Crystal-Clear Coding 

Coding -  Refurbishment of Orthotics
(Volume 90)

The Question: 

Is there a code for the refurbishment of orthotics(L3010)?

Thank You,

Cindy

The Answer: 

It's not stated if she's looking for a diagnosis code, or a procedural code.

I typically use an E/M code, based upon time, materials, and complexity.  Many would consider this a non-covered service, and code accordingly.
 
Rick Horsman, DPM

Coding - I&D of Abscess 
(Volume 90)

The Question: 

Thanks so much for getting back to us so quickly,  I have another case I would like an opinion on.
 
Here is a portion of our dictation:

Removed dressings and Iodoform packing and flushed with sterile saline.  Applied saline soaked Iodoform into the wound, although did not fully fill up the wound as will let it try to begin to granulate in, but keep the skin incision open for drainage.  Applied dry sterile dressing after it was repacked.  Pt is to continue with non-weight-bearing, although she may put some weight on the heel.  Fit and dispensed removable cast to allow more protection and some ambulation, particularly on the heel.  Reevaluate in 4 days.
 
Patient is 12 days post-op for right foot abscess.  We are seeing her about every 3-4 days for this sterile dressing change.  How would you bill this,  some say an office visit with modifier.  I would like your opinion.  This is taking several minutes and does not qualify under an E&M code, the patient is not in the global period for an I&D.
 
Thanks,

Deb

The Answer: 

(A Compilation of two emails from Dr. Horsman)

This is a longer and more complex problem
 
If the patient is clearly out of the global period...I don't see anything here other than an E/M.  No other services are billable... at least, not based upon this documentation
 
If it IS within the global, and the patient is Medicare, it's all free.

I will base my answer on Medicare-- other carriers may have different policies.
 
First...The primary assumption is that this patient is NOT subject to a global period. Assuming 12 days post op, and how the original services were billed, the patient is either just out of the global, or still in it. (They mention leaving skin incision open for drainage...that sounds like a 90 day global to me.)
 
Removal of dressing, packing, irrigation, and repacking.  That is NOT wound debridement as billable by a physician.  It's basically a dressing change.  Depending upon medical necessity, quality of documentation, etc., you could bill it as an E/M (CPT 9.9212 or 99213.). you would have trouble supporting billing for this- especially every 3-4 days
 
For Medicare, the removable brace would likely also be a non-covered item (fractures only).
 
I would look VERY closely at the global period, and seriously consider (if appropriate and medically necessary) sharp debridement of the wound.
 
Hope that clarifies (don't shoot the messenger).

Rick Horsman, DPM

"Coding -  Compartment Syndrome"
(Volume 89)

The Question: 

Could you please give me a ICD-9 code for Compartment Syndrome -  Dr. says pressure in the calf that pushes on the nerves and tendons which causes pain.  Could you please E-Mail an answer to us?
 
Thank you very much for your time,
 
Alice

The Answer: 

ICD-9 729.9    Compartment Syndrome, NONTRAUMATIC
 
ICD-9 958.8    Compartment Syndrome, TRAUMATIC
 
 
Rick Horsman, DPM

Coding -  Hemi-Implant
(Volume 88)
 
The Question: 

Need CPT code for this [hemi implant] procedure, can you help?

SuzyQ


The Answer: 

A bunionectomy with implant of any configuration (hinged, hemi, etc) would be CPT 28293.  There is NO CPT code for a lesser MPJ or IPJ implant.  You would have to used the unlisted code CPT 28899.  It is suggested you submit the claim with documentation, and offer a similar procedure which DOES have a code, so as to approximate value

Rick Horsman, DPM

Coding -  Diabetic Foot Care
(Volume 87)
 
The Question: 

Gayle --

Looking for the new Medicare codes for billing Diabetic foot care.  The url I was given, http://cms.hhs.gov/, led me to a Medicare site but I couldn't find anything.  Any help you or the list can give me will be much appreciated.  Thanks!

Holly Mollo
Centre Footcare
State College, PA


The Answer: 

Gayle,

I will assume that Molly is looking for policies and codes for providing routine foot care to persons with diabetes, with the specific policies for Pennsylvania. I would direct her to her own Medicare carrier's website, which should have the latest policies. It would do her no good to review national policies, when they are clarified and codified by her own carrier.
 
If she is asking regarding wound care, same issue, and same directive.
 
If asking regarding the diabetic therapeutic shoe bill, I would direct her to her regional DMERC carrier website.
 
As you know, HHS gives national policy directives; but individual carriers have the authority to determine exactly how that will be implemented for their states. That makes a world of difference in required diagnosis and procedural coding, "linking" of codes, etc.
 
Rick Horsman, DPM

Coding -  Walking Boots
(Volume 84)
 
The Question: 

Do you know what Dx codes I can use
to bill with L4360 to be reimbursed from Medicare
properly?

Thank You,

Nicole
Teaneck, NJ


Do you know what Dx codes I can use
to bill with L4360 to be reimbursed from Medicare
properly?

Thank You,

Nicole
Teaneck, NJ


The Answer: 

L4360 (pneumatic walking boot) and L4386 (non-pneumatic walking boot) have to be billed through DMERC.  They cannot be billed through your regular Medicare payor.  You must obtain a DMERC provider number.  Talk to your local carrier about getting an application for this.  They may direct you to the national DMERC payor that covers your area. 

Codes that have worked in the past have included 917.2, 239.2, 726.90, 755.9, 727.1, 736.72, 726.79, 735.1 & 735.4.  In the past DMERC has also covered cast boots for treatment of diabetic ulcers, but recently they have come out saying they are going to be restricting the use for ulcers.

Scott Schroeder, DPM
Wenatchee, WA

Coding -  Q-Modifiers
(Volume 81)
 
The Question: 
(from Volume 80)

Question: Is it necessary to use Q modifiers when billing for an initial or ongoing convalescent hospital or office visit?

Thanks again for your help.

Kate Prado
Dr. Mike Prado

Question: Is it necessary to use Q modifiers when billing for an initial or ongoing convalescent hospital or office visit?

Thanks again for your help.

Kate Prado
Dr. Mