Biopsies


 


I have a patient who presented with 6 abnormal, yellow, thick (possibly fungal) toenails. The patient is diabetic with neuropathy and angiopathy. The right 2nd and left 1st nails appear to show the greatest abnormality, 100% of nail is affected while the other 4 have 50% or less involvement. I believe, in this particular case, it is medically necessary to perform two biopsies in order to gain a better picture of the abnormal toenail condition as well as establish an effective treatment plan.


 


Is it appropriate to biopsy these two nail units (including nail plate and associated nail bed) in order to confirm diagnoses (onychomycosis, onychogryphosis, psoriatic nail, etc.)? If not, why?


 


Guy Del Prince, DPM, Ashtabula, OH


 


Response: Just to be clear, a biopsy of a nail unit under anesthesia is typically recommended to rule out nail bed or fold lesions for malignancy (an example) versus rule out onychomycosis.


 


You will need to consider (because payers will) not only medical necessity and circumstance, but standard of care when determining the best testing procedure for the particular presentation. When definitive treatment is considered for onychomycosis (e.g., oral medication, in particular, but in some cases if there is a payer requirement for FDA-approved topical medication), cultures or PAS stains are usual and customary, not biopsy of nail unit.



 


Tony Poggio, DPM, Alameda, CA


 


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07/29/2017    

CODINGLINE CORNER



Query: Billing CPT 28308 with CPT 28270


 


I dictated that there was a joint contracture at the metatarsal-phalangeal joint as well as deformed metatarsal outside the normal metatarsal parabola. Can I bill CPT 28270 (capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint [separate procedure]) with CPT 28308 (osteotomy, tarsal bones, other than calcaneus or talus; with autograft [includes obtaining graft] [e.g., Fowler type])? I can find no CCI edits that say I can’t.


 


John Powers, DPM, Tucson, AZ


 


Response: If you perform a metatarsal neck area osteotomy and the same (relatively close, exposed) surgical site as the capsulotomy/tenorrhaphy whether to gain exposure for the osteotomy or to release the joint, the two procedures may be bundled together by payers. CPT 28270 is defined as a “separate procedure” in which one procedure is “commonly carried out as an integral component of a total service or procedure” and not separately billed.


 


If, however, the capsulotomy is “carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported by itself, or in addition to other procedures/services by appending modifier -59 to the specific “separate procedure” code to indicate that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure.”



 


Tony Poggio, DPM, Alameda, CA


 


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07/25/2017    

CODINGLINE CORNER



Query: Who Repays in a Medicare Audit?


 


In the event of Medicare audit of a practice, if money must be repaid to Medicare for incorrect billing for services performed by a podiatrist employed by the practice, who is liable/responsible for repayment... the employed podiatrist, the employer podiatrist, or both?


 


Troy Harris, DPM, Swansboro, NC


 


Response: Medicare will seek back money paid from the entity that they paid the money to – in this case it sounds like the group practice. As far as what happens after that, that would be determined by the contract you have with the practice.


 


Richard Rettig, DPM. Philadelphia, PA



 


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07/22/2017    

CODINGLINE CORNER



Query: Referring Physician – Routine Foot Care


 


My billing company stated that all Medicare Part B new patient visits require the name of the referring primary care physician. If they don’t have a physician’s name, then the billing company puts the podiatrist's name on the referring line. Is this true? The billing company also states that if you use diabetes without complications (E11.9), that is an automatic denial. What if the patient is well controlled with or without medications? Do you look for another diabetic code?


 


Joseph Knochel, DPM, Prescott, AZ


 


Response: Medicare does not require a patient to be referred by primary care to see any physician (as would be the case in a gatekeeper HMO setting). You can put your own name there if there is no referral. Years ago, when Medicare still recognized consultation coding, specialists needed an “outside” physician referral…since it was a requested opinion.


 


Regarding diabetes, routine foot care is covered for a diabetic patient only when the patient has a severe lower extremity manifestation (complication) of vascular disease or neurologic loss. If the patient is blessed with being well-controlled and has no neuropathy or vascular compromise, then routine foot care is not covered for them.



