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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: Surgical Preparation of Wound for Graft


Is there a time limit on how many days before applying a tissue graft (CPT 15275) that the preparation (CPT 15004) can be performed? 


David Hauser, DPM,  Holland, OH


Response: There is no written policy I am aware of that sets, restricts, or limits the number of days prior to application of tissue graft or skin substitute material when you can "prepare" the recipient site. Having said that, "medically necessary and reasonable" as well as standard of care would ultimately dictate the reimbursement. The question you need to answer is how far out from the application of the graft material would it be reasonable and effective to prepare the site. 


Note that CPT guidelines state: "Surgical preparation codes 15002-15005 for skin replacement surgery describe the initial services related to preparing a clean and viable wound surface for placement of an autograft, flap, skin substitute graft or for negative pressure wound therapy...Do not report 15002-15005 for removal of nonviable tissue/debris in a chronic wound (eg, venous or diabetic) when the wound is left to heal by secondary intention. See active wound management codes (97597, 97598) and debridement codes (11042-11047) for this service." 


Harry Goldsmith, DPM, Cerritos, CA 



Query: Subtalar Arthroereisis Coding


Since there is no specific code for subtalar arthroereisis, can we use CPT 28725 with "-22" modifier? 


Michael Giordano, DPM, Rochester, NY


Response: The code you are to use is 0335T (extra-osseous subtalar joint implant for talotarsal stabilization). This is a Category III code specific for the procedure you are performing. 


It would be unacceptable to use CPT 28725 (arthrodesis; subtalar). It certainly would be inappropriate to add a "-22" (increased procedural service) modifier. There is a "CPT Assistant" article specifically addressing this. Using CPT 28725 would be misrepresenting what was actually done. 


You should be aware that there are a number of payers who do not cover the subtalar arthroereisis procedure (denied as investigational). You should request pre-authorization of 0335T. 


Tony Poggio, DPM, Alameda, CA



Query: I&D of Abscess 


What would be the appropriate ICD-10 code corresponding with an incision and drainage of abscess of foot/toe? We have been using L03.031 (cellulitis of right toe) and L03.032 (cellulitis of left toe), but want to make sure this is the best code to fit the procedure CPT 10060, or CPT 10061. 


Gary Unsdorfer, DPM, Medina, OH


Response: In ICD-9, abscess and cellulitis fell under the same code. This is no longer the case with ICD-10.  You listed the cellulitis codes here. I suggest considering these options for I&D of abscess: 


L02.611 (cutaneous abscess of right foot) 

L02.612 (cutaneous abscess of left foot) 


There are no different codes for an abscess of the toe versus other part of the foot, so these are appropriate for either. If there is also cellulitis associated with the abscess, the cellulitis codes may be added as well for a secondary diagnosis. 


Jeffrey Lehrman, DPM, Springfield, PA 



Query: CPT 97597 and an E/M Code


Is it possible to bill CPT 97597 (selective debridement) of an ulcer along with an E/M code with a "-25" modifier? The debridement keeps getting denied. For example, 

CPT 99212-25 ICD-10 M20.41 (other hammertoe(s) (acquired), right foot) 

CPT 97597 ICD-10 L97.512 

[L97.512: non-pressure chronic ulcer of other part of right foot with fat layer exposed] 


Pamela Eernisse, DPM, Chicago, IL


Response: Yes, you can bill the visit with a "-25" modifier on the same visit as a CPT 97597 - but be sure you meet the requirements of using a "-25" modifier. The "-25" indicates that the visit is significantly separate and identifiable from the procedure performed on the same day. A good way of making sure that your documentation supports both is to remove all documentation relating to the debridement. 


Do you still have the history, exam, and medical decision-making (or any 2 of these 3 on an established patient visit) documented at a level to support the office visit code you want to bill? Do you clearly show the medical necessity of the visit, which is completely different from the history, exam, and medical decision-making? If so - then use the "-25" modifier - but I do not recommend automatically appending the "-25" modifier on codes just to get them paid. 


Don Self, Don Self & Associates, Inc. Whitehouse, TX 



Query: 2016 Medicare Deductibles


Are offices collecting at time of service or billing Medicare first and then the patient? 


