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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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08/30/2014    

CODINGLINE CORNER


Query: E/M Bullet Points for Exam


 


When counting the bullet points for an exam to determine what office visit level to code, does each limb count as a bullet point? I'm being told by my billing office that the only time that bilateral counts is for the musculoskeletal. So, a vascular palpation of DP/PT pulses either on one or both feet counts as only one bullet. Is this correct? Can someone lead me to the place to read the exact definition? 


 


Theresa Hughes, DPM, Galesburg, IL


 


Response: Your billing office is correct. You'll want to look at the musculoskeletal exam in the 1997 E/M guidelines. They can be found starting on page 32 of this pdf file


 


Joan Gilhooly, CPC, CPCO, Lebanon, OH 


 



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08/27/2014    

CODINGLINE CORNER


Query; Help Coding Neuroma Injections 


 


I would appreciate help with how to get paid for injections of more than one neuroma administered on each foot. Currently, most insurance plans are only allowing for payment for one of the two injections that I give. For example, if I place cortisone injections in the left foot 2nd and 3rd intermetatarsal spaces, they are only paying for one injection (CPT 64455), saying that the other injection is included with that payment. This is also happening with sclerosing injections (CPT 64632). 


 


Danny Albertson, APRN, London, KY 


 


Response: The answer to this question is in the definition of the steroid neuroma injection code(s). It states injection(s) meaning one or more in the same foot. The terminology was a concession that was made when the neuroma injection codes were developed at CPT. Injection of the second foot would be allowed, but will be subject to the multiple procedure discount. 


 


Phill Ward, DPM, APMA CPT Advisor, Durham, NC


 



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08/23/2014    

CODINGLINE CORNER


Query: Which Takes the *-59* Modifier


 


When billing CPT 11719, CPT 11721 and CPT 11056 together, which one gets the "-59" modifier? 


 


Robert Bello, DPM, Garden City, NY 


 


Response: You are not allowed to bill CPT 11719 and CPT 11721 on the same day on the same patient. 


 


When billing CPT 11721 and CPT 11056, assuming that all of the requirements for routine foot care have been met, the "-59" modifier would be appended to the CPT 11721. 


 


Robert Weatherford, CPC, Jacksonville, FL


 



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08/20/2014    

CODINGLINE CORNER


Query: Bandages Dispensed During Visit


 


I have a Medicare patient who qualifies for bandages, according to the Florida LCD, and does not have home healthcare. So, I am dispensing those bandages while the patient is in the office. So if I bill for a debridement in the office, can I bill for bandages with POS 12 for home use on the same day as the debridement (POS 11)? The bandages will be used by the patient the next day at home. 


 


Marc Katz, DPM, Tampa, FL 


 


Response: You will need to look at the carrier's LCD on surgical dressings to see if the wound itself qualifies for a surgical dressing, which type of dressing, and how many dressings you may dispense per month. If the patient is not on Medicare, surgical dressing coverage may be carved out to a third-party DME commercial supplier. In addition, you need to see if the patient otherwise qualifies. If they are on VNS services and/or receiving home healthcare from Medicare, you would not be reimbursed by Medicare (or possibly even other third-party payers). 


 


Paul Kesselman, DPM, Woodside, NY 


 



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08/16/2014    

CODINGLINE CORNER


Query: E/M Code with CPT 11721


 


I was wondering how significantly separate an E/M should be to bill it in addition to CPT 11721. My provider always performs a foot exam on a patient who receives nail debridement services which is understandable because most of the time the "Q" modifier needs to be met. The provider does not bill for this exam separately. 


 


However, my question pertains to when the patient arrives for nail debridement services, and during this routine foot exam is found to have tinea pedis in between the toes (for example). The doctor will usually prescribe a cream and bill an E/M for this service. I am conflicted with billing the separate E/M because my provider always performs the same foot exam, and the only thing different is giving a prescription for the patient's tinea pedis. Any thoughts or opinions? 


 


Hollie Gunderson, CPC, CSFAC, Holland, MI


 


Response: The "at risk" foot exam you refer to that is performed with each nail debridement service is not a separately identifiable E/M service. 


 


However, the situation you describe with tinea pedis is separately identifiable from the nail debridement procedure if it meets the standards for an E/M, taking into consideration the need for 2 of the 3 three key components (for an established patient): history, exam, and decision-making. Certainly, those criteria are met in taking the medical/problem history, examining the feet, and diagnosing/managing the tinea pedis. This service should be separately identifiable from the nail debridement. I would code the appropriate level E/M with a "-25" modifier. 


