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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: Coding Severe Equinus Procedures


I need help with coding for a paralytic equinus procedure. I performed an Achilles tenotomy along with a posterior ankle capsulotomy/release along with a posterior subtalar joint/release. Any coding recommendations?


Jeffrey Klein, DPM, Waterford, MI


Response: I recommend one code which, I believe, is meant to cover these procedures. CPT 27612 arthrotomy, ankle, with posterior release, with or without Achilles lengthening.


Howard Zlotoff, DPM, Camp Hill, PA


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From: Paul Kesselman, DPM


Most important here is that state Medicaid plans are free to enforce their own rules regarding the need for Surety Bonding for DME Suppliers. Fortunately, physicians under Medicare were able at the Federal level to obtain an exclusion and do not require a Surety Bond under Medicare. That exclusion appears to not be in place in Texas. I urge you to contact your state component (TPMA) to:


1) Inquire if your state component as well as those representing MDs/DOs and orthotists/prosthetists are subject to the same exclusion rights we have under Medicare. Based on your scenario, shoes would not be the only exclusion. Acute care needs, such as CAM boots, crutches, surgical dressings, etc., would also be in the mix. The same rationale used for exclusion from Surety Bonding with Medicare at the Federal level should be invoked with your state Medicaid program. The state associations should contact their national associations for assistance.


2) Your state component should be able to provide you with guidance on whether you can charge a Medicaid patient for the payments they would otherwise be paying to a Medicaid provider. Each state has different rules on this.


Paul Kesselman, DPM, Woodside, NY



From: Cosimo Ricciardi, DPM


Recently there was a post by Dr. Blum about collecting cash from Medicaid beneficiaries. I have always thought that you cannot do this. If a patient has Medicaid and a physician doesn’t accept that Medicaid, that physician cannot bill the patient. 


I write this because I’m pretty sure it’s a federal statute and I don’t want my colleagues to think it’s okay to collect cash from Medicaid beneficiaries. I would also like to know if I am incorrect. Perhaps one of the more qualified billing experts can opine.


Cosimo Ricciardi, DPM, Ft. Walton Beach, FL



Query: Medicare/Medicaid Billing for Diabetic Shoes


My Medicaid DME supplier number recently came up for renewal. They are asking for a surety bond, and I’ve been quoted $1000 for the bond. Based upon demographics, it’s not worth it. So as it is right now, Medicaid will not process any of my DME claims unless I renew. So here’s the question: Let’s say I choose NOT to renew, and a patient with Medicare primary, Medicaid secondary comes in and I want to prescribe diabetic footgear. Since I’m not going to be billing Medicaid for the 20%, is there any problem collecting that from the patient (collecting up-front of course)?


Paul L. Valenza, DPM, Kerrville, TX


Response: Not a problem. If the Medicaid information is on the claim to Medicare, Medicaid will not pay the 20% whether you are approved or not approved for DME. When you do this, please make sure the patient's Medicare deductible has been met.


Donald R Blum, DPM, JD, Dallas, TX


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From: Doug Richie, DPM


I have another follow-up question for Dr. Kesselman: It is assumed in this situation with Dr. Kaczander, that he, the podiatric physician, performs the initial evaluation of the patient, bills the E/M code and then refers this patient to the certified orthotist in that same office. If this certified orthotist does the casting, fitting, and adjustment of the AFO device, who bills Medicare for the L-code? Is is proper for the physician/employer of the certified orthotist to bill Medicare for the L-code when he/she never performed the casting, fitting, and adjustment? This practice is becoming more common in our profession and needs clarification.


Doug Richie, DPM, Seal Beach, CA


Response: It is impossible to provide one universal response which applies to all the possible scenarios posed by this follow-up question. The first part of the question implies the DPM is referring the patient to someone in the same office. Does the referral constitute a "hand off" to the other person to evaluate and treat that patient or is the DPM still involved in that aspect of the treatment? 


