Crystal-Clear Coding  

by Rick Horsman, DPM, and Scott Schroeder, DPM
 

The Question: 
 Can you please give me the ICD-9 code for peripheral neuropathy with evidence of callus formation?

Thank you,

Cindy

The Answer: 

ICD 700 for the callous

ICD 356.9 for the peripheral neuropathy
 
Rick Horsman, DPM
Olympia, WA

Qualifying For Routine Foot Care
(Volume 99)

The Question: 

Hi,

I have been seeing Medicare patients for the last 2 years.  Almost all had seen other podiatrists over the years for various problems.  Two doctors (I will not name them) always billed Medicare for routine footcare yet many patients have no vascular or neurological class findings, nor do they claim to have such problems, nor does their PCP document any such pathology.  I have read the Medicare rules about routine footcare and spoken to many doctors about them.  A couple of older practioners told me "you can always find something to make it covered by Medicare".  I have been telling these patients that they do not qualify for routine footcare and will not be covered by Medicare.  About 20% come back to see me but the rest never return.  Am I missing something?  It seems Medicare rules change from state to state from what I read, so what are the rules for Washington state?  Someone told me the "magic" diagnosis to use is pain, but almost no one tells my staff who takes H&Ps they have pain- and what level of pain must exist if this is the magic diagnosis?  An article from our state newsletter said severe vascular or neurological conditions must be present for Medicare coverage but if that is true I think less than 40% would qualify for routine care.  Has there been any data to suggest what % of Medicare patients qualify for routine footcare?  I don't want to be charged with fraud for not billing a covered service, so is there any way I can cover myself against such charges when I determine routine footcare is not covered from Medicare?  Thanks for your help.

Name withheld by request

The Answer: 

Gayle,

Regarding coverage in such matters, there are "hard facts", and there are "softer facts".
 
As you know, for many years, residents of WA State were covered for RFC with underlying conditions such as use of anticoagulants, artificial joints, cardiac valves, etc.   We also see patients with mental retardation, cerebral palsy, etc, that obviously cannot provide self-care, and no one in their right mind will attempt to provide it for them....
 
FYI.... many of those clinical at risk conditions are still covered in other (non-Noridian) states... including California (I was just there).
 
Prior history of amputation is pretty straightforward; hard to waffle on that.
 
Everything else is tactile... did I, or did I NOT feel that pulse?  Was that the patient's pulse, or my own?  How many pulses must be absent to qualify?  Must they be on the same extremity, or must it be both?
 
What constitutes "cool" or "atrophic" skin?
 
Did you, or did you not feel that monofilament?  at how many sites?
 
Did that leg move after percussion with the reflex hammer?
 
How much of this is the effect of progressive increase in age; how much is rapidly progressive neuropathy, and of what cause?
 
Some physicians choose to set a very hard line; hoping to disqualify as many patients as possible from covered routine foot care.  That makes it a non-covered (read that as "cash") service.  You can provide it as often as you wish, charge anything you want, and document as much or as little as you choose.
 
Others recognize that for many of these patients, they have no other options.  They clearly have risk factors, and could not afford a cash service.  Should they be denied the care?
 
It is tempting to look at this matter in a black and white way, when in reality, it's a gray world.  The neurologic and vascular evaluations are among the "softest", most subjective, and most non-reproducible of medical evaluation.
 
I don't know if I answered the question, but I hope I have at least formulated some of the problems inherent in answering it.
 
Rick Horsman, DPM
Olympia, WA

Qualifying For Therapeutic Shoes
(Volume 99)

The Question: 

I have a patient that has arterial insufficiency(440.20) with foot deformity(736.7), however he is not diabetic. Does he qualify for therapeutic shoes(diabetic shoes)?
 
Thank you,
 
Cindy Arnett

The Answer: 

As of now, although we all recognize that this patient would undoubtedly benefit from the Therapeutic Shoe program, they are NOT eligible for it.
 
For reasons that defy logic (probably lobbying by the ADA, who forgot to mention that there might be "one or two" individuals with arterial disease, profound neuropathy, and foot deformity who happen to NOT be diabetic, but would certainly benefit from the program), it is strictly and specifically limited to those with diabetes.  That is ALSO true of the LOPS benefit...only good for those with diabetes.
 
Now, if you've had a pancreas transplant, and are now euglycemic, are you still considered diabetic and eligible for the program?  The latest I have heard is that you ARE still eligible throughout your lifetime.
 
Rick Horsman, DPM
Olympia, WA

The Answer: 

Suggested diagnosis codes for "nerve impingment":
 
Note that tarsal tunnel syndrome is 355.5. Use of a code in that general area would seem to imply entrapment neuropathy...
 
Related:
as such I recommend:
 
355.8    Mononeuritis
other descriptions for this same ICD-9 code:
Nerve Disorder, Lower Extremity NEC
 
956.9    Injury, Peripheral Nerve
 

Rick Horsman, DPM
Olympia, WA

The Answers: 

Current coding for injection of a peripheral nerve with a sclerosing alcohol solution is CPT 64640.
 
However, there is a rapidly-growing groundswell of opinion among carriers nation-wide (and some providers) that this is an inappropriate and overly-valued code.
 
Providers are certainly "safe" using CPT 20550 (which pays a LOT less...).  But, if current discussions proceed, carriers may retroactively determine that a great many claims billed under CPT 64640 were inappropriately over-paid, and may ask for reimbursement. That could be VERY painful....
 
Rick Horsman, DPM
Olympia, WA

The Answers: 

I have not personally used L3020 but in reading the definition (foot insert, removable, molded to patient foot, longitudinal/metatarsal support, each) this actually looks better than the L3030 depending on how "longitudinal/metatarsal support" might be defined.  It looks like this should be fine to use.
 