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


Response: From CMS: "Providers must collect the unmet deductible and co-insurance from the patient. Consistently waiving these charges could be construed as program abuse. If the patient is unable to pay, you may ask him or her to sign a waiver outlining their financial hardship. If no waiver is signed, the patient's medical record should reflect that there were normal/reasonable attempts to collect from the patient prior to writing-off the charge." 


Therefore, ask them to pay if you know that they have not met their deductible. You can find this out by checking on the CMS Connex site, which gives up-to-date beneficiary information. Be watchful that their secondary insurance (if they have one) might pick up the deductible. Generally speaking, you may want to think about holding the claim if you suspect patients cannot afford or do not know whether they have met their deductible. 


Joseph Borreggine, DPM, Charleston, IL 



Query: BCBS Denial of L4360 


I received a denial for L4360 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise) with a reason "Procedure is not consistent with the modifier or missing a modifier." The diagnosis used was S92.325D (nondisplaced fracture of second metatarsal bone, left foot). The HCPCS coding was L4360-LT. 


David Sands, DPM, Great Neck, NY


Response: Chances are Blue Cross Blue Shield is requiring the "KX" modifier. This stipulates you have met and have the required documentation. The "KX" is also one of many payment modifiers required by payers. With the AFO category (which CAM walking boots belong), you also will be required to use a site modifier. In your scenario, it appears the "LT" modifier would be appropriate. 


I am also concerned that you are using L4360 to indicate you dispensed a pneumatic CAM boot which is custom-fitted required by a person with significant expertise. My experience and audits I've reviewed indicate that you likely dispensed an off-the-shelf pneumatic boot, which should be coded as L4361-KX-LT. 


Paul Kesselman, DPM, Woodside, NY



Query: Fracture of Great Toe


A patient came in and had a fracture of the left great toe. We billed for the x-ray and fracture care. Five days later, he came in because he had dropped something on the fractured toe and was in more pain. We x-rayed the foot again, and he now has 2 fractures on the same toe. How can we bill for the x-ray and fracture without it looking like a duplicate claim? An "A" added to the fracture diagnosis codes will look like we are billing everything twice for the same incident. Any suggestions? 


Allan Hetelson, DPM, Bensalem, PA


Response: Having an x-ray taken for a new injury is appropriate and reasonable. There should be no issue about billing the second x-ray. Make sure your records document the two separate injuries at different times and indicate that a second fracture of the same toe occurred. 


As for the treatment, I don't think you should bill for fracture care again unless the actual treatment changes (i.e., open reduction, fixation, etc.). If the treatment continues to be closed treatment with immobilization, I would not consider billing fracture care again. 


Howard Zlotoff DPM, Camp Hill, PA



Query: Meaningful Use Measure 10


It is my understanding that since the first two sections of Measure 10 are not applicable to podiatry - namely immunizations and syndromic surveillance - we are therefore required to participate with two registries. As far as I know, the only registry now available to podiatry is the US Wound Registry. I have signed up with this registry and have begun uploading data to them already. However, I would like to know if we really do need to participate in two registries, and if so, what other registries are available. 


I know that the APMA and other organizations are working at setting these up for us currently, however as far as I know, we need to participate with the registry within the first 60 days of the reporting period...and for 2016 that would be the end of February. Does anybody have any information regarding the registries and the requirement to participate in one or two of them regarding podiatry? 


Mark Stempler, DPM, Staten Island, NY


Response: You do not have to participate in two registries if you are using the US Wound Registry. You can both submit PQRS and meet the requirements of the 3rd Measure of Meaningful Use Objective 10 with the US Wound Registry. 


Jeffrey Lehrman, DPM, Springfield, PA 



From: Sarah Whittaker, DPM


As the MN CAC Representative, both I and my Clinic Administrator have been actively involved in numerous conversations with the other APMA CAC Reps regarding the confusion of converting from ICD-9 to ICD-10 and how NGS (our jurisdiction 6 MAC carrier) has applied those changes to their LCDs indicating medical necessity. 


Shortly after the release date of 10/01/15, we all agreed that a letter needed to be drafted to NGS noting that some converted ICD-10 codes were missing in the Routine Care LCD posted. NGS was very accommodating to this feedback and asked for a list of the codes missing, stating they would be happy to update the missing...