 


Jeffrey Lehrman, DPM, Springfield, PA


 



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08/14/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Steven J. Kaniadakis, DPM


 


In a response to Dr. Andrew Resler's post, it was for this reason that I invented a specially designed electronic super-bill, which helps solves this and other problems. The priority (ICD) diagnosis is one that only the treating provider knows should be used with the product or service provided. It should not be a billing/coding person who makes the primary diagnosis. A problem with current electronic superbills, as well as old paper ones, includes that they do not all offer methods to match CPT and/or HCPCs with ICD code numbers and descriptions.


 


The super-bill enables the treating provider to actually place the ICDs in a priority sequence, so the (primary position) first one listed takes priority, and it is adjacent to the CPT/HCPCS code rendered and/or dispensed. Secondary, tertiary, and other diagnosis codes are taken into consideration by others. Medicare only looks at the first one listed. Often billers and coders, even experts, only look at the first ICD with a given CPT/HCPCS code. So, it is a very prime position which deserves attention by the treating provider.


 


Steven J. Kaniadakis, DPM, St. Petersburg, FL

08/13/2014    

CODINGLINE CORNER


Query: What Diagnosis Goes First? 


 


For routine foot care in New York, what comes first in the order of the diagnosis codes when you are billing for diabetes WITH a qualifying condition: the diabetes code (ICD-9 250.6_ or ICD-9 250.7_), the nail code (ICD-9 110.1) or the hyperkeratosis code (ICD-9 701.1)?  Of course, we know that the date the patient last saw their treating physician must be included. The reason I ask is that I used to always bill the diabetes code first, then started getting rejections about 3-5 years ago and was told the diabetes code goes last. Now I have ONE patient that Medicare will not pay on stating that the diabetes code must come first and this happened on this ONE patient for 2 claims. All other patients have been paid using diabetes diagnosis last! 


 


Andrew Resler, DPM, New Windsor, NY


 


Response: I have never seen a health plan require a supporting diagnosis be listed first on a CPT/HCPCS that is being billed. I recommend going back to the claim and look at the remark codes to see if there is a different reason for the denial. Logically, you list the REASON first for the CPT you are billing, and the supporting reason next. Hence, if you are trimming/debriding nails - say WHY they need the trimming/debriding *first* - then the required supporting diagnosis (systemic disease). And, of course there are qualifying modifiers. 


 


Karen Hurley, CMM, CPC, Lakewood Ranch, FL 


 



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08/09/2014    

CODINGLINE CORNER


Query: Refunding an Overcharge for a Deceased Patient


 


We have a married couple who were both patients here at our office. The wife has since died, but her husband is still a patient. The wife is due a refund from a copay that was overpaid. The patient's husband stated there is no estate and he is not the power of attorney for his wife. Is it legal to make the check out to the husband's name and/or transfer the refund the husband's account? 


 


Dawn Dryden, DPM, Batavia, NY


 


Response: PM News does not provide legal advice.  In New York, if there is a Will, it must be probated, likely giving the husband the power to pay debts and receive an income due her. If there is no Will, the estate will go the husband. If the decedant had less than $30,000 in personal property, the husband can file a simple small estate affidavit, which would allow him to collect this sum from you. 


 



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08/06/2014    

CODINGLINE CORNER


Query: Referring Provider on Claim Form


 


I have just started having problems with foot x-ray rejections for the referring provider. When I bill for an x-ray, I put our doctor in the ordering physician field and never enter a physician in the referring provider area. Medicare (Michigan) states that Item #17 and 17B for referring provider name and NPI are missing. I have tried to put our doctor in that box, but then I get a rejection, "The referring provider is not eligible to refer the service billed." The front desk will usually put a referring physician (family doctor) name, but this is not done on all patients. 


 


My question is...which physician name goes in the referring doctor box - our physician or the patient's family physician? Is this a new requirement? All of a sudden these rejections are popping up. 


 


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


 


Response: Item 17/17B is the box that is used for either ordering or referring. The only other two boxes on the claim form that take the provider name/NPI (boxes 24J and 31) are both for the physician who PERFORMED the x-ray study! My guess is that the problem you're running into is the requirement with the new 1500 claim form (the new 5010 standard that was required effective 4/1/14) that you're not adding the correct 2 digit "qualifier" in the designed space in Item 17. 


 


Since a doctor ordering an x-ray on his own patient is an ORDERING physician (not a referring physician), the 2 digit qualifier that should be added to the ordering physician's name/NPI number in Item 17 is "DK." Try the above changes and see if it helps to get your denial issue resolved. 


