08/22/2018 Kristin Happel
It's Time to Clean Up Our Act (Richard M. Hofacker, DPM)
Dr. Hofacker asks if the type of billing he saw
on his patient's invoice from another podiatry
office is the norm. No, it is not, at least not
with podiatrists I bill for in various parts of
the country. The Medicare allowed amount for a
11308 in Ohio is $190.97 when performed in an
office setting. Leaving aside whether or not
this was actually performed (I doubt it was, and
should have been billed in the 1105X range, if
at all), it would appear several things could be
at play here to result in this patient having
such an outrageous bill.
Without seeing the actual invoice, my guess is
one of two things(or both) is going on: 1. The
podiatrist she saw is not contracted with her
insurance company, and she has no out of network
benefits, so any dollar amount that is charged
is allowed, and put as patient responsibility.
Which means that this podiatry office does not
have a "normal" fee schedule in place.
Every fee schedule I have ever seen will
generally take the Medicare allowed amount, and
charge 130-200% above that amount and round up.
Some will take the highest allowed amount from
whatever insurance companies they deal with, and
round up. Thus, the 11308 should have been
billed at $250-$380.
2. There is some charge or several charges on
her invoice that were not allowed by her
insurance company, and she is being billed for
them (rightly or wrongly), at this not "normal"
fee schedule. Some of you may remember the
podiatrist from Wisconsin a few years back who
made the news for crazily over-billing his
patients. That didn't work out so well for him,
as his license was suspended. Billing like this
other office appears to be doing will eventually
get them in trouble, is my guess.
Here is what I suggest, and wish every
podiatrist would do: 1. Learn and understand
your MAC and other insurance carriers LCD's and
medical policies on the services you perform.
While not every code you bill has a LCD or
medical policy, many of them do, and you should
know them. Ask yourself right now: "Do I know
what my MAC's LCD is on RFC?" If the answer is
"No", you need to look it up and learn it.
2. If you don't have the time or inclination to
do the above, make sure your billing/coding
staff does, so they can educate you as
3. Set a fee schedule that is reasonable, and
within industry standards. If you choose to not
participate with insurances, and run a cash only
practice, again, be reasonable. If you are
charging $1000 for a cortisone injection, you
are out of line.
4. Purchase a Podiatry Coding Companion, such as
the one published by Optum, and actually read
it, or reference it when necessary. I have found
that these are far better and more educational
then any coding seminar I have ever attended.
Some of you may find codes in there that you
have been legitimately performing, but have not
been billing for, and you can increase your
revenue if you do.
5. Always remember that it is your signature
that is on an insurance claim, and that
regardless of whether you have a coding and/or
billing staff at your office, that you are
ultimately responsible for what gets billed out
on that claim, and for how much. While there is
no doubt that what insurance companies reimburse
providers for are not fair amounts, it does not
excuse a provider from rooking a patient with an
outrageous bill, but it does illuminate the
necessity of providers educating themselves on
proper coding/billing practices. With all the
potential changes coming for podiatrists in
regards to how they bill, knowledge is power.
Now is the time to get educated.
Kristin Happel, Podiatry Biller, Chicago, IL
Other messages in this thread:
08/22/2018 Ron Werter, DPM
RE: It's Time to Clean Up Our Act (Richard M. Hofacker, DPM)
RE: It's Time to Clean Up Our Act (Joseph
Borreggine, DPM) and Richard M. Hofacker, DPM
From: Ron Werter DPM
Dr. Hofacker's comments remind me of something
that a new patient's daughter related to me
recently. 92 y/o gentleman brought in by his
daughter came to me because they were outraged
with the billing of the previous doctor. She
received 2 checks from Anthem Insurance for the
one visit of the previous podiatrist of her
father totaling $1,550. She told me that she had
taken her father to other podiatrist for the
past 6 years for nails and corns.. On the last
visit to this other podiatrist, when dad was
called into the room as usual, she remained in
the waiting room. He returned to her after his
treatment 15 minutes later and said there's a
different doctor. She found that peculiar since
there was no notice that the other doctor had
left or retired.
The father has an insurance plan that pays both
in and out of network, out of net is 60/40. When
she called the doctor’s office about the
received checks she was told to just mail the
checks to him and not to worry about the co-pay.
She called and emailed the doctor’s office again
about this and was told by phone and email not
to worry because they would not be charged for
the co-pay. She received a copy of the total
bill the podiatrist submitted, from the
insurance totaling $2,400. She was still
outraged, called the insurance company and got
from the insurance company an itemization of the
He billed: 99204 IOV, 93923 non-invasive
vascular, 11755 nail unit biopsy, 97598 debride
skin and sub Q greater than 20 cm, 11721 mycotic
toenails, 11056 debride corns.
She asked me how could he have done all this in
15 minutes. I told her to request from the
doctor a copy of his chart notes, which she did,
She showed me the notes and they appeared to be
a what I would call a minimal routine care
follow-up note. Minimal HPI, minimal medical
history, exam was manually palpating pedal
pulses with no mention of other class findings
(which I guess he felt counted as a segmental
vascular exam) no mention of a non-invasive
vascular exam, and a dermatology exam which only
noted which nails were mycotic. No other
physical exams. No other E/M notations.
Certainly not a 99204 initial visit which we
cannot bill for because the exams are out of
scope. No mention of nail biopsy or even the
nail clipping sent to lab. No note of deep ulcer
or deep debridement of same which he billed a
How fraudulent is this. How unethical is this.
Can someone like this just continue ripping off
the insurance companies and the patients with no
recourse? Someone like this is not going to
police himself. Is there anything that can be
done in cases like this?
Ron Werter, DPM, NY, NY