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Query: Billing Lapidus/Akin

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

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

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

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

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

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

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

Harry Goldsmith, DPM, Cerritos, CA

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Other messages in this thread:



Query: Retaining EOBs


How long should we keep paper Explanation of Benefit (EOB) payment vouchers? We are thinking of shredding 2011 and 2012. 


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


Response: State laws generally govern how long medical records are to be retained. However, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 administrative simplification rules require a covered entity, such as a physician billing Medicare, to retain required documentation for six years from the date of its creation or the date when it last was in effect, whichever is later. Your state may require a longer retention period.


Source: Mary Pat Whaley, Manage Your Practice


Barry Block, DPM, JD, Forest Hills, NY



Query: Meaningful Use 2016


I have successfully attested for Meaningful Use for 2012, 2013, and 2014. Due to a change of EHR systems, I will not be able to successfully attest for 2015, which will mean a reduction in 2017. If I am able to successfully attest for 2016, will the penalty remain or will it go back to full payment? 


Michaele Crawford, DPM, Butler, PA


Response: I would not be so fast to assume you cannot attest in 2015. The rules for Meaningful Use have changed for 2015, and one of the changes is that you only need to meet Meaningful Use for 90 consecutive days this year. If you have 90 days of Meaningful Use with either system you could successfully attest. 


That being said, if you do not attest in 2015 you will have a penalty for 2017. What you do in 2016 will determine if you have a penalty in 2018. So if you meet Meaningful Use in 2016 you will not have a penalty in 2018. 


Michael L. Brody, DPM, Commack, NY 



Query: Encounter with a Painful Normal Nail


When a Medicare patient presents complaining of toenail pain without any signs (i.e., no class finding and no paronychia) other than pain, can a low level E/M service code be billed if the nail was debrided, dressed, and topical antibiotics and soaks advised? 


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


Response: It all has to do with 1) what was actually done and 2) documentation. If you have a normal nail, with no class findings and no paronychia, how do you know that the nail is causing the problem? Normal nails are trimmed, not debrided (this implies thickness), so be careful of your terminology. Why would you apply a topical antibiotic to a nail that has no infection? 


Yes, you can evaluate any problem and bill an appropriate E/M level if there are symptoms present. Where the problem arises is when doctors try to embellish the presentation as a way to get non-covered routine foot care paid. Otherwise, it is a CASH service. 


Tony Poggio, DPM, Alameda, CA



Query: Unable to Dispense a Custom DME Item


Is there a way to charge Medicare for cost of custom fabrication of a DME item that became ready for dispensing just after a patient died? 


Sandi Wise, Thousand Oaks, CA


Response: This is covered in detail in your DME Supplier Manual. Use the Date of the Beneficiary's date of death as the DOS. Send this claim in manually, along with an attached sheet detailing all your expenses to the claims address of your DME. Materials to send include a paper claim and the following: copies of lab invoices, shipping costs, costs of materials used to cast the patient, overhead expenses incurred in casting the patient (this includes your employees' time in setting up the room, fillng out the lab order, utilities, etc.) and a wage for yourself for the time you spent with the patient. 


In many cases, the DME MAC will simply pay the fee schedule; in other cases, your costs will be reimbursed and at least you won't lose any money (other than for the time you took to write up the reimbursement request). DO NOT simply send in a claim electronically, even if you think the reimbursements would be the same as though you actually delivered the device. 


In case of an audit, a lack of a Written Proof Of Delivery will guarantee you will need to refund the money. Having all your documentation concerning the beneficiary's death and the paper work you've attached will assure you won't be refunding any money (at least not due to a lack of written proof of delivery). For more information, check out the Medicare Supplier's Manual Chapter 5 Section 4 of The Fall 2015 DME Supplier's Manual. The subchapter is entitled: "Artificial Limbs, Braces, and Other Custom-Made Items Ordered but Not Furnished." 


Paul Kesselman, DPM, Woodside, NY 



Query: ICD-10 Diabetic Codes and Nail Care


Previously, I used ICD-9 250.60 (Type II diabetes with neurological manifestations) and ICD-9 357.2 (polyneuropathy in diabetes) to qualify my diabetic patients for nail care. With ICD-10, it appears that E11.42 (Type 2 diabetes mellitus with diabetic polyneuropathy) is the most specific, and therefore the only required code. My software converts ICD-9 250.60 to E11.40 which appears to be an unspecified code. Any thoughts as to whether both E11.42 and E11.40 need to be used, or whether E11.42 is sufficient? 