 


Joan Gilhooly, CPC, CPCO, Lebanon, OH 


 



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08/02/2014    

CODINGLINE CORNER


Query: Tenotomy and Capsulotomy Coding


 


I performed an extensor tenotomy and dorsal metatarsal-phalangeal joint (MPJ) capsulotomy along with a flexor tenotomy and proximal interphalangeal joint (PIPJ) plantar capsulotomy through a minimal incision with one suture closure for each wound. What would the appropriate coding be? 


 


In the past, I have been billing CPT 28011 for the percutaneous flexor tenotomy and percutaneous extensor tenotomy. I was wondering if CPT 28270 (capsulotomy MPJ) or CPT 28272 (capsulotomy PIPJ) would be appropriate? 


 


Ron Werter, DPM, New York, NY


 


Response: In each incision, you are performing both a tenotomy and a capsulotomy with one incision. I agree with you that you should only bill one of those two things for each incision. An argument could be made against this because there are no CCI edits that exist between these codes, but I still think the right thing to do is pick one or the other as both procedures are being performed through one simple incision. 


 


I think it would be fine to use the capsulotomy codes instead as you suggest. They have mostly higher RVUs than the tenotomy code. If you are using CPT 28011 instead of CPT 28010, be sure you are cutting multiple tendons and documenting appropriately. 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 



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08/01/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Simon Young, DPM


 


With all due respect to Dr. Albert, at least Dr. Root did initiate independent research and studies. I don't know if through evolution that the biomechanics and foot function have changed that much. The medical community no longer acknowledges theories or anecdotal thoughts, but valid studies. My experiences with residents, sad to say, is they have very little interest in biomechanics or implementing biomechanical principles for conservative or surgical treatments. Oftentimes, the biomechanical thought processes, even in prescribing shoes, is relegated to the orthotist. The resident's sole interest, sad to say, seems to be surgery. 


 


Believe me, I would be more than happy to be proven wrong. The only thing that distinguishes podiatrists from other professions is their extensive knowledge of...


 


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

07/31/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Steven L Goldman, DPM, MBA


 


While I do not wish to escalate nor inflame this matter any further, I would like to comment on the post between Dr. Ribotsky and Dr. Albert. Firstly, the question posed by Dr. Ribotsky was framed as a question that makes assumptions and treats them as fact. Secondly, I would have assumed if a question related to the ABPM exam process and content would be asked, it would be directed to the Chairperson of the exam committee, or at the very least, to someone ON the examination construction committee. The simple fact is that the content and relevance of the examinations generated and administered by ABPM are constantly updated by the committees who produce them.  


 


Steven Goldman, DPM, MBA, Chairperson, ABPM Certification Examination Committee, SteveGoldman@att.net

07/29/2014    

CODINGLINE CORNER


Query: Unna Boot and Edema


 


A patient comes into the office for ulcer debridement and is noted to have associated pitting edema. When billing ulcer debridement, can you also bill for application of a compression Unna boot? Also, what diagnostic code would be used? 


 


Craig Sapenoff, DPM, West Palm Beach, FL 


 


Response: There is an applicable NCCI edit between ulcer debridements (CPT 1104x) and an Unna boot application (CPT 29580). The ulcer debridement is a column 1 code, while the Unna boot is a column 2 code. And, there is a '1' indicator. 


 


What that means is that: (a) the Unna boot cannot be used on the same foot/leg as the ulceration debridement; and (2) if you apply the Unna boot to the other foot/leg, a "-59" modifier (distinct procedural serve) would be appended to the Unna boot application code, CPT 29580. 


 


Paul Kinberg, DPM, Dallas, TX 


 



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07/28/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A



From: Art Hatfield, DPM


 


The question is: will other doctors in the group want to write for narcotics of your patients. I wouldn't. If anything goes wrong and there is legal action, they will also be named. Besides, I don't think the fee for the DEA license will be any less if you don't include the narcotics schedule.


 


Art Hatfield, DPM, Long Beach, CA, afootjob@juno.com

07/28/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B



From: Richard Boone, Sr., Esq.


 


Although I rarely disagree with the counsel of the Learned Editor, I must respectfully submit that the statement that "any doctor in the group could write a prescription for your patient as long as he/she either examined the patient or reviewed the patient's chart" may not be completely accurate for every state in the union. 


 


In some states, for instance, the laws governing prescriptions specify that the prescription "may be issued only to persons or animals with whom the practitioner has a bona fide practitioner-patient relationship." Code of Virginia, 1950, § 54.1-3303. A "bona fide practitioner-patient relationship means that the practitioner shall (i) ensure that a medical or drug history is obtained; (ii) provide information to the patient about the benefits and risks of the drug being prescribed; (iii) perform or have performed an appropriate examination of the patient, ... [which] shall have been performed by the practitioner himself ... or by a consulting practitioner prior to issuing a prescription; and (iv) initiate additional interventions and follow-up care, if necessary, especially if a prescribed drug may have serious side effects."  Id. 


