Crystal-Clear Coding  

by Rick Horsman, DPM, and Scott Schroeder, DPM
 

Coding Evans And Cotton Osteotomies
(Volume 111)

The 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 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.

Rick Horsman, DPM

Coding Hospital Consult and I&D
(Volume 111)

The 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 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?”

Rick Horsman, DPM

Dear Gayle,
 
I have been billing medicare for the ICD-9 code 701.1 (acquired keratodema) along with the CPT code 11040. We were getting paid for this up until about a week ago, now they are not paying. Has there been a change in the way I should be billing for this?

Thank you,
 
Susan Petrizzo

The Answer:

In the state of Washington we can bill 701.1 with a secondary diagnosis of pain - 729.5 and get paid for 11040 (debridement of a painful callous).  This is what the current guidelines read but they are in the process of trying to change them.  We have had problems where they stopped paying for this in the past and a phone call to the local Medicare provider representative informing them of the problem has taken care of it.  Usually there is a glitch in the computer system or Medicare has a new reviewer who does not understand the policy and has to be set straight.

Scott Schroeder, DPM

Coding Neuroma Injections
(Volume 110)

The Question:

Hi! What is the proper code for neuroma injection?
 
Dr. Rodriguez

The Answer:

I have my personal opinion that the correct coding should be CPT 64550- injection of a peripheral nerve. BUT; it's not as simple as that--in Noridian states
 
Noridian Medicare is currently arguing that CPT 64450 is NOT the correct code to use for injecting a neuroma. Providers are currently directed to bill this as CPT 28899 (unlisted foot service). This is true for Medicare only, in those states administered by Noridian Medicare.
 
In all other states, and for all other insurers, I would bill it as CPT 64450. Don't forget to also bill for the therapeutic supply (i.e. steroid) with the appropriate HCPCS J code.
 
Since there seems to be so much confusion with some carriers in this matter, we are petitioning to get a new CPT code to reflect injections of neuromas, and one for tarsal tunnel. In the meantime, we're stuck with this. Such is the result of poorly-drafted CPT code terminology
 
Rick Horsman, DPM

The Question:

Gayle,

I have a patient that got DM shoes months ago had to have surgery and needs a different pair of shoes.  Will Medicare pay for another pair under the 1-year rule if I send in a medical necessity letter with the claim?

Thanks,
Loretta

The Answer:

Under DMERC guidelines the patient is eligible for a new pair of Diabetic shoes and three pairs of multi-density molded insoles every "calendar" year meaning from January to December.  The patient can receive a new pair at the beginning 2006 even if she/he received a pair in October of 2005.  To my knowledge this rule is very strict.  I do not know if you will be able to bypass this or not.  My recommendation is to contact by phone the provider relations representative with your region's DMERC carrier and ask them directly if they will allow this and if so what hoops you have to jump through.  I would first recommend checking to see if they received the full three pairs of multi-density insoles they are entitled to for this year.  If not, then a pair of custom molded insoles can be made from molds of their feet after the surgery but they would have to use their old shoes until the beginning of the year.  One lab that does these custom diabetic insoles is Safestep.  They can be reached at (203) 874-7722 or on the web at www.safestep.net. These are not functional orthotic devices, they are multi-density diabetic type insoles molded to the feet.  Functional foot orthotic devices (polypropylene, graphite, etc.) are not covered by Medicare. If DMERC informs you that shoes and insoles after surgery are not covered and they have already received three pairs of insoles for the year then the patient is going to be responsible for the new pair of shoes and insoles.
 
Scott Schroeder, DPM