 


Tony Poggio, DPM, Alameda, CA


 


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07/18/2017    

CODINGLINE CORNER



Query: L4360 Billing Issues


 


When billing UnitedHealthcare (UHC) Community Plan  CPT L4360 (pneumatic walking boot prefab) with place of service (POS) 11 or 12, we get denied stating that it's an invalid POS. Also, when using “KX” modifier, they are denying, stating that it’s an invalid modifier. The funny part is that the UHC Community has paid multiple claims of ours and multiples ones aren’t paid. Can someone help me regarding this issue?


 


Rajesh Daulat, DPM, Glendale, AZ


 


Response: UHC Community Plan is a Medicaid Advantage Plan and for most DME items requires a pre-authorization. If you did not obtain that, then this may be their odd way to illustrate that rejection. It makes little sense to me, but I have given up trying to be logical when it comes to denials from insurance companies.


 


Don’t assume that Medicare’s rules automatically transfer to other payers. It is quite possible that using place of service (POS) 12 (home) is incorrect for a particular payer. Also, don’t assume that the “KX” modifier is required, even though its use (to qualify payment) would be for Medicare and for most Medicare Advantage Plans.


 


Don’t assume they want you as the referring doctor. Your NPI is required in 17 and 17B. As they may want that of the doctor who referred the patient to you, even though the prescription/order was written by you. Since this is a very unpredictable and illogical pattern to the payments, I would have your state PIAC rep contact your state UHC Community Plan office. Be sure your PIAC representative has both redacted, without patient information paid and unpaid examples, so they would be able to demonstrate the illogical payment patterns.


 


Paul Kesselman, DPM, Woodside, NY



 


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07/15/2017    

CODINGLINE CORNER



Query: CPT 28291 Denial


 


I billed CPT 28291 (hallux rigidus correction with cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint; with implant) to Tufts (health plan), and it got rejected. The explanation says, “This charge is denied. The plan considers this procedure to be experimental or investigative. Unless the member has executed a valid waiver, prior to services rendered, the member may not be billed.” Any advice would be appreciated.


 


Julie, Office of W. Anthony Wakim, DPM, Brockton, MA


 


Response: this is an inappropriate response by Tufts, and revisits an issue from many years ago. When I was at APMA, we fought the idea that a bunionectomy with implant (which had been paid by all payers for decades) all of a sudden became “experimental or investigational” in the eyes of some payers. We won many of these ridiculous battles about implants being experimental.


 


Contact MPMS and have them get to APMA, and make them aware of this. Fight this…it is archaic, and inaccurate information.


 


Mike King, DPM, Roswell, GA



 


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07/11/2017    

CODINGLINE CORNER



Query: Hammertoe and Plantar Plate Repair


 


I recently performed hammertoe corrections on toes 2 and 3 of the right foot, as well as a repair of a plantar plate tear of the 2nd metatarsal-phalangeal joint, right. Does anyone have coding suggestions to include plantar plate repair?


 


Kevin Davis, DPM, Russellville, KY


 


Response: There currently is not a CPT code for billing a complete plantar plate repair. Therefore, I would use the unlisted foot/toe code, CPT 28899. However, if you search coding sites, you will find some individuals suggest that you use CPT 28313, which I personally feel is an inappropriate code for the procedure.


 


Joseph Borreggine, DPM, Charleston, IL



 


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07/08/2017    

CODINGLINE CORNER



Query: Conservative Verruca Treatment


 


A patient has a mildly painful plantar verruca. After discussing treatment options, the patient elects a conservative approach, such as salicylic acid treatment. The patient returns for monitoring the progress and effectiveness every few weeks. In order to evaluate the lesion, debridement of the macerated tissue is required. What is the correct way to bill for these services?


 


Tiffany Hauptman, DPM, Mt Pleasant, IA


 


Response: Everything you are relating describes an evaluation and management (E/M) visit only. You should not use the ulcer debridement CPT codes because this is not an ulcer. You should not use the CPT 1105X codes because those are for corn or callus debridement.  CPT 1711X codes describe “destruction” and the examples of destruction given include laser surgery, electrosurgery, cryosurgery, chemosurgery, and surgical curettement.


 


Jeffrey D Lehrman, DPM, Springfield, PA



 


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07/04/2017    

CODINGLINE CORNER



Query: Wound Biologics


 


My representative for Epifix says we now have to document the ‘waste’ of the product not used/applied to the product supply code (e.g., Q4131-JW). How is that ‘waste’ measured (i.e., a circular product measures 2.4 cm in diameter and the ulcer measures 1.0cm X 0.5cm)?  