 


Whether a bona-fide relationship exists can be a tricky question, especially if it's being answered by a jury. It's probably safer, in the long run, to write one's own prescriptions and orders.


 


Richard W. Boone, Sr., Esq., Fairfax, VA, RWBoone@aol.com

07/26/2014    

CODINGLINE CORNER


Query: Narcotic Prescription Written by Another Group Doctor


 


I have recently joined a mid-sized podiatry group. I have also changed my scope of practice and no longer do osseous surgery. As a result there are very few times when I need to write for narcotics. I would like to drop my narcotics license. 


 


Would I be able to have one of my associates write the script on my patient? Would he/she incur any liability? What type of documentation would be appropriate? 


 


Michael Forman, DPM, Cleveland, OH


 


Response: PM News does not provide legal advice. Since you are a member of a group practice, any doctor in the group could write a prescription for your patient as long as he/she either examined the patient or reviewed the patient's chart. This would need to be documented in the patient's chart. Any doctor who writes a prescription for any patient incurs liability for that act. 


 


Barry Block, DPM, Forest Hills, NY


 



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07/25/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B



From: Michael Forman, DPM


 


Dr. Ron Freireich asked about the cloning of notes. I agree with him. Things are what they are. If you describe a condition and it is the same, why not use the same words? The same holds true for the past medical history.  Unless something happened from the time you last asked, the past medical history is going to be the same. We have not yet perfected time travel. If you provide the same treatment, the note is going to be the same. 


 


On the other hand, if there is a change, we are obligated to note that change. I still remember Dr. Gerard Yu's comment about some of the charts he saw in our teaching clinic. A note may start, "This 38 year old male..."  and then forever this man remained 38 years old.


 


CMS is making us run scared regarding cloned notes. Again, if things are the same, why would you want to change a few words just to make the note different?


 


Michael Forman, DPM, Cleveland, OH, im4man@aol.com

07/25/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A



From: Tony Alosco, DPM


 


Do internists treat hypertension, diabetis, and arthritis with medications or just maintain the condition!?


  


Tony Alosco, DPM, Guttenberg, NJ, tonyfoot@netzero.com 


 


Editor's comment: Yes, prescribing medication is treating a condition. There is a significant difference between treating and curing.

07/24/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Ron Freireich, DPM


 


If we see a patient for a mycotic nail care visit and then see them two months later for the same chief complaint, how different can one's progress note be?  Why are we taking something so simple and making it so complicated? 


 


Ron Freireich, DPM  Cleveland, OH, rafdpm@sbcglobal.net


 


Editor's comment: PM News does not provide legal advice. Most insurance companies pay providers to treat conditions, not to maintain them. If a patient presents with mycotic nails every two months and all you do is debride them, the question arises as to the approriateness of treatment. Has the patient been given the option of an oral antifungal? Has the patient been prescribed or dispensed a topical antifungal? Is the condition improving, getting worse, or staying the same? Has the patient been educated on the importance of pedal hygiene or the availability of UV antifungal shoe sanitizers? Any technician could debride mycotic toenails, but as podiatric physicians, we have the responsibility to treat onychomycosis. While a cure is not usually feasible, treatment options are.  

07/23/2014    

CODINGLINE CORNER


Query: Macro Audit Question


 


Our office conducts routine internal audits of our providers' chart notes. Since transitioning to EMR, the doctors have been able to create "macros" for routine nail care treatment. When a patient presents to the office for nail care, most times the diagnosis and treatment are the same. If the doctors' chart notes are almost identical from visit to visit, would that be a problem from an external auditing standpoint? 


 


Kelly Bruce, Kingston, NY


 


Response: The key word is "almost identical." Auditors now use computerized software programs to detect macros; thus identical notes on many charts are likely to trigger an audit. A macro is acceptable to use as a starting point, but should be modified to reflect even small variations that each individual patient exhibits. If not, the implication is that you simply used an old-fashioned rubber stamp to write your chart.


 


Barry Block, DPM, JD, Forest Hills, NY   


 



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07/19/2014    

CODINGLINE CORNER


Query: Home Health Care Questions


 


The home health care agency told us that G0180 could be billed for setting up home health care for dressing changes, physical therapy, and skilled nursing. We would like to know what has to be done to legitimately bill this code? Also, what needs to be documented if, in fact, podiatrists might also bill this code? 