Roger Friedman, DPM, Elyria, OH


Response: E11.42 is to be used because it's the most specific code; I would not use E11.40 since it's the "unspecified" code. 


Joseph Borreggine, DPM, Charleston, IL 



Query: Coding for Plantar Fibromas & Capsulitis


Can someone please explain to me why they did not add 2 specific codes for 1) plantar fibromas (as we know it is NOT the same as plantar fasciitis) and 2) Capsulitis/predislocation syndrome that was given a non-specific code M77.9? I intend to use metatarsalgia because enthesiopathy, in my opinion, is not correct for capsulitis. What other codes are colleagues finding that are not correct or not accurate? 


Anthony Hoffman, DPM, Oakland, CA


Response: ICD 10, although greatly more specific, has many holes in it. No, it doesn't make sense that more codes don't exist with more specificity for the conditions you mention, but that is the way WHO (World Health Organization) saw it. I would ride with what works for the majority, and is accepted for coverage until it can be made more diagnosis-specific. It should be noted that APMA has submitted many revisions to CMS, but they have not been added as of yet; maybe next year. 


Mike King, DPM, Fall River, MA 



Query: NGS: ICD-10 Claim Denial


I Billed 1) L84 2) L603 3) E11.51 


CPT 11056-Q8 [linked to 1,3 above] 

CPT 11719-Q8 [linked to 2,3 above] 


I was denied on both CPT codes as not medically necessary. I included the MD's name and NPI number as well as last date seen on the claim. Do I have the diagnoses out of order? What is it that I am doing wrong? 


Sheldon Miller, DPM, Rockaway Park, NY


Response: E11.59 is not in the NGS LCD. I recommend that you use E11.59 (Type 2 diabetes mellitus with other circulatory complications). 


Mitchell Breidbart, DPM, Whitestone, NY 



Query:  Bilateral L3000 & Unilateral Diagnosis Coding


With the new ICD-10, often the codes are now for one limb (as opposed to bilateral). We, however, prescribe orthotics bilaterally unless the patient has only one limb. Does anyone have a recommendation on what to do for the coding? For example, a patient has posterior tibial tendinitis, right; no symptoms on the left. How do you bill for orthotic(s) as a pair? 


Cheryl Christensen, Everett, WA


Response:  I would bill: 


L3000-RT with pointers to: M76.821, Q66.51, M21.6x1 

L3000-LT with pointers to: Q66.52, M21.6x2 


Paul Kinberg, DPM, Dallas, TX



Query: Matching Procedure Codes to Diagnosis Codes


I am trying to find a reference that shows what CPT codes (e.g., CPT 11000) can be billed with what ICD-10 diagnosis codes. Is there a chart or reference as to what diagnosis code can be used? 


Jack Ressler, DPM, Tamarac, FL


Response: The APMA Coding Resource Center (, in addition to containing the most comprehensive of ICD-10 features for foot and ankle specialists, also includes a CPT tab containing, among other things, procedural CPT codes links to both potential ICD-9 (for residual claims) and ICD-10 codes. 


Harry Goldsmith, DPM, Cerritos, CA 



Query: Candida Antigen Injection for Warts


When doing a Candida antigen injection for warts, is the correct procedure code, CPT 95115 (professional services for allergen immunotherapy not including provision of allergenic extracts; single injection)? What would be the HCPCS code for the injectable? 


James Hatfield, DPM , Encinitas, CA


Response: The real answer starts with a question: Aren't you destroying a wart? CPT 17110 is defined 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." Aren't you destroying this using chemosurgery? 


I do not recommend CPT 95115 (professional services for allergen immunotherapy not including provision of allergenic extracts; single injection). There is no "J" code for this to bill. 


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



Query: ICD-10 Listed on Lab Order Form


What ICD-10 code would I use on the blood test request form to check liver function for a patient currently on Lamisil? 


Steven Fessel, DPM, Nanuet, NY


Response: When ordering the lab test, you are ordering it because you are prescribing a drug for long-term use for an infection. 


1) The infection = B35.1 (onychomycosis); 

2) The lab is being ordered because you are having the patient use a drug that could have potential problems used for a long term, ICD-10 Z79.899 (other long term (current) drug therapy);  or 

3) ICD-10 Z51.81 (encounter for therapeutic drug level monitoring). 


