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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:


09/28/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Paul Kesselman, DPM


 


There are two "orders" which are required by Medicare regarding DMEPOS items. The first is a dispensing order, the second is the detailed written order. A dispensing order is akin to a prescription, which can be verbal or written. It is quite simple and may be oral and without specific name brand, model numbers, and with very brief information about the patient. A dispensing order is required prior to the item being provided to the patient.


 


As for the detailed written order, this requires much more information about the item being provided (e.g. name brand, size, width, model number, etc.) as well as very detailed information about the patient. In addition, a detailed written order must be provided prior to the claim being sent to Medicare. However, as physicians who supply our own patients, these separate documents are not required. Rather, the elements of the dispensing order (prescription) and Detailed Written Order (DWO) are required within the patient's medical record. 


 


Paul Kesselman, DPM, Woodside, NY 

09/27/2016    

CODINGLINE CORNER


Query: Medicare DME Orders


 


Medicare DME dispensing rules require an "order" by the physician, but what does that entail? Is that part of the physician's note or a separate note such as a written prescription? Please advise. 


 


Amy Meehan, Billing Manager, Potomac, MD


 


Response: The physician order is the prescription. In the case of DME, there would be no difference. The order would need to include patient identifying information, item name/description, diagnosis, and the expected length this device will be needed (e.g., lifetime for an AFO vs. 3 months for crutches). 


 


The physician-supplier does not need to produce a unique prescription for their own patient for DME or supplies. That order can be included within the physician's medical record. You should check with your DMAC to see about any other requirements. Make sure that your records include what you are prescribing, the medical necessity, why a custom device is required vs. an OTC device, the level of disability/impairment, symptoms, etc. 


 


Tony Poggio, DPM, Alameda, CA 


 


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09/24/2016    

CODINGLINE CORNER


Query: Multi-Layered Compression Dressing


 


When billing CPT 29581 for a multi-layered compression dressing system, does anyone bill for the supplies as well (e.g., "A" codes) or have those typically been included in the payment for the application? 


 


Mike King, DPM, Alpharetta, GA


 


Response: The costs of the supplies are included in the allowance for the application procedure and not separately. 


 


The key to using CPT 29581 is that you are applying a multi-layer compression SYSTEM. There are specific items that are expected to be used, if you don't purchase pre-packaged kits. While it would be cheaper to put together your own layer materials (same as in the kits), the systems kits are more convenient. 


 


Tony Poggio, DPM, Alameda, CA 


 



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09/20/2016    

CODINGLINE CORNER


Query: Amputation with I&D


 


I performed a procedure which included an I&D of plantar space infection and partial first ray resection. My thought is to use code CPT 28003 for the incision and drainage. Would the amputation of the toe and metatarsal head be included, or is it billable separately (CPT 28810)? The Incision was carried to encompass the partial ray resection and the I&D. 


 


R. Kurt Meier, III, DPM, Brick, NJ


 


Response: CPT 28003 is appropriate for an I&D that is done below the level of fascia in multiple areas. The description of CPT 28810 reads, "amputation, metatarsal, with toe, single”. If you did not amputate the entire metatarsal, I do not think 28110 is appropriate. For a partial first ray amputation (hallux and part of the 1st metatarsal), I suggest both CPT 28820 (amputation, toe; metatarsophalangeal joint) and CPT 28122 (partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [e.g., osteomyelitis or bossing]; tarsal or metatarsal bone, except talus or calcaneus) with a "-59" modifier on CPT 28122. 


 


Now the question is whether you should code both the I&D and the partial first ray resection. If the incision portion of your I&D was actually part of the incision to do the partial first ray amputation, my opinion is that the I&D was a component of the amputation and should not be separately billed. Conversely, if the I&D was its own distinct procedure or independent from the amputation, then it can be separately billed. In this situation, your documentation should indicate that the the I&D was a different procedure or surgery, different site, or a separate incision from the amputation. 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 


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09/17/2016    

CODINGLINE CORNER


Query: Contusion Great Toe Left


 


I keep having problems understanding the right way to use "x" character in ICD-10. I saw a patient for a contusion to the great toe nail, left foot. I billed S90.45xA and Aetna rejected it. 


What did I do wrong? 


 


Robert S Steinberg, DPM, Schaumburg, IL


 


Response: You used a code for superficial foreign body in the toe, rather than for a contusion. And you would not have used the "x" as there is a valid 6th place number specifying the location. The "x" is used only as a place marker when there are no character choices listed for the sixth spot when a seventh is required (for example). There are some codes that use more than one "x" as place markers, so you need to research carefully. 


 


Had the patient presented with a superficial foreign body of the right great toe, active care encounter, you would have coded S90.451A.  However, you said you treated a contusion that included damage to the nail, so that would be coded S90.211A (contusion of right great toe with damage to nail, active management). You did not say what CPT code you used, but it should be appropriate for the treatment of a contusion right great toe with damaged nail. 


 


Katherine Sharp, Keystone Professional Solutions, Woodbury, TN 


 


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09/14/2016    

CODINGLINE CORNER


Query: Coverage: Medicare Advantage Plans


 


I was under the impression that Medicare Advantage plans must provide or offer the same level of benefits as traditional Medicare. I run into plans in New York City (e.g., UnitedHealthcare and VNS plans) that limit "routine care" to 4 visits per year. This is obviously less than the every 61 day coverage that traditional Medicare offers. Is this legal? 


 


Stephen Bennett, DPM, NY, NY


 


Response: In Pennsylvania, some plans, in ADDITION to the Medicare-required routine care for at-risk patients (diabetes, peripheral arterial disease, etc.), also provide a certain number of "routine care" visits for those NOT at any risk -- that benefit would be over and above Medicare Part B's allowance, and certainly would be legal. So are you sure that is not what you are experiencing? 


 


Richard Rettig, DPM, Philadelphia, PA 


 


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09/10/2016    

CODINGLINE CORNER


Query: Physical Therapy Billing


 


We have a physical therapist on staff. What is the proper channel to bill physical therapy services? Do we use the NPI of the actual physical therapist administering the service? Or, do we use the NPI of the DPM? Should we use the physical therapist's NPI as rendering, and DPM as supervising? Does anyone have recent experience with the utilization of actual physical therapy services within their DPM practice? 


 


Melissa Robitaille, DPM, Richmond Hill, GA


 


Response: We have performed PT/OT billing for over 20 years, though not as part of a podiatry practice. The physical therapist should be enrolled under your group and the billing go out with the PT as the rendering provider (with the physical therapist's NPI, of course) and the DPM as the referring provider. Be sure whoever does your billing is aware of the required modifiers, particularly for Medicare. All other aspects pertain, of course - medical record documentation, Rxs, etc. 


 


Richard Papperman, MBA, CHBME; President, Cape Medical Billing, Cape May Court House, NJ


 


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09/06/2016    

CODINGLINE CORNER


RE: Updated Taxonomy Codes for DPMs


 


An updated set of taxonomy codes has been developed and is set to go into effect January 1, 2017 (for some Medicare contractors, October 1, 2016). It is of utmost importance that you check your taxonomy coding which you submitted to Medicare. The following are accepted codes for podiatrists: 


 


Podiatrist - 213E00000X [definition] Foot & Ankle Surgery - 213ES0103X[definition] Foot Surgery - 213ES0131X [definition] Primary Podiatric Medicine - 213EP1101X[definition] Public Medicine - 213EP0504X [definition] Radiology - 213ER0200X [definition] Sports Medicine - 213ES0000X [definition].


 


It is especially important to note that for podiatrists, General Practice - 213EG0000X [definition], is being eliminated. Therefore, if you are registered with Medicare under this taxonomy code, you may need to contact your MAC and have the taxonomy code changed. Whether this will be something you can do without an 855 revalidation, I leave it for the enrollment specialists to comment on. 


 


Paul Kesselman, DPM, Woodside, NY


 


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09/02/2016    

CODINGLINE CORNER


Query: Digital Radiography Penalties?


 


I am still unclear on how to bill Medicare for x-rays beginning January 1, 2017. If we upgraded to DR (not CR) radiography, how do we show our Medicare contractor that we are not subject to the reduction? Do we need to bill the technical component and professional component separately? Are there any new or different modifiers? What does Medicare require? 


 


Michael Nirenberg, DPM, Merrillville, IN


 


Response: Whereas the final rule has the following statement about mammography: "We established a HCPCS modifier for CT services rendered on machines that do not meet an equipment standard," it does not specifically state how they will identify DR, CR, and analog systems for x-rays. It is probable that we will have new modifiers to identify the type of digital imaging system we are using in our office. 


 


Michael L Brody, DPM, Commack, NY 


 


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08/31/2016    

RESPONSES/COMMENTS (CODINGLINE CORNER)


RE: Charcot Check-Up (Karen Banks, DPM)


From: Robert D. Phillips, DPM


 


I realize that I do not have the same billing issues that most private practitioners do; however, I do face the same issues of Charcot joints that chronically break down into ulcers on the bottom of the foot. The big issue here is whether the treating physician can document what would happen if he lets the patient go longer than two weeks.


 


What happens if he lets the patient go 2.5 weeks or 3 weeks between visits? Are there pre-ulcerative changes in the keratoses? I have some Charcot joint patients who, if I don’t see them every 2-3 weeks, will come in with a new ulceration under the foot. This is documented. The fact that a callus can build up in 2 weeks time would necessitate debridement speaks greatly about the ineffectiveness of the shoes/orthotics that the patient is wearing.