Editor's notes: Dr. Whittaker's extended-length letter can be read here



Query: Waiver of Co-Pays


Medicare does not allow the routine waiver of co-pays and deductibles, but it my understanding that it doesn't say to what lengths we must go to collect. Is asking for the payment enough? Is one mailed statement enough? Also, I have read where a practitioner may forgive the co-payment in consideration of a particular patient's financial hardship; for example, patients seen in a group home or psychiatric setting. What would need to be done to prove financial hardship? 


J. Lovejoy, Office of Charles Perry, DPM, Cambridge, OH


Response: This is right from the CMS Handbook


"Providers must collect the unmet deductible and coinsurance from the patient. Consistently waiving these charges could be construed as program abuse. If the patient is unable to pay, you may ask him or her to sign a waiver outlining their financial hardship. If no waiver is signed, the patient's medical record should reflect that there were normal/reasonable attempts to collect from the patient prior to writing-off the charge." 


Joseph Borreggine, DPM, Charleston, IL



Query: Coding for Plantar Warts


When CPT 17110 is used, Aetna rejects claims coded with B07.01 & B07.02, which is what appears in the APMA's CRC. When we finally got someone on the phone, and the connection to India was not disconnected, we were told to "try" B07.8 (1 &/or 2, I assume). By the way, Blue Cross Blue Shield of Illinois and UnitedHealthcare accept B07.0 (1 &/or 2). Is anyone else having this problem? 


Robert Steinberg, DPM, Hoffman Estates, IL


Response: Neither B07.01 or B07.02 appear in the APMA Coding Resource Center. If your diagnosis was plantar wart, the APMA Coding Resource Center's ICD-10 Quick Index notes 

B07.0 - plantar wart. There is no 5th character (-1 or -2) option. There is no laterality with plantar wart. B07.01 or B07.02 would not be a valid ICD-10 code. Aetna correctly rejected those codes. 


Harry Goldsmith, DPM, Cerritos, CA 



Query: Bilateral Total Contact Casts


We have a few patients who require wound debridement and application of total contact casts bilaterally. We have one payer who continues to initially deny the payment for the casts. We appeal and the claims go under review and eventually get paid, but it takes 4-6 months. Here is the coding and sequencing we are using including the modifiers: 


CPT 11042  CPT 97597-59  CPT 29445-59-RT  CPT 29445 59-LT  Are we missing something? 


Mardon Day, DPM, Nashville, TN


Response: If the payer is Medicare, you would code the application of bilateral total contact casts as CPT 29445-50-59 (1 unit). 


Some other payers may have similar coding requirements; others may want the cast application billed on two lines. 


As far as the debridements, Medicare (and maybe the payer you are referring to) does not pay for debridements performed on the same limb that a cast is applied. And, obviously, if the payer did, the debridement to and including subcutaneous tissue and the selective debridement would need to be on two totally separate locations. You need to make sure that is clearly documented in your chart. Check with the payer for written policies on this. 


Tony Poggio, DPM, Alameda, CA 



Query: Bait and Switch to Non-Par Doc


Recently, I was having a conversation with a 4th year resident after surgery. He was informed that many podiatrists have an associate who is out-of-network, and that they bill the surgery under the non-par associate, thus collecting a much larger fee. Of course, the resident thinks that this is the bucket of gold at the end of the rainbow. I informed the resident that my feeling was that this practice was at the least unethical and possibly constitutes fraud and abuse. He replied that "everyone does it." I do not have any legal background, but I would appreciate knowing if this practice is above board. 


Name Withheld


Response: If the surgery is done by the participating doctor, it cannot be billed by another doctor in the group, whether that doctor is par or non-par. Billing any service under a different name than the person who performed it is fraud, plain and simple. This is so basic that I cannot understand why anyone would think differently. I have a term for the "everyone does it" crowd: future clients. 


J. Kevin West, Esq, Parsons Behle & Latimer, Boise, ID



From: Michael M. Rosenblatt, DPM


I am old enough to try to shed some light on Dr. Joseph Borreggine's comments about the "history" of covered routine foot care. However, as a DPM who has helped defend fellow DPMs who have been accused of abusing this privilege, I rather doubt that it is actually an "annuity," as he suggests. DPMs who go to nursing homes are watched, literally with eyes in the walls. RFC abuse is one of the most successful fraud complaints that investigators can put together, literally...with shoe-string evidence. I say that because interviews with NH patients are often part of prosecution evidence. C'mon now... 