Categories Z40-Z53 are intended for use to indicate a reason for care. They may be used for patients who have already been treated for a disease or injury, but who are receiving aftercare or prophylactic care, or care to consolidate the treatment, or to deal with a residual state. 


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



Query: ICD-10 Code for Atrophy of Fat Pad


Any suggestions for ICD-10 code for atrophy of fat pad? We previously used ICD-9 709.09 (dyschromia; other). No code comes up in the crosswalk on the APMA Coding Resource Center. 


Julie Hoffman, Office of Scott Hoffman, DPM, Worthington, MN


Response: When I speak to providers and billers, I find that ICD-9 codes were often used incorrectly. Dyschromia is defined as an alteration of color in skin, hair, or nails. It has nothing to do with atrophy of the fat pad. In ICD-10, there is a code for hypertrophy of fat pad (M79.4). When it comes to diagnosing patients' conditions, the atrophy of a fat pad causing foot pain or metatarsalgia would have more appropriate diagnoses. 


If you are looking for a skin condition, the ICD-9 code was ICD-9 709.8 (other specified disorders of skin). It crosswalks to ICD-10 as L98.8 (other specified disorders of the skin and subcutaneous tissue). 


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



Query: Non-Pressure Ulcer Codes


What is the difference between the codes for non-pressure ulcers with fat exposed with necrosis, and with skin breakdown? 


Tina Wright, Muncie, IN


Response: This is your way to indicate the depth and involvement of the ulcer. 


For these L97 codes, if the breakdown of tissue associated with the ulcer is limited to just a breakdown of skin, use a sixth character of "1". 


If the ulcer is deeper and the fat layer is exposed, use a sixth character of "2". 


Jeffrey Lehrman, DPM, Springfield, PA



Query: ICD-10 Code for Tailor's Bunion


Am I correct that there are NO separate codes for a tailor's bunion? Every time I enter ICD-9 727.1 (bunion/bunionectomy) into my crosswalk, I am getting the standard hallux valgus, acquired codes. Although all this ICD-10 stuff has me thoroughly exhausted, I am still fairly certain a 5th metatarsal deformity isn't a "hallux". 


Jeffrey Worman, DPM, Largo, FL


Response: The closest code we have in ICD-10 for a tailor 's bunion is: 


M21.6X1 (other acquired deformities of right foot) 

M21.6X2 (other acquired deformities of left foot) 


Jeffrey Lehrman, DPM, Springfield, PA  (Similar response from David Freedman, DPM, Silver Spring, MD)



Query: ICD-10: Post Surgical Fracture


If I have a patient who fractured an osteotomy 2 weeks post-op who needs a revision surgery...and I coded the fracture as S92.3120 (displaced fracture of first metatarsal bone, left foot), do I use "A" (it is not technically the initial visit on the operation day) or a displacement of implant, T84.233? Do I need a "Z" code in this case or only for post-op visits for x-rays? And how exactly do I use the "Z" code for the post-op visit? 


David Soomekh, DPM, Beverly Hills, CA


Response: One of the problems with your scenario is we don't know if the fractured osteotomy site (2 weeks post-op) was a complication of the surgery or the direct result of a trauma. Presuming the patient tripped on the stairs and came down hard on the operative site, you have a trauma resulting in a fracture which just happened to be in the surgical repair [osteotomy] site. If your active treatment of the fracture is surgical, that encounter (operating session) would be coded  S92.312A 


The 7th character "A" "initial encounter" does not mean the same as CPT terminology of "initial encounter". In ICD-10-speak, it is an encounter in which active treatment is being rendered (e.g., operating room to initiate treatment of the fracture). It's not a follow-up. You could add the displacement of the internal fixation device coding if you wanted (again, with an "A" as the 7th character); although I seriously doubt its addition would play into whether or not you will get paid. 


Regarding a "Z" ICD-10 code, the simple answer is no. You would use the same fracture code, S92.312_, but change the "A" 7th character to "D" to signify a post-operative follow-up of the fracture with routine healing of the fracture to validate post-operative x-ray medical necessity. You would absolutely not use Z47.89 (encounter for other orthopedic aftercare) because there is an Excludes1 associated with that code that states: "aftercare for healing fracture-code to fracture with 7th character D". 


