FootZine,  Volume 111
An Independent
Newsletter  for Podiatric Staff

from  Gayle S. Johnson





It was wonderful to catch up with long-time friends, and great to meet new ones, at the APMA meeting in Seattle last month.  FootZine came up in several of those conversations, and so, with help from some excellent friends, we're back. 

The purpose for FootZine remains the same: To share informative and useful articles, and provide a forum for exchange of ideas and information that will be beneficial in our podiatric offices.  The Calendar and Networking areas remain, as well as the Practice Management, Coding, HIPAA, DME and other featured articles.  As before, each issue of FootZine and all the articles are archived at .

The last issue of FootZine failed to reach about half of our subscribers, due either to email address changes or increased security settings on spam filters.  To be sure that you receive your copy of FootZine via email, please be sure to add this address <> to your address book, or otherwise indicate that it is "friendly", not spam.  Unfortunately, there have been periods when the server hosting FootZine has been hacked, or when the host changed servers, resulting in lost emails.  If you have sent a subscription request or an inquiry and not received a reply, please do try again.

  ~ Gayle


Technology makes it possible for people to gain control over everything, except over technology. 
         -  John Tudor


*_* Letters *_*

From:  drpmac
re:      Global Services

Can you tell me where to find what all is actually included in the surgical package?  (such as insertion/removal of k-wire, dressings, etc...)  My doctor has said to bill the removal of k-wires (20680).  The k-wire was put in following a 4th toe Arthroplasty.  They were exposed and were removed in the office three weeks after surgery.  I know the CCI edit shows it is included, but he said to use a -58 modifier.  We did this and it was paid.  It is my understanding that if he put the k-wire in with intentions of removing it during the 90 day global period it was included in surgery.  Which is correct?  I have situations that come up occasionally on what can or cannot be billed separately from the surgical procedure during the global period.  I would like to be able to show him this in writing to clear up the confusion.  I appreciate your help.

 Editor's Note: This question is addressed in the "Feeture Article", below.    ~ Gayle

*_*    Calendar    *_*

WSPMAA Fall Seminar.   Free to members of WSPMAA
October 2, 2010
Location: Virginia Mason's Main Hospital
925 Seneca St. Seattle
4th floor, behind cafeteria
Room name: Correa A
TIME: 8am-3pm registration: 7:30-8:00am.
lunch provided: 12-1pm.

*_*     *_*     *_*

AAPPM Fall Practice Management Workshop
November 4 to 7, 2010 
Lago Mar Beach Resort, Fort Lauderdale, FL
contact the Lago Mar Resort & Club by calling 1-800-524-6627
For seminar brochure, go to:

FootZine's Calendar page is found at

*_*    Crystal-Clear Coding Q & A   *_*
by Rick Horsman, DPM

The First Question:

The physician consulted in the hospital on a patient with an abscess of the foot.  The decision was made to perform surgery that day.  The patient had private insurance, not Medicare.  Am I correct in billing the consultation with modifier 57?  Incision and drainage of the abscess with excisional biopsy was performed.

The First Answer:

Let's walk through this scenario in stages.

The patient was seen in the hospital, at the request of another physician.  Technically, a consultation is a request for your opinion- not for you to assume care.  If your doctor provided only an evaluation and opinion regarding what to do, and provided associated documentation to the original requesting physician, he clearly meets the definition of a consultation.  As you know, Medicare no longer recognizes any consultation codes.

Many such services which are interpreted as consultations are in fact referrals.  Accordingly, they would be billed with regular E/M codes, not consultation codes.  That is the basis for Medicare's refusal to accept consultation codes.

Assuming the patient was a new patient to your physician, this would be a new hospital visit.  For non-Medicare payers, you could also bill it as a consultation.

After evaluation, the decision was made to perform surgery that day.

The determination whether or not to use modifier 57 depends upon how you coded/billed the incision and drainage.

Modifier 57 is used on the E/M service used in which determination is made to perform a surgical service within 24 hours, when that surgical service has a 90 day global (that is the definition of a “major procedure”).