 


One of the things that would help document the need for a check-up is a pedobarograph examination of the patient wearing the diabetic shoes/orthotics. Even with the best shoe/orthotic therapy, pathological forces cannot always be adequately alleviated to prevent callus and ulcer formation in the Charcot joint patient.


 


Robert D. Phillips, DPM, Orlando, FL 

08/31/2016    

CODINGLINE CORNER


Bret Ribotsky: Please share a few ideas that can be implemented to improve the foot surgery experience for patients?


 













Dr. Ali Sadreich



 


Ali Sadreih: I have tried to place the patient above everything else. I have written a post-op manual that I give to each surgical patient. I direct them to my website which has many videos that explain everything from what to do if your dressing gets wet, to what to expect pre- and post-surgery.  All in all, I have tried to make the experience the best for the patient.  


 













Drs. Brian Fullem and Amox Saxena



 


Meet the Masters is broadcast each Tuesday night at 9 PM (EST). This week's guests are sports podiatrists Drs. Brian Fullem and Amol Saxena. You can register for future events by clicking here

08/30/2016    

CODINGLINE CORNER


RE: CMS Grace Period for ICD-10 to End


 


For those of you who never even realized it, the one-year grace period in effect for ICD-10 announced last summer by CMS and AMA will end on October 1. 


 


One of the complaints associated with the "grace period" was that CMS never coordinated a similar grace period from commercial payers. And the majority of those payers did not go along with CMS's "flexibility". Over the past year, I have remarked that essentially CMS's/AMA's announcement of flexibility was little more than a public relations effort for that very reason. If a practice needs to code the highest level of specific for non-Medicare payers, are they really going to change to "grace" mode for Medicare claims? Really? 


 


Regardless, CMS noted that on October 1, 2016, providers will be required to use the "correct degree of specificity" when coding ICD-10 on their claims. That is interpreted as, for example, only using unspecified codes when the situation warranted their use and ensuring that the ICD-10 codes billed and the medical record documentation are supportive of one another. 


 


Interestingly enough, the years of delays leading up to ICD-10 implementation allowed many practices - providers and coders - time to prepare for the transition from ICD-9 to ICD-10. All-in-all, the transition was relatively smooth with minimal glitches, confusion, and loss of productivity reported. 


 


Harry Goldsmith, DPM, Cerritos, CA


 


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08/26/2016    

CODINGLINE CORNER


Query: Charcot Check-Up


 


I have a new patient from out of state. She has Charcot deformity with associated lesions. She wears molded inserts and currently has no breakdown of her lesions. She has, by history, had ulcerations in the past. Her past podiatrist was checking her every two weeks with debridement of the lesions. He was charging an office visit on these encounters. Am I missing something here? Is this a legitimate and legal way to see this patient? I think this would fall under the category of debridement of lesions and have a 60-day follow-up. I would understand if there were any hint of breakdown. I would like to make sure this is followed well and the condition not deteriorate. At the same time, I don't want to illegally bill Medicare. Give your specific coding if you think this is worth an office visit every two weeks. 


 


Karen Banks, DPM, Thomasville, GA


 


Response: I think your suspicions are right on. I believe I understand that you are saying the doctor is seeing the patient every two weeks for a callus check and debridement of any hyperkeratotic lesions. If this is the case, the service is palliative, and would fall under the routine foot care guidelines and limits. If the paring of calluses is the primary service performed, if the patient qualifies for routine foot care or qualifies under loss of protective sensation (LOPS), the reimbursement would be based on a 60-day cycle or 6-month cycle, respectively. If the patient needed palliative care sooner, then that would be paid directly by the patient. 


 


The coding would be the CPT 11055 series for routine foot care (with the appropriate ICD-10 codes) or G0245 (or G0246) plus G0247 for LOPS (with the appropriate ICD-10 codes). E/M service coding only would be appropriate when there is a new diagnosis or a "significant, separately identifiable" reason for re-evaluation and management. The level of E/M would be based on medical necessity and documentation. 


 


Tony Poggio, DPM, Alameda, CA 


 


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08/23/2016    

CODINGLINE CORNER


Query: Lesser MTPJ Implant


 


I performed a total silastic implant on a 3rd metatarsal-phalangeal joint (MTPJ) for an arthritic condition. At the same time, same foot, I performed a partial implant on the first MTPJ. I cannot find a proper code other than an unspecified code for the lesser implant. Does one exist? 


 


Marc Lederman, DPM, West Hartford, CT


 


Response: There is no code for lesser metatarsal joint implant procedures. Therefore, your options are: 1) CPT 28899 (unlisted foot/toe procedure), assign a fee, and provide operative report for manual review. Request peer review from insurer. You might want to contact the insurer prior to surgery since some consider this type of procedure investigational and won't cover it at all; or 2) CPT 28122-59, ostectomy, lesser metatarsal. Consider the procedure as an arthroplasty of the lesser metatarsal joint. 