It is possible to get paid from NH foot care. However it requires very, very careful charting and evidence of...


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



From: Joseph Borreggine, DPM


I would actually like to know who lobbied to have RFC paid for by Medicare. Do any of our readers know the history behind the podiatric lobby and  the reason for allowing this to happen? 


What was the premise behind getting Medicare to pay for RFC? The only reason I could imagine was to increase the populous that could see a podiatrist because they could now afford to do so. But, I heard that for about 35 years or more, DPMs would charge cash for "C&C." I have heard that it was $15-25 a visit for nail and/or callus care. Nobody seemed to have a problem with...


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



From: Todd G. Lewis, DPM


Try using CPT Code 20600 (see below). I use 20600, 20604, 20605, and 20606 with no issues with reimbursement. Aspiration and Injection CPT Codes:


Puncture aspiration of abscess, hematoma, bulla, or cyst (10160)

Injection, therapeutic; carpal tunnel (20526)

Injection, therapeutic; single tendon origin or insertion (20551)

Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst eg, fingers, toes) (20600)

Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) (20605)

Arthrocentesis, aspiration and/or injection; major joint or bursa eg, shoulder, hip, knee joint, subacromial bursa) (20610)

Aspiration or injection ganglion cyst (20612)

Aspiration or injection bone cyst (20615)


Todd G. Lewis, DPM, Wichita, KS



Query: Proper Code for a Nerve Block for UHC


A patient was seen in our office with a painful neuroma and the doctor injected it. [NOTE: The date of service was prior to ICD-10 implementation] We billed ICD-9 355.6 (Morton's neuroma), ICD-9 729.2 (neuritis), and ICD-9 729 (pain). The procedure was CPT 64450 (peripheral nerve block, therapeutic/diagnostic) with the appropriate site modifier ("LT"). UnitedHealthcare has denied the claim saying the CPT code is "not appropriate." Does anyone know the proper payable CPT for nerve block injection for UHC? I have not seen this denial before... 


Michal Levinsky, Office of Dr. Arnold Ravick, DPM, Washington, DC


Response: Did you inject an anesthetic/steroid? If so, the appropriate code is CPT 64455, not CPT 64450. The description of this code specifically addresses Morton's neuroma. 


Tony Poggio, DPM, Alameda, CA



From: Daniel Chaskin, DPM


If a carrier misinterprets federal guidelines such as that all routine foot care is not covered, and if enough federal judges overturn enough appeals, would this reverse any policy that was misinterpreted at the carrier level?


Daniel Chaskin, DPM, Ridgewood, NY



From: George Jacobson, DPM


Many years ago in a Medicare World far, far away, I billed CPT 20550 with the diagnosis bursitis. Then one day, the Empire no longer permitted it. There is no code in the Empire for steroid injection for bursitis. There was no rebellion. There are many codes that are no longer covered for certain diagnoses. CPT 20550 is used for fewer diagnoses today than when started in 1984. 


I can't say that I disagree with Dr. Amarantos, but they can't be the ones to arbitrarily decide what is covered and what isn't covered without any input from the professions. Maybe they decide not to cover a fractured toe because...


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



From: George Jacobson, DPM


If indeed there is a new interpretation of RFC, it should have been in a bulletin. The response to this post needs to be stronger. The State associations affected need an experienced healthcare attorney to attack this situation. Although an individual should seek competent advice as well, it may be too costly on an individual basis. Many years ago, Florida fought an RFC issue and won. We do not know the particulars here and whether it is widespread. This sounds like an important survey question see if it is a limited or extensive problem. If they get away with this in one region, we'll see it spreading to other regions.  


George Jacobson, DPM, Hollywood, FL



From: Gregory T. Amarantos, DPM


Why worry about it? Now you can charge the patient whatever fee you feel you deserve. No more audits, "Q" modifiers, or "Meaningless Use." The sooner our profession realizes we are chasing decreasing reimbursements, the better. When you provide quality care, the patient will value your services and pay you accordingly. Presently, how many patients come to us because Medicare pays? When is the last time a patient said thank you for the routine care you provided?  