The second part of the question infers...


Editor's note: Dr. Kesselman's extended-length response can be read here



Query: Orthotist Hiring


Our practice recently hired a certified orthotist which has greatly benefited our patients. Is the orthotist allowed to bill an E/M CPT for his services under the attending physician‘s name? There is a physician present while he’s there but doesn’t always stop in to see the patient.


Bruce Kaczander, DPM, Southfield, MI


Response: Sorry, but the orthotists fee for the orthotic and prostheses includes the E/M code. Medicare does not allow CPOs, COs, or CPeds to bill E/M codes. This is often why non- Medicare carriers pay a higher fee for the non-physician providers.


Paul Kesselman, DPM, Woodside, NY


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Query: Billing for injection of Non-Covered Drug


Can I bill for an injection if the drug we are injecting is not covered by the insurance?


Tonia Silva, Office Manager for Alanna Wargula, DPM, Lakeport, CA


Response: Yes, you can. I would make it clear to the patient why you are using it, that it may be “off label” and why indicated. Make sure to document same as well. Most injections do not describe the product being injected, simply the technique, location, or reason for said injection.


CPT 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”)

CPT 20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (e.g., fingers, toes); without ultrasound guidance


These are some examples not displaying the product injected.


Michael King, DPM, Roswell, GA


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Query: Coding for Lapidus Bunionectomy with a Proximal Phalanx Osteotomy


A Lapidus bunionectomy procedure was performed with a proximal phalanx osteotomy of the same toe. There is an edit on these two codes, so I believe that they are not reimbursed separately unless they are performed on separate toes; however, the surgeon believes that the osteotomy should be reimbursed because it was not of the metatarsal, but of the proximal phalanx. Any insight?


Jessica Diaz, Billing Specialist, Bellevue, NE


Response: You can code for both of these procedures performed on the same ray of the same foot at the same encounter. There are two combination options:

#1 CPT 28297 for the bunionectomy and the met-cuneiform fusion (Lapidus), and CPT 28310 for the phalangeal osteotomy; or

#2 CPT 28298 for the bunionectomy and the phalangeal osteotomy, and CPT 28740 for the met-cuneiform joint fusion.


I believe either of these two combinations would be correct for coding for the procedures you described. Of these two options, I suggest the combination of CPT 29298 + CPT 28740.


Jeffrey D Lehrman, DPM, Springfield, PA


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Query: Diplaced Tibia Fracture


My patient fractured her anterior malleolus of tibia (displaced & closed). I can only find codes for medial and lateral. The doctor is telling me that it is anterior. What code would you use for this?


Angela Knowles, Billing for Robert Taylor, DPM, Frisco, TX


Response: I suspect that there is a little miscommunication in this situation. Trauma is the primary focus of my practice and I have never heard the term “anterior malleous” of the tibia. I suspect that the doctor might be referring to a pilon fracture. I recommend confirming that as it directly affects the coding.


Jon Goldsmith, DPM, Omaha, NE


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Query: Weil Osteotomy and Capsulotomy with Tenorrhaphy


I billed a Weil osteotomy with capsulotomy and with tenorrahphy for a 2nd metatarsophalangeal joint. The osteotomy was paid for, but the capsulotomy and tennorhaphy were not. (Codes 28308 and 28270) Any suggestions as to why?


Robert Taylor, DPM, Frisco, TX


Response: When the CCI edits are checked for CPT 28308 and CPT 28270, the procedures are not bundled together. Theoretically, both procedures should be paid by using the appropriate modifier, that modifier being -59. Then why was CPT 28308 paid, but CPT 28270 not paid?


When a lesser metatarsal osteotomy (i.e. Weil osteotomy) is performed, in order to gain access to the surgical site, a capsulotomy of the respective metatarsophalangeal joint needs to be performed. Since the capsulotomy is an integral part of the surgical procedure (CPT 28308: Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each), the capsulotomy (28270: Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint [separate procedure]) is not separately payable.