There are many available choices for the incision and drainage and debridement described.  Some of these have zero global days, some have 10, and some have 90.  The operative report would seem to suggest that debridement included to the level of subcutaneous tissue, perhaps muscle, but not bone.

CPT 11042 includes debridement to a level including subcutaneous tissue, and has zero global days.

CPT 11043 includes debridement to include muscle, and has 10 global days.

CPT 11044 includes muscle and bone, and incorporates 10 global days.

Accordingly, with any of the above referenced codes, it would be inappropriate use modifier 57, as none of the surgical procedures performed has 90 global days.

To the contrary, if this was billed as an amputation, ostectomy of bone, or incision and drainage of abscess below the level of fascia (such as 28003, 28005, 28008), these services all have 90 global days, and you could then utilize the 57 modifier.

But remember, when you select a code with 90 global days, all those hospital visits, office visits, etc. are all included in the global allowance, and not separately billable.  In some instances, it is most reasonable and appropriate to use a lesser procedure with a shorter global interval.

The excisional biopsy/culture obtained is incidental to the I&D, and not separately billable or payable.  As they say, “you’re already there- how much extra work does that require?”

The Second Question:

"The doctor performed an Evans calcaneal lengthening osteotomy, as well as a Cotton plantarflexory osteotomy of the first cuneiform, and aspiration of iliac crest bone marrow for grafting. I used CPT 28300 and 28307; would that be correct?”

The Second Answer:

There are many surgical procedures performed in the lower extremity which have become known by their original proponent's names.  A modified McBride or Austin bunionectomy are typical examples, as is an Evans calcaneal osteotomy, or a Cotton osteotomy of the first or medial cuneiform.  The reference to “cotton” is to Dr. Cotton - not to the clothing material.

A calcaneal osteotomy is appropriately coded as CPT 28300.  It is the same code used for an Evans, or Dwyer, or a Chambers type osteotomy, and is paid the same, whether with or without internal fixation.

A Cotton osteotomy  of the medial cuneiform is coded 28304. It reflects an osteotomy of any or all of the tarsal bones.

There is an additional CPT code that reflects an osteotomy of the tarsal bones, but with autograft. That means obtaining bone (from a distant site) from the patient him/herself to interpose within the osteotomy itself- this is coded as CPT 28305. That seems to be what this physician has performed. Since this code includes obtaining any associated graft, obtaining the bone graft is not separately billable.

If the surgeon used "bank bone” , such as freeze-dried bone, etc., there would be no additional reimbursement or billing opportunities.

Now, to the pricing based upon coding:

CPT 28300         17.52 RVUs
CPT 28304         15.82 RVUs
CPT 28305         17.87 RVUs

You put the highest valued procedure first. That would be CPT 28305. The next code would be 28300-59. It will be discounted 50% by the payer.

As stated above, since 28305 includes obtaining the bone graft utilized, obtaining the graft is not separately billable, or payable.

Crystal-Clear Coding tips are posted on the FootZine web site on this page:

*_*    FootZine Feeture Article    *_*

Rick Horsman, DPM

Part One

Fundamentally, physicians perform one of three clinical services: 1) cognitive services, 2) procedural services, or 3) a combination of cognitive-procedural services, in varying degrees.  "Cognitive" services are those performed "with your mind, your mouth, and your pen."   These are billed as E/M services.  The contrary are "procedural" services performed primarily "with your hands."  These might involve surgery, injections, x-rays, cast applications, physical therapy, etc.; essentially anything performed as a "hands on" service.

In today's podiatric practice, some office visits involve only procedural services while other office visits involve only cognitive services.  However, many office visits are made up of components of both.

Global services or a "global package" represent a bundling of specific services or component procedures that are "included" in any given CPT code.  Primarily, when one thinks of global services or a global package, though, it seems to a CPT surgical code.  In essence, the principle of global services is that there are certain fundamental and component elements to any procedural service that are included within the designated value of that specific procedural service. 