 


As far as coding a partial implant of the first metatarsal-phalangeal joint, you would bill CPT 28293 (bunionectomy with implant). 


 


Howard Zlotoff, DPM, Camp Hill, PA 


 


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08/20/2016    

CODINGLINE CORNER


Query: Routine Nail Care Coding


 


If a patient has neuropathy from chemotherapy, but is not a diabetic and does not meet class findings (Q7, Q8 or Q9), is the patient covered under Medicare for routine nail care? I looked in the routine foot care LCD, but the language is unclear. 


 


Susan Yu, DPM, Urbana, OH


 


Response: The Ohio LCD says the patient must have class findings to be covered for routine foot care. However, directly under that it says, "Benefits for routine foot care are also available for patients with peripheral neuropathy involving the feet, but without the vascular impairment outlined in Class B findings. The neuropathy should be of such severity that care by a non-professional person would put the patient at risk. If the patient has evidence of neuropathy but no vascular impairment, the use of CLASS FINDINGS MODIFIERS IS NOT NECESSARY. This condition would be represented by the ICD-10-CM codes in the 3rd table of “ICD-10 Codes that Support Medical Necessity” listed below.” 


 


In the codes that are listed below, one of the options is G62.0, drug-induced polyneuropathy, which is what I consider the appropriate code for neuropathy from chemotherapy. This tells me that the patient you are asking about should be covered for routine foot care with a qualifying diagnosis of G62.0 even in the absence of class findings. I suggest you document the nature of their neuropathy and that having this done by someone other than a podiatrist would place this patient at risk. 


 


Finally, be aware that G62.0 has the instruction to "Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)”. You should include that if you know the drug. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 


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08/12/2016    

CODINGLINE CORNER


Query: Medicare: Is a DEA Number Required to Enroll in Medicare?


 


If I will not prescribe narcotics in my practice, is there a way to enroll with Medicare without a DEA number? 


 


Troy Harris, DPM, Swansboro, NC


 


Response: From CMS -"Provider Enrollment - Drug Enforcement Administration (DEA) Information Required 


 


The Internet-based Provider Enrollment, Chain and Ownership System (PECOS) Release 7.19.0, has been enhanced to require DEA registration information in Section 2 along with license and certification information effective with enrollment applications (including revalidations) completed on or after January 12, 2015. The new requirement for DEA registration information also applies to paper applications. Because the paper CMS-855I enrollment application does not include a space to enter the state in which the DEA certification was issued, contractors will develop applications where the DEA certificate has not been submitted with the application or the state where the certification was issued cannot be found elsewhere within the application. To prevent delays and development of your CMS 855I enrollment applications and revalidations, providers should include the DEA certificate when submitting their paper CMS-855I applications." 


 


Joseph Borreggine, DPM, Charleston, IL 


 


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08/09/2016    

CODINGLINE CORNER



Query: Getting Paid for an E/M and Strapping


 


When billing for an office E/M visit and strapping (CPT 29540), we are finding that payers are frequently bundling the two together, and paying for the strapping (which is of course the lesser charge). How do we bill correctly to get paid for both? 


 


Linda, Office of Lewis Giglia, DPM, Fairport, NY


 


Response: The established E/M service is a component service included in the "comprehensive" strapping application according to the CCI edits [Medicare]. If, however, you use modifier "-25", you override the CCI edit. You can only used the "-25" modifier when the E/M is "a significant, separately identifiable evaluation and management service." In those cases, you should get paid for both the strapping and the E/M visit. Non-Medicare payers have similar payments, but their own versions of bundling edits. 


 


For example, if you are treating a patient with an established plantar fasciitis diagnosis by the application of a subsequent strapping, the E/M service would be included in the strapping allowance. 


 


Joseph Borreggine, DPM, Charleston, IL 


 


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08/02/2016    

CODINGLINE CORNER


Query: Getting Paid for an E/M and Strapping


 


When billing for an office E/M visit and strapping (CPT 29540), we are finding that payers are frequently bundling the two together, and paying for the strapping (which is of course the lesser charge). How do we bill correctly to get paid for both? 


 


Linda, Office of Lewis Giglia, DPM, Fairport, NY


 


Response: The established E/M service is a component service included in the "comprehensive" strapping application according to the CCI edits [Medicare]. If, however, you use modifier "-25", you override the CCI edit. You can only use the "-25" modifier when the E/M is "a significant, separately identifiable evaluation and management service". In those case, you should get paid for both the strapping and the E/M visit. Non-Medicare payers have similar, but their own versions of bundling edits. 


 


For example, if you are treating a patient with an established plantar fasciitis diagnosis by the application of a subsequent strapping, the E/M service would be included in the strapping allowance. 


 


Joseph Borreggine, DPM, Charleston, IL 


 


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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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