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


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From: John Moglia, DPM


I am attempting to follow CMS guidelines for avoiding penalties in the future. Has anyone come up with a simple worksheet to include in the patient record of the Practice Improvement Activities relevant to podiatrists to avoid the penalty as per Dr. Brody’s advice for Non-EHR practices.


I can’t find any sensible coherent guidelines on the CMS website. I would gladly pay Codingline or any other consultant if they provide this advice.


John Moglia, DPM, Berkeley Hts, NJ



From: Tip Sullivan, DPM


I would like to point out the obvious. One sure way to avoid the government MIPS program penalty is to choose not to participate! There are some successful practices out there that have taken that line. I would encourage some to try it--especially those close to retirement.


Tip Sullivan, DPM, Jackson, MS



Query: MIPS 2020 Avoiding the 5% Negative Adjustment 


How can a practice that does not utilize an EMR obtain 15 MIPS points and avoid a negative adjustment in 2020?


Ira Cohen, DPM, Downey, CA


Response: The easiest way for a practice that does not have an EHR to obtain 15 points is to fully participate in Practice Improvement Activities which is worth 15 points. You do not need  an EHR to do this and you can report this via attestation which is free through the CMS website.


There are many ways to meet Practice Improvement Activities and many are not very difficult.


Michael L. Brody DPM, Commack, NY


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Query: ABN Requirements


I need clarification on ABN requirements. I understand that Medicare does not require an ABN for non-covered services BUT I need additional clarification about the frequency of ABNs for services that are potentially covered. For instance, with a diabetic, high-risk foot care patient, if they come in consistently every 5 weeks (maybe because their calluses require debridement more often than the 61 days), do we have to have an ABN signed every other time they come in for the service (obviously not the time Medicare does cover) OR can we just have them sign an ABN annually?


Daniel C Albertson, APRN, Bluegrass Regional Foot and Ankle Associates


Response: An ABN needs to be filled out every time you perform a service that you feel will not be covered by medicare. Keep in mind that the routine foot care 60-day rule is an edit, not a global issue, so technically an ABN would not be required but it is a good idea to fill one out anyway.


Tony Poggio, DPM, Alameda, CA


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Query: Dorsal Exostectomy


I have a patient with spurring on the dorsal midfoot area. I will not be fusing it. I am first trying to remove the spurring (exostectomy) at the tarsal-metatarsal joint area. What code should I use?


Doan Trinh Pham, DPM, Tracy, CA


Response: The most appropriate CPT code to use for a procedure that is performed to “remove the spurring (exostectomy) at the tarsal-metatarsal joint area” is: CPT 28122: Partial excision (craterization, saucerization, sequestrectomy or diaphysectomy) bone (eg. osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus.


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


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Query: Modified McBride Coding


I am doing modified McBride procedures where I am removing the medial 1st met head,  performing both a capsulotomy and lateral release. What code should I use for surgery?


Doan Trinh Pham, DPM, Tracy, CA


Response: I would use CPT code 28292: Correction, hallux valgus (bunionectomy), with sesamoidectomy,when performed; with resection of proximal phalanx base, when performed, any method.


Please review this excellent article from Podiatry Management Jan 2017 for all the new coding changes in 2017 for bunionectomies: 


Joseph Borreggine, DPM, Charleston, IL


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Query: E/M During Global


Can we bill an E/M code during the post-op period for an open 1st ray amputation when a debridement is not performed? This high-risk patient is being seen weekly for 4 months at the wound center and the wound treatment changes periodically.


Judy Outsa, DPM, Louisville, KY


Response: The amputation codes carry a 90-day global. That applies to related procedures and E/M services. This will also vary between payers as to what is considered included in the global allowance or not. Your documentation must clearly state that the E/M service is not related, although from your post, it does.


Tony Poggio, DPM, Alameda, CA


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Query: Post Surgical ICD-10 Question


If you have a post-surgical incision that dehisces, what is the ICD-10 code to use? I dispensed a tall CAM boot at this visit, since I could not put a cast on. I’m not sure what code to use for that as well.


Jennifer Swan, DPM, Westerville, OH


Response: There are various ways to report dehiscence. These two are the most specific:


T81.31-  (dehiscence of surgical site, skin/subcutaneous tissue)

T81.32-  (dehiscence (internal structures) of surgical site)


Requires a 7th characters for either.


The CAM walking boot is outside of the global consideration and not impacted by global reductions in cost.  The HCPCS codes that can be billed (typically) for include:


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)

L4361 (walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf)


Mike King, DPM, Roswell, GA


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Query: Medicare-Approved Anticoagulants


We are trying to find a list of Medicare-approved anticoagulants that qualify for routine foot care. If anyone can assist, it will help our new medical assistant in documentation.


Marc Colaluce, DPM, St. Petersburg, FL


Response: Your Florida Routine Foot Care LCD says: “For patients requiring anticoagulation therapy, the provider must document in the medical record the significant risk and danger posed by the non-professional rendering routine foot care services.”


And the only relevant codes I could find in your LCD are:

D68.8   Other specified coagulation defects

D68.9   Coagulation defect, unspecified


I do not see any list of anticoagulants listed. I think it just has to be an anticoagulation agent.


Jeffrey D Lehrman, DPM, Springfield, PA


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Query: Pneumatic CAM Boot Post-Lapidus


How do I appropriately code dispensing a pneumatic CAM walking boot to be worn post-surgery? I am not sure what ICD-10 codes to use post-operatively? Do I apply the same codes used for the surgery?


Jennifer Swan, DPM, Westerville, OH


Response: A pneumatic CAM walking boot is coded as either L4360 or L4361, depending on which you dispensed and the medical necessity.


The difference in the two is how much adjustment or modification needs to be done to the boot. L4360 implies modifications (i.e., “trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise”) to the boot. I can tell you that on Medicare audits, the denial rate for L4360 is significantly higher than for L4361.


I would use the ICD-10 codes that reflect what the patient has post-surgery that requires the use of a pneumatic walking boot.


Tony Poggio, DPM, Alameda, CA


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Query: Shortening of Foot Extensor Tendons


I am searching for a CPT code for the shortening of the extensor hallucis longus and extensor hallucis brevis tendons. I have found a code for “leg/ankle”, but not for the foot. Any suggestions?


Alanna Wargula, DPM, Lakeport, CA


Response: I don’t think a code exists for this. The closest thing I could find was CPT 28226 (tenolysis, extensor, foot; multiple tendons). However, tenolysis is release of a tendon from adhesions, so I don’t think that is appropriate if the procedure was a tendon shortening. If the only procedures done were shortening of the tendons, unless I am missing something, I think you are stuck with CPT 28899 (unlisted procedure, foot or toes) and submitting the required additional information along with it.


If you go this route, I suggest sending along with the claim the op report, a narrative description of what you did, and a CPT code whose work value is similar to the work you performed in your procedure.


Jeffrey D Lehrman, DPM, Springfield, PA


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Query: Lesser Metatarsal Joint Implant


One of our doctors performed outpatient surgery on a patient for two procedures. One was CPT 28299 (bunionectomy with double osteotomy) for M20.12 (hallux valgus [acquired], left foot).  The other was a lesser metatarsal joint implant for M19.172 (post-traumatic osteoarthritis, left ankle and foot). The code we are thinking of using for the lesser metatarsal implant procedure is CPT 28899 (unlisted foot/toe procedure).  Are there any better choices?