So, what ARE the included elements of a procedural service?  It depends upon the carrier/payer.  One should be aware that Medicare holds the overall title to having the most stringent rules.  For purposes of discussion, we will devote our time to Medicare rules.

"Global services" under Medicare include (this is not an all-inclusive listing): "usual and customary" postoperative global care (0, 10, or 90-days); supplies and dressings used within the office setting; any anesthesia administered by the operating surgeon; intraoperative use of a C-arm or fluoroscopy by the surgeon; preoperative evaluation "after the decision is made to operate," removal of any fixation device intended to be removed within the global period without a return to the operating room; post surgical management of pain or wound complications without a return to the operating room; in fact, management of any and perhaps all complications that do not require a return to the operating room; application of the initial cast or splint with 24 hours of a surgery;  removal of any cast, splint, or dressing by the doctor who applied it; just to name a few of the most common inclusions.

Notably, the global service under Medicare does NOT include: E/M services or procedures unrelated to the diagnosis of the original procedure; medically necessary x-rays; medically necessary cast reapplications; casting supplies; preoperative examination "to determine the need for surgery"; DME; medically necessary supplies dispensed for patient self/at home use; management of complications that DO require return to the operating room; unrelated surgeries performed in another's global period; just to name a few of the most common exclusions. 

For services provided within the global period, but which are unrelated to that procedure, billing with modifiers would be as follows:

Unrelated E/M services are billed with a "-24" modifier.

Unrelated procedural services are billed with a "-79" modifier. This has no effect on payment, but does begin a new global period.

For services provided within the global period, but which are related to the original procedure, the billing is as follows:

         NOTE:  Related E/M services are never billable in a global period. 

         Staged or related procedural services are billed with a "-58" modifier.  The provider would be reimbursed 100% up to the maximum fee schedule allowance for the procedure.  The new procedure resets the global period.

         Related procedural services performed in a global are billed with a "-78" modifier.  The "-78" modifier  requires a documented return to the operating room.  While the professional service is paid for the  procedure, the practice expense portion is not.  This results in an approximate 50% reduction in the fee  schedule allowance for the procedure.  The global period does not reset with the use of a "-78" modifier. 


Medicare has stated that the global period begins the day of a "minor procedure".  A minor procedure has been defined by Medicare to include those procedural services with 0 or 10-global days.  That includes most diagnostic and/or therapeutic injections, debridement of ulcerations, wound care, management of avulsions, matricectomies, etc.

Medicare has also stated that the global period begins the day before any "major procedure" (90-day global).  That includes virtually any procedural service involving resection of bone.  Notably, non-Medicare payers may have entirely different rules.

      Part Two of Dr. Horsman's "Global Services" will appear in the next issue of FootZine 


"In order that people may be happy in their work, these three things are needed: They must be fit for it. They must not do too much of it. And they must have a sense of success in it."   -  John Ruskin


*_*    Gems of Practice Management   *_*
by Hal Ornstein DPM, FACFAS and Lynn Homisak, PRT

Awareness               by Lynn Homisak, PRT

Sam overheard a young baseball player say to his teammate (with the coach in ear distance), “Coach only sees what he wants to…. he only sees the times I miss the ball!”  The coach turned to his player and assured him that coaches do see everything!  “Then why, Coach, do I only hear it when I do something bad, or really good.  What about all the stuff I contribute on a regular basis that helped to make this team the best in our league?  Don’t you ever notice those everyday things?”  The coach still argued that he saw everything, but shamefully admitted that sometimes, the “expected” things are just taken for granted.  From that point on…. he became more aware and recognized his players, even at the “un”expected times.