Gary Friedlander, DPM  Phoenix, AZ


 


Response: When one measures a wound, it is in sq. cm or sq. mm. Measuring Calculation Refresher: The area of a circle is the A = p × r2 (radius squared) or A = (p/4) × D2 (diameter squared). Compare this to the area of the wound and subtract the difference.


 


In your example, the wound is 1 sq cm and the Epifix measures 2.4 cm diameter. The area would be A= 3.14(pi) x (1.2 x 1.2) (this is the radius squared) = 5.42. 5.42 cm – 1 cm equals waste of 4.42 cm squared. The waste would be rounded to 4 units (I rounded down because the remainder was less then 1/2 (0.5).


 


Donald R Blum, DPM, JD, Dallas, TX



 


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07/03/2017    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Martin V. Sloan, MS, DPM


 


Dr. Arons' question concerning low reimbursement for the bunionectomy with fusion of the tarsal-metatarsal joint, CPT 28297, resurrects the long-standing disparity in payment between this and the much-less-complicated McBride bunionectomy, which is much easier to do, with fewer potential complications and much less follow-up time. The allowable payment for the McBride is $735.52, MUCH more than the $613.85 for the Lapidus. It would seem proper for APMA to address this issue with CMS, although they've said such action might open up the proverbial can of worms and send all payments downward.


 


Martin V. Sloan, MS, DPM, Abilene, TX 

06/30/2017    

CODINGLINE CORNER



Query: Lapidus-Type Bunionectomy


 


I was told at the recent Midwest Podiatry Meeting to bill a Lapidus bunionectomy as CPT 28297 (correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthordesis, any method). I was appalled when I was reimbursed approximately $600 for this difficult and time-consuming procedure. Should I have billed this another way? Would an appeal to the insurance company (Aetna) be of any value?


 


Barry H. Arons, DPM, Springfield, VA


 


Response: If the procedure is removal of the medial eminence of the first metatarsal head and fusion of the first metatarsocuneiform joint with resection of the articular surfaces (for reduction of the 1st IM angle), the correct code to submit is CPT 28297 (correction, hallux valgus [bunionectomy], with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthordesis, any method).


 


In Virginia, your Palmetto Physician Fee Schedule assigns a value of $613.85 to this code. It looks like Aetna is in line with Medicare on this one.


 


Jeffrey D Lehrman, DPM, Springfield, PA



 


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06/27/2017    

CODINGLINE CORNER



Query: Airwalkers and Fracture Care


 


For fractures being billed to Blue Cross Blue Shield insurance, can I bill the Airwalker or CAM Walker separately from fracture care global code?


 


Matthew German, DPM, Livonia, MI


 


Response: Yes, you can. Casting (subsequent, not initial casting), DME, casting supplies, and x-rays are all outside of the global payment for fracture care.


 


You can bill separately for all such products within the normal guidelines of medical necessity and per the payer’s plan.


 


Mike King, DPM, Roswell, GA



 


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06/23/2017    

CODINGLINE CORNER



Query: Bunion Correction with Joint Implant


 


I was given the code, CPT 28293 (bunionectomy with implant), but when I looked up the code in the APMA Coding Resource Center, it says the code has been replaced with CPT 28291 (hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant), but it is not coming up as a valid code in our EMR. When I look in the podiatry coding book, CPT 28291 is not a listed code. Could you please let me know which code I should be using?


 


W. Anthony Wakim, DPM, Brockton, MA


 


Response: The code, CPT 28291, from the APMA Coding Resource Center is the correct code. The problem with your EMR is that it’s not updated, and you need to find a way to update your CPT code directory and eliminate the old code, replacing it with the new code.


 


CPT 28293 was deleted as of January 1, 2017. CPT 29891 is a cheilectomy with implant code.


 


Joseph Borreggine, DPM, Charleston, IL



 


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06/20/2017    

CODINGLINE CORNER



Query: Verruca Laser Surgical Coding


 


How would you bill laser surgery that included destruction of “over 6 islands, many colonies” of warts’?


 


Michael Giordano, DPM, Rochester, NY


 


Response: When the issue is the “destruction of warts” by laser surgery, the response is pretty straightforward. The appropriate coding is based upon the total number of lesions involved.


 


CPT 17110 is described as destruction (e.g. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions.