I am not talking about Medicare with the L3000 series codes.  These are for the private insurance companies.

Scott Schroeder, DPM
Wenatchee, WA

Scott and I agree.  If it's Medicare, L3020 won't work either. NONE of these codes are payable by Medicare. The ONLY payable codes are the A codes used with the diabetic shoe program.
 
Rick Horsman, DPM
Olympia, WA

Can a correction of hammertoe 28285 and saucerization 28124 be billed together for work on one toe?  Thanks for any info.!!!

S. Davis

The Answer: 

I will answer relative to Medicare, which typically sets the highest (most strict) standard.

No, you cannot bill both CPT 28285 and CPT 28124 on the same date, unless the services are provided on separate digits.  If that were the case, use the digit-specific T modifiers to unbundle the CCI edit.

Regardless of what you may do to a single digit in order to make it "good", most insurance plans will not pay more for any single digit than their allowance for CPT 28285.

Rick Horsman, DPM

Can you please give me some clarification in regard to orthotics HCPCS L3010 and reimbursement from DMERC?  Is this a reimbursable item and what are the diagnosis codes to get reimbursed for this item?  I have spoken with DMERC but, I'm still a little confused.

Thank you,

Cindy

The Answer: 

In response to Cindy's question: To my knowledge Medicare does not cover the code L3010 (foot insert, removable, molded to patient model).  This would be the patient's responsibility.  They will cover special types of insoles and shoes for Diabetics that meet certain criteria in the A5500-A5511 series of codes.

Scott Schroeder, DPM

The Answer: 

Scott is correct.

Medicare ONLY covers inserts (or orthotic devices) under the terms of the Diabetic Therapeutic Shoe program, and those service may only be billed via the A550x series.

Any billing to Medicare using the L301x series will be promptly and summarily rejected.

Rick Horsman, DPM

Would like to know the codes to use when billing multiple injections on one foot and/or both feet for neuromas.

Also how to bill for custom orthotics.

Thank you, Gayle.

Debbie McGovern (David McGovern, D.P.M.)

The Answer: 

When billing multiple injections in one foot you should use the -59 modifier, ie- 20550 & 20550-59.  If billing bilateral you can use the -50 modifier indicating it is a bilateral procedure, ie- 20550-50 and then increase the fee on this to 1 1/2-2 times your normal billed amount for one injection.  You just have to have one line item that way.  The other option with a bilateral injection is to bill it with the -59 modifier as above.  I think Medicare at least in our area is trying to encourage the use of the -50 modifier.  Certain insurance companies and Medicare in your area may only allow a certain number of injections per office visit.
 
For custom orthotics the codes of L3000 or L3030 should be used.  You would bill for each foot.  For instance L3000 Left & L3000 Right.  You would use the appropriate diagnosis code as the foot condition dictates.  Some insurance companies cover them and others don't.  If not, it would be the patient's responsibility and they should know this up front.  L3000 (foot insert, removable, molded to patient model) is probably a more appropriate code than L3030 (foot insert, removable, formed to patient's foot) but I have found in our area some of the insurance companies are not recognizing L3000 as well and we have had some problems with it so we've been continuing to use the L3030 code.  Reimbursement may be higher with one or the other.
 
Scott Schroeder, DPM

Coding -  Dystrophic Nails
(Volume 92)
 
The Question: 

What is the correct way to bill trimming of dystrophic nails for non-Medicare
patients?

Beth Miller, RN
Coding Auditor
Quality Assessment

The Answer: 

Beth,

Depending upon where you are in the country, the answer might differ somewhat, but I'll do the best I can.

First, for Medicare (realizing that you excluded this, but it is relevant):

A nail which is thickened, incurvated, etc., is, by definition, "dystrophic". Dystrophic nails are "debrided", and billing for Medicare is via the CPT 11720-11721 series.

A nail which is not thickened, incurvated, etc., is termed "hypertrophic". Such nails are merely reduced in length. Such care is termed "trimming", and billed via CPT 11719.

If the patient has risk factors, that is conditionally covered routine foot care.  For most carriers, if the patient has symptoms (pain, redness, swelling, inflammation, hemorrhage), it is covered NON-routine foot care.  If the patient has no risk factors, and no symptoms, it is a non-covered service.

For non-Medicare payers, it has been my own experience that most payers are absolutely thrown by the nail debridement codes-- equating the use of those codes (11720 and 11721) with non-covered routine foot care.

Assuming the patient has symptoms, for most non-Medicare payers, I bill it as an E/M service.  In my 29 years of practice, that has been what they prefer.  For the most part, I only use the nail debridement codes for Medicare.

Again, there are regional differences across the country.  I am most familiar with coverage issues west of the Mississippi. 


Rick Horsman, DPM 

The Answer: 

There are a variety of ways this can be billed.

Depending on the insurance company this may be a covered or non-covered service.  If the dystrophic nails are painful, which many times they are due to their thickness, then it should be covered and be billed with an E&M code 99212-99213 depending on involvement of work-up, or a new patient code, with diagnoses of 703.8 and 729.5.  Another way to bill would be a debridement
code of 11721 if 6 or greater toenails are debrided, or 11720 if 5 or less are debrided.  The same diagnosis codes can be used.  If the dystrophic toenails are not painful, then it would depend on the specific non-Medicare insurance company if this was a covered service or not.  If they are mycotic (fungal), then there is a pathologic process going on and I imagine it would be covered service.

Scott Schroeder, DPM