 


Leslie B., Office of Charles Perry, DPM, Cambridge, OH


 


Response: The home health certification codes are certainly a legitimate set of codes and revenue. The forms the home health care agency (HHA) sends you should contain the relevant information needed to care for the patient. Certainly, you should corroborate this information and be sure this is reflected in your progress notes. 


 


G0179 is a Home Health Care Certification for a patient you had previously certified. 


G0180 is a Home Home Health Care Certification for a patient's initial certification. 


Any legitimate diagnosis code which is appropriate to the patient's health issue is appropriate. 


 


Note that if another physician (MD/DO/DPM) has already filed a certification for this patient and period of time, you will not be paid. 


 


Paul Kesselman, DPM, Woodside, NY 


 



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07/16/2014    

CODINGLINE CORNER


Query: Diabetic Shoes - Date of Service?


 


What date of service do I need to use when billing DMERC Region B- Michigan for diabetic shoes? Should I use the day the patient was cast or the day the shoes were dispensed? The paperwork is sent to the patient's physician treating the patient for diabetes (certifying physician). That paperwork is dated for the day we cast the patient for the shoes. Previously, DMERC told me the date on the paperwork to the physician should match the date of service. If I use the dispense date, then it won't match. Which is correct? 


 


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


 


Response: All DME, not just diabetic shoes, to all carriers (not just Medicare DME carriers) must be billed on the date the item (in this case the shoes and insoles) are dispensed to the patient. The only other dates you must worry about is that the shoes and insoles are dispensed within 6 months of the time the treating physician's note was written stating the patient needed the diabetic extra depth shoes and insoles. You will also need to document an in-person visit with the patient's doctor to determine the proper shoes and insoles that are best to treat the patient. 


 


There is a check list for therapeutic shoes that comes from CGS (Region C DMAC) that will help you to fulfill all the diabetic shoe requirements. 


 


Paul Kinberg, DPM, Dallas, TX


 



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07/12/2014    

CODINGLINE CORNER


Query: Arthroplasty of Lesser MPJ


 


I have a patient who has damaged cartilage clinically on MRI of the 2nd metatarsal head. She has had exhaustive conservative treatment which has failed. The planned procedure, since she does not have spurring or joint narrowing, is opening the joint, removing damaged cartilage, subchondral drilling and infiltration with platelet rich plasma. Any ideas for coding? 


 


Maureen Crotty, DPM, Tulsa, OK


 


Response: I suggest CPT 28052 (arthrotomy with biopsy; metatarsophalangeal joint). You didn't describe the arthroplasty other than subchondral drilling of the metatarsal head. The drilling of the cartilage would be included in the overall joint procedure allowance. 


 


I suggest you pre-authorize the platelet rich plasma (PRP) injection (billed as 0232T - iInjection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed - or billed as an unlisted procedure, CPT 28899). Note that many payers still consider the use of PRP as investigational. 


 


Tony Poggio, DPM, Alameda, CA  


 



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07/09/2014    

CODINGLINE CORNER


Query: Arthroplasty of Lesser MPJ


 


I have a patient who has damaged cartilage clinically on MRI of the 2nd metatarsal head. She has had exhaustive conservative treatment which has failed. The planned procedure, since she does not have spurring or joint narrowing, is opening the joint, removing damaged cartilage, subchondral drilling and infiltration with platelet rich plasma. Any ideas for coding? 


 


Maureen Crotty, DPM, Tulsa, OK


 


Response: I suggest CPT 28052 (arthrotomy with biopsy; metatarsophalangeal joint). You didn't describe the arthroplasty other than subchondral drilling of the metatarsal head. The drilling of the cartilage would be included in the overall joint procedure allowance. I suggest that you pre-authorize the platelet rich plasma (PRP) injection (billed as 0232T - injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed - or billed as an unlisted procedure, CPT 28899). Note that many payers still consider use of PRP as investigational. 


 


Tony Poggio, DPM, Alameda, CA 


 



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07/08/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Carla-Ruth Poma


 


When coding because of additional time spent with a patient and father, in this case, the use of code 99354 would be appropriate. I agree, in this case, that CPT 99214 is not warranted. More appropriate would probably be CPT 99212 or 99213, depending on notes. Using these codes plus the addition of code CPT 99354 will increase the time allowance; therefore, the payment allowance and the provider will be able to meet the other criteria of the correct E/M procedure code.


 


Carla-Ruth Poma, Owner, Michigan Medical Billing Specialists, Inc., South Lyon, MI
AAPSM