Harry Goldsmith, DPM, Cerritos, CA 



Query: Routine Foot Care & E/M Coding


I have been in practice 30 years and have always been under the impression that if a patient on Medicare returns back to your office for scheduled periodic covered palliative foot care (i.e., trimming of nails and calluses) that, unless there is a new problem, all you can bill for is the palliative care services.  A podiatrist in my area told me that he bills an E/M code at the same time as CPT 11719 and CPT 11055 codes, even if there is no new problem because he checks the pulses and reviews medications the patient happens to be on. Have I been missing something all these years? 


PM News Subscriber


Response: You are correct! In my opinion, your colleague is asking for trouble. Most LCDs used to say that billing an E/M service on the same visit as performing a routine foot care service had to be for a different diagnosis. The E/M could not be used to re-qualify the patient for routine foot care coverage as that was built into the routine foot care coding and payment. 


Even though that statement no longer appears in most LCDs, I doubt that the MACs have changed their computer tracking of those services. There are more than a few DPMs who have recently gotten into trouble with the ZPICs, OIG, and/or the FBI for doing what your colleague suggests. To be "forewarned is to be forearmed" is an old English proverb that is certainly as true for this scenario as anything that came up in jolly old England. Except perhaps, the punishments are a little more civil today. 


Paul Kinberg, DPM, Dallas, TX



Query: ER Consult Taken to Surgery


How should the following scenario be coded? Patient seen in ER for a consultation for a chain saw injury to the medial left foot. He is taken to the operating room on the same day. In the OR, I repaired the flexor hallucis brevis and abductor hallucis tendons. The wound was irrigated with pulse lavage and primarily closed. Patient admitted to the hospital for pain control and observation; then discharged next day. 


Richard D. Wolff, DPM, Oregon, OH


Response: Starting with the emergency department visit: Medicare does not recognize consult codes, so if this is a Medicare patient, do not use a consult code. For all other payers, an encounter is only considered a consult if you do not completely take over care of the problem. I suggest you choose the appropriate level and type of E/M for your ED encounter and attach a "-57" modifier to it indicating that this E/M resulted in the initial decision to perform the surgery, and that surgery will be performed in the next 24 hours. 


The surgery: CPT 28200 is "repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon”. The abductor hallucis participates in flexion of the hallux. For the repair of both tendons, I suggest CPT 28200 x 2 units. The irrigation and closure are components of the tendon repair and should not be billed separately unless the closure was a complicated repair that required extensive work. 


Jeffrey Lehrman, DPM, Springfield, PA 


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Query: Calcaneal Osteotomy


One of my doctors is asking if CPT 28300 (calcaneal osteotomy) can be billed twice during one surgery. He is talking about two separate incisions to do the type of procedure he wants to do, and I haven't seen anything one way or another stating whether the CPT 28300 code can be billed twice in one session. 


Jennifer P., Office of Mid-South Foot & Ankle Specialists, Memphis, TN


Response: Yes, CPT 28300 can be billed twice during one surgery for two different osteotomies performed at two different locations to correct two different deformities


Your options are to bill it is as: CPT 28300 x 2 units or on two lines as: 

CPT 28300 

CPT 28300-59 


Jeffrey Lehrman, DPM, Springfield, PA


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Query: ICD-10 Coding: Abscess Foot


When coding for the treatment of a foot abscess, do you also include B95-97 to identify the organism likely causing the abscess? 


Bill Hughes DPM, Council Bluffs, IA


Response: For all of the ICD-10 L02- (cutaneous abscess, furuncle and carbuncle) codes, we are directed to "Use additional code to identify organism (B95-B96)". 


If you know the organism based on culture results, I suggest you choose the appropriate code to identify that organism. If you do not know the organism, I suggest that you do not guess, but rather do not code any organism at all. 


Jeffrey Lehrman, DPM, Springfield, PA 


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Query: Casting for Orthotics


We normally bill CPT 29799 (unlisted procedure, casting or strapping) when billing for casting of the orthotics. Some insurance companies pay; most do not. Has anyone billed code, S0395 - impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic? 


Susan Yu, DPM , Urbana, OH


Response: S0395 is a valid HCPCS code, but in my experience (maybe it is regional), many payers are looking for a regular CPT code. I have found it hit or miss depending on the payer, even depending on the plan. You might want to check with your most common commercial payers to see what their code preference is. 


