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
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Technology makes it possible for people to gain
control over everything, except over technology.
- John Tudor
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.
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TIME: 8am-3pm registration: 7:30-8:00am.
lunch provided: 12-1pm.
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contact the Lago Mar Resort & Club by calling
For seminar brochure, go to:
FootZine's Calendar page is found
Coding Q & A *_*
The First Question:
by Rick Horsman, DPM
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
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
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
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
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
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
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
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
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:
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:
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"
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
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
"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
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
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
schedule allowance for the procedure. The
global period does not reset with the use of a
WHEN DOES THE GLOBAL PERIOD BEGIN?
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,
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
of Practice Management *_*
Lynn Homisak, PRT
by Hal Ornstein DPM, FACFAS and 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
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 Lynn@soshms.com)
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
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
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 FootZine.com 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.
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!
2002-2010 Gayle S. Johnson. All Rights Reserved.
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