Office of Mary Gail Kwiecinki, DPM, Libertyville, IL


Response: Unfortunately, there is not a CPT code that describes placing an implant into a lesser metatarsophalangeal joint to correct a situation such as M19.172 (post-traumatic osteoarthritis, left ankle and foot). It would probably be best to use CPT 28899 (unlisted procedure, foot or toes). I recommend submitting the claim hard copy on a CMS-1500 claim form accompanied by the operative report which accurately describes the procedure that was performed. I also believe that it would be in one’s best interest to pre-certify the procedure with the insurance carrier to make sure that the procedure being performed is not classified as “experimental” or categorized in some fashion that would pre-empt reimbursement.


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


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RE: Modifier for CR Imaging (Jeffrey D Lehrman, DPM)

From: David J. Freedman, DPM, Michael Tritto, DPM


Dr. Lehrman’s post was not completely correct. Here is an update. I contacted Novitas to see what was the best recommended billing for the FY modifier. While you can break the billing down into the PC/26 option, as Jeff related for x-rays with CR imaging, they recommended straight one line billing. The example for a podiatrist to bill for an x-ray with CR imaging is: 73630-RT-FY.


David J. Freedman, DPM, Silver Spring, MD


I would like to add a comment about billing for x-rays with the FY modifier. Most of us bill x-rays globally, meaning we bill on one line. This indicates we are billing for both the technical component (TC) and the professional component (PC). The CMS guidance to carriers, as well as the information our group has received from our carrier Novitas, confirms that we can continue to bill on one line (globally) and just add the FY modifier. The carrier will reduce the fee by 7% of ONLY the TC part, not the entire value of the code. They are required to do this for globally billed codes per CMS. While billing on two lines and breaking out the TC and PC will likely still be paid, it is unnecessary.


Michael Tritto, DPM, Rockville, MD 



Query: Modifier for CR Imaging


Since our office is still using a CR imaging system, what is the appropriate modifier we are to bill with to Medicare? The “FX” modifier seems to apply to film x-ray. Also, based on what I have read so far, the penalty is only on the technical component. Since we normally bill for both the technical and professional components (all in one, no modifiers except for the “RT” and “LT”), do we now need to break down charge and bill separately for the technical and professional components with “TC” and “PC” modifiers?


Coleen Merrill, Office Administrator, Office of Evan Merrill, DPM, Medford, OR


Response: CMS now requires appending the “FY” modifier to claims for the technical component of a digital x-ray that employs a CR-specific cassette (utilizing an imaging plate to create the image) in place of a traditional film cassette. This “FY” modifier will result in a 7 percent reduction to the technical component (and the technical component of the global fee). This reduction is expected to last until 2023, when the reduction is slated to increase to 10 percent.


I suggest “breaking it down” as you described with the same code on two lines, one with a “26” (not a “PC”) professional component modifier (assuming those requirements are met) and the other with both “TC” and “FY” modifiers.


Jeffrey D Lehrman, DPM, Springfield, PA


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Query: CPT 64450 + ICD-10 G57.3- Denials


CPT 64450 (injection, anesthetic agent; other peripheral nerve or branch) when billed with ICD-10 G57.31 or G57.32 (lesion of lateral popliteal nerve, right lower limb or left lower limb, respectively) is now (as of October 1) being denied by Blue Cross Blue Shield and Medicare (Novitas) as “investigational and not medically necessary”. The only LCD I was able to locate is L35107 which has been superseded or retired. I am not finding an active LCD. Is anyone getting this paid? What am I doing wrong?


Emilie Arambula, CPC, Colorado Springs, CO


Response: In Colorado, your MAC is Novitas. They just retired the LCD for “Pain Management of Peripheral Nerves by Injection” (L35107) on December 1, 2017.  CPT 64450 is included in that retired LCD.


When an LCD is retired, it does not automatically mean that CPT codes discussed in that LCD will no longer be payed. However, in this case, based on what we have been hearing, the retirement of Novitas LCD, L35107, has coincided with denial of payment for CPT 64450 and CPT 64455.


Jeffrey D Lehrman, DPM, Springfield, PA


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