Tony Poggio, DPM, Alameda, CA


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Query: Internal Hardware Coding


Can commercial payers be billed for internal hardware (screws) in an outpatient office setting? If so, what might the codes be? If not, can the patient be billed? 


Jennifer Patronik, Mecklenburg Foot & Ankle Associates, Charlotte, NC


Response: Yes, you can bill for implants used in surgery. The most common code I have seen billed in L8699 (prosthetic implant, not otherwise specified). You should pre-authorize this (and a tray/room fee) by providing the payer information about the implant. In-office surgery may not be worth it if you are not compensated for your material and fixed costs. Also make sure that the implant you use is considered medically necessary for the surgery you are doing. 


It would not be a bad idea to ask about the reimbursement rate. There are a number of versions of surgical screws out there: standard, cannulated, dual thread, etc. There can be a significant variation in the cost of these items. If your payer only allows a certain amount for screws placed in surgery, then you may need to choose between the various options out there to make it cost-effective for you. 


If the screw is not covered, you could bill the patient as long as the payer doesn't have in your contract that you cannot or that the item is included in the surgical professional allowance. Make sure you have the patient sign an ABN or equivalent. Screws are not cheap. You can not balance bill them simply because you believe the reimbursement for the screw is not adequate. 


Tony Poggio, DPM , Alameda, CA 


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Query: Medicare Provider Address Change


I need to change my Medicare provider address, but I want to still bill Medicare. How much time can I hold my claims for Medicare before they are void? Is it one year? 


David Zuckerman, DPM, Cherry Hill, NJ


Response: You have one year to submit a claim. 


That said, once you change address, that becomes effective immediately. Medicare will not forward any mail, and any mail returned to them will result in your account being frozen. I would clear the deck with your claims before the switch date or you can get caught up in a very sticky mess (translated: no payments for a long time). 


Tony Poggio, DPM, Alameda, CA


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Query: ICD-10: Removal of Surgical Screws


I have a patient who has 2 screws in the medial malleolus of the left ankle that were put in several years ago. Now they are protruding and painful. They need to be removed. What ICD-10 would I use? 


Pratap Gohil, DPM, Kokomo, IN


Response: Series T84 requires a 7th character. The appropriate 7th character is to be added to each code from category T84 options. They are: 

A initial encounter    D subsequent encounter      S sequela 


This is not acute, so no "A." This is not complicated, so no "S." That makes "D" just right. 


T84.127D (displacement of internal fixation device of bone of left lower leg). Another option may be T84.39- (other mechanical complication of other bone devices, implants and grafts; Inclusion Term: Protrusion of other bone devices, implants and grafts)... 

T84.398D (other mechanical complication of other bone devices, implants and grafts). 


Either of these should work, so pick the one that is most relevant to your case. 


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


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Query: Billing CPT 28285


I would like to know if I can bill for a hammertoe correction, CPT 28285 with a capsulotomy/tenotomy, CPT 28270. This is what the doctors report says: "Sharp and blunt dissection was used to create a plane between the subcutaneous and capsule at the level of the proximal interphalangeal joint, after which time a transverse tenotomy capsulotomy was performed." I would also like to know if I can bill the same code, CPT 28285, with CPT 28272. I thought the capsulotomy was already included in CPT 28285. 


Della Roes, Lake Havasu City, AZ


Response: The CCI edit will allow CPT 28270 to be billed with CPT 28285 because they are on different joints; interphalangeal and metatarsophalangeal, respectively. However, CPT 28272 cannot be billed with CPT 28285 because they are the same joints - interphalangeal. 


Joseph Borreggine, DPM, Charleston, IL


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Query: Removal and Replacement of Implant


What would be the best procedure code for the removal of a subtalar implant and re-implantation of new subtalar implant at the same time? The patient has Medicare Noridian. 


Timothy Shea, DPM, Concord, CA


Response: When removing and reinserting an implant, that is essentially billed as one procedure. There is no additional allowance to remove the original implant. You would only bill to insert the new implant. 


That said, many payers do not reimburse for subtalar implant (arthroereisis) procedures - investigational/experimental - so be sure you pre-authorize the procedure (S2117 or 0335T). Since Noridian does not have a mechanism for pre-authorizing the procedure, I strongly recommend that you have the patient sign an ABN so they know they may be held financially responsible. 


Tony Poggio, DPM, Alameda, CA


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