 


CPT 17111 is described as above, but substitute 15 or more lesions.


 


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



 


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06/16/2017    

CODINGLINE CORNER



Query: Routine Foot Care and the *-59* Modifier


 


When billing multiple routine foot care codes (e.g., CPT 11720 and G0127), possibly with CPT 11055 (or CPT 11056 or CPT 11057), can you use a “-59” modifier on both codes, or is that not appropriate? I have heard through the grapevine that if you do, then both codes will be reimbursed at a 100% each.


 


Joseph Borreggine, DPM, Charleston, IL


 


Response: According to the Correct Coding Initiative (CCI) file, CPT 11720 is secondary to CPT 11055, CPT 11056 and CPT 11057. In order to obtain reimbursement for CPT 11720, a “-59” modifier must be appended to the CPT 11720 code assuming the nails are distinct and separate from the corns and calluses.


 


HCPCS code G0127 is secondary to CPT 11720, so the “-59” modifier would be required with the G0127 code. This also assumes the nails debrided are separate and distinct from the dystrophic nails that were trimmed. It is extremely important to document the location of all corns and calluses that are pared and cut and differentiate which nails were debrided and which nails were trimmed.


 


Robert Weatherford, CPC, Jacksonville, FL



 


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06/13/2017    

CODINGLINE CORNER


Query: Fracture Diagnosis


 


When submitting diagnosis of a fracture, do I have to have a date of injury?


 


Alex Gorenshtein, DPM, Winchester, VA


 


Response: It is not necessary to add the date of injury unless it is pertinent to the case or payer.


 


Some payers, such as Workers’ Comp may want to see the date in the notes  and even in the coding for reimbursement. It is not really mandatory to report the date of the fracture. It is a good idea, however, to properly document in your notes the date of injury and perhaps even location.


 


Mike King, DPM, Roswell, GA


 


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06/12/2017    

RESPONSES/COMMENTS (CODINGLINE CORNER)


RE: Pre-Surgical Dispensing of DME


From: Paul Kesselman, DPM


 


The main issue here is that there is no medical necessity for the DME prior to surgery (according to Medicare and other carriers). It is a great idea to dispense devices prior to medical necessity for patients to practice using the device absent the influence of narcotics, etc. It unfortunately is not a covered service under Medicare. 


 


There will be more on this topic in the September issue of Podiatry Management.


 


Paul Kesselman, DPM, Woodside, NY

06/02/2017    

CODINGLINE CORNER



Query: Wound Care Center POS Code


 


We are beginning to treat patients at a local wound care center. What location/place of service code do I use?


 


Michael Giordano, DPM, Rochester, NY


 


Response: There are 2 Place of Service (POS) codes that became effective January 1, 2016 that would apply directly to a wound care center.


 


POS 19  Off Campus – Outpatient Hospital A portion of an off – campus hospital provider based department which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.


 


POS 22 On Campus – Outpatient Hospital A portion of a hospital’s main campus, which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.


 


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



 


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05/30/2017    

CODINGLINE CORNER



Query: Weil Metatarsal Osteotomy


 


Can I use diagnosis code, ICD-10 M77.41 (metatarsalgia, right foot) for CPT 28308?


 


Brian Buckrop, DPM, Moline, IL


 


Response: I do not suggest using M77.41. I recommend the metatarsal deformity codes:


 


M21.6X1   Other acquired deformities of right foot


M21.6X2   Other acquired deformities of left foot


 


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



 


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05/26/2017    

CODINGLINE CORNER



Query: Denials on Multiple CPT 28285 Billing


 


I am having an issue with billing CPT 28285. When we perform a hammertoe repair, we bill CPT 28285 on one line with 3 toe modifiers and 3 units. We are not getting paid. Do we need to bill each on a separate line? Other suggestions?


 


Russell Petranto, DPM, Toms River, NJ


 


Response: We bill the 3 hammertoes on 3 different lines.  For example:


 


CPT 28285-T1


CPT 28285-T2-XS (or “-59”)


CPT 28285-T3-XS (or “-59”)


 


We use “XS” for Medicare and “-59” for private insurance. Some of my colleagues will say you do not need either because the “T” modifiers are supposed to be distinct. My experience is that if you do not add them to the 2nd and subsequent procedure, they will be denied.


 


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



 


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