Instead, when you tell the patient the service is not covered, the response is "well, the Dr. Foot doctor down the street always charged Medicare, and I never had to pay", and they walk down the street for the next visit. Let's  follow the dental profession; the staff provides the routine care and we walk in and say hello. My last dental cleaning was $234, which included a $71 fee for the dentist to say hello and "inspect" the cleaning and provide the "exam." Follow the new rules, provide quality care to your patients, and enjoy the fruits of your labor with reduced stress. What a way to start the New Year!


Gregory T. Amarantos, DPM, Chicago, IL 



Query: Are They Now Excluding RFC Coverage?


As of December 1, we started getting rejections on all claims submitted to WPS Medicare for CPT 11721 (nail care) on patients who fully meet Medicare guidelines for this service. The rejected claims state that this is "not a covered service." Furthermore, they started a take-back of all money they paid on claims for this code going back to October 1, 2015. In addition to this, we're also starting to get rejections from all other insurances on this, too (with-take backs) as they claim they are following Medicare guidelines on this. 


My staff has had numerous conversations with people at WPS Medicare since the beginning of this month when this started and the bottom line seems to be that "Any nail care/routine foot care is a non-covered service" with no exceptions. I am not aware of any notification regarding this change from Medicare. Did Medicare make a new ruling regarding this recently? Are others experiencing this problem? Is there something we are missing that now needs to be added on to the claims with ICD-10? 


Tom Silver, DPM, Golden Valley, MN


Response: With the institution of ICD-10, many payers have taken the opportunity to change policies, although we were promised they would not. WPS and NGS have made the greatest changes we have seen, with some at Novitas too. 


I would make sure to download and review the latest version of your LCD. You may want to also contact the CAC rep in your area and ask for some advice, updates, and assistance. 


Mike King, DPM, Fall River, MA 



Query: Medicare Therapeutic Shoe Denials


We have submitted claims for diabetic shoes using the diagnosis code, E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified), and it has been denied twice with remark saying "diagnosis codes incorrect." Can anyone shed light on this? 


Bonnie Vader, DPM, Brooklyn, NY


Response: I would not use ICD-10 E11.40 since it is an "unspecified code", but rather use ICD-10 codes: E11.42 (Type 2 diabetes mellitus with diabetic polyneuropathy),  or E11.49 (Type 2 diabetes mellitus with other diabetic neurological complication), or E08.49 (diabetes mellitus due to underlying condition with other diabetic neurological complication). 


Also check the DME MAC LCD on the Diabetic Thereapeutic Shoe Policy for further information on the diagnoses that can be used for New York State. 


Joseph Borreggine, DPM, Charleston, IL 



Query: Codes for Foreign Body Removal


What is the difference between these foreign body removal codes:  CPT 10120 (incision and removal of foreign body, subcutaneous tissues simple and CPT 28190 (removal of foreign body, foot)? Both codes refer to removal of foreign body, subcutaneous. 


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


Response: The best answer to your query on this topic is found from Supercoder "The difference between these codes is that 28190 specifically identifies the foot in the definition, while the more generic 10120 does not list a specific body site. However, 10120 does include the word incision in the definition. 


Do not use 10120 for the procedure presented because...(if the) physician did not make an incision...there are lingering questions about when to use 10120 and 28190. Code 28190 is obviously anatomically specific. However, some experts believe 28190 may be intended for operative procedures. The RVUs attributed to 28190 support this argument. Code 10120 has 2.43 RVUs while code 28190 has 4.90 RVUs. So, contrary to common sense, the code with more RVUs does not seem to require an incision. It is unlikely CPT intended to assign 4.90 to the simple procedure of pulling out a foreign body or splinter, but the language of the definition supports 28190 in this situation." 


Joseph Borreggine, DPM, Charleston, IL 



From: Matthew B. Richins, DPM


We are having the same problem and are also being told it is an excluded diagnosis. During the appeals process, I was told, "bunions and calluses are excluded." I found that an odd choice in wording and wonder if there is an internist on their board who does not know the difference. 


Matthew B. Richins, DPM, Joplin, MO