This same conversation could have easily taken place between a doctor and staff.  How many assistants wonder if their doctor is aware of all that goes on around them, and (like the ball player)…... just comments on the things that go wrong?  As managers, you need to be aware of things your staff does.  In fact, do a check on yourself and see if you notice new things that you didn’t before.  One tip: If you do happen to notice more than you did before…. let them know it.  I can assure you, they will appreciate the acknowledgment.  (Want a copy of my checklist? Email

*_*     *_*     *_*

Giving Your Patient a Pound of Gold in a One-Ounce Bag   by Hal Ornstein DPM, FACFAS

The perception of time spent with your patient is related to your energy directed toward them.  Their psychological and medical needs can be fulfilled in a short time with simple techniques.  This starts with their perception and expectations.  Their expectations can be exceeded by making their perceptions reality.  Much of this information shows common courtesies our parents taught us as children, which are frequently lost in adulthood.

Each and every patient encounter should begin with eye contact and a friendly smile as you cross the doorway into the room.  Follow this with a handshake even if you’ve seen the patient a hundred times.  This delivers a clear message of warmth and caring and helps to reduce the fear factor patients often experience.  This opens their minds and ears to what you then tell them about their conditions.  These simple skills say to the patient that you are friendly and relate to them at the same level, not from the ivory tower where many physicians seat themselves.

As you begin to speak with them, place both hands on their feet.  Studies have consistently proven that human touch portrays compassion.  Begin your conversation with a question relating to their overall well being such as “How have you been?”.  This may lead to an extended conversation so be sure to control the conversation by switching to how their podiatric problem is doing, i.e. “So how’s the heel feeling?”.  At this point LET THEM SPEAK and get it all out.  The typical patient will do this fairly quickly.  However, if you interrupt them early on in the encounter to move the visit along they will feel you are rushing.  If they speak their piece, the rest is yours to control.

Time spent with the patient will be reduced if you take control of the visit.  This sounds obvious, but too often the patient leads the visit.  The patient is in the office because you are the expert.  Deliver your treatment plan with confidence and the patient will be more likely to accept quicker and with less apprehension.  Stay away from statements such as “you may benefit from.…” and “I think this may work….”.  Emphasize the importance of the treatment by using phrases like “this is critical for you to have relief.”  “This will make a significant difference is how you’re feeling” and “our goal is to get you better as quickly as possible so you can return to your normal activities and reduce the chance of surgery.”

Perception of time is an amazing thing!

Previous "Gems" can be found on their own pages of the web site, at


If you want happiness for an hour, take a nap.
If you want happiness for a day, go fishing.
If you want happiness for a year, inherit a fortune.
If you want happiness for a lifetime, help somebody.    -Chinese Proverb


The help I have received in preparing this issue of FootZine has been a source of happiness for me.  Those who contributed their time and ideas were happy to do so.  My thanks again to Hal, Barry, Lynn, Rick, and all the behind-the-scenes encouragers.  If what we share here is helpful to you, that will make me happy.  And as you know, getting letters to include in the next FootZine will make me really happy!

  ~ Gayle


*_*     *_*     *_*

Copyright 2002-2010 Gayle S. Johnson. All Rights Reserved.
DISCLAIMER: Acceptance and publication of any letter, article, news item or advertisement does not necessarily constitute or imply approval or endorsement by myself of the product, idea, or content therein. I reserve the right to edit or to not publish any material received. Any letters published are the property of FootZine. Any health- or legal- and financial- related information is for educational purposes only and should not be construed as medical, legal or financial advice, or a substitute for the advice of a healthcare professional, attorney, financial advisor or any other consultant or professional. Information pertaining to legal matters should not perceived as legal advice, nor should discussion about such issues as Medicare, coding, and billing be considered as definitive. All content is presented as being only the opinions of the contributors and is for educational purposes only.

FootZine is provided free of charge.  To ensure delivery to your inbox and not to the bulk, spam or junk folders, please add to your address book.

To Subscribe or Unsubscribe, simply send your email request to me at: or

or click one of the links below and include Subscribe or Unsubscribe as the email subject.

Subscribe to FootZine


FootZine Archive

Copyright 2002-2010, Gayle S. Johnson.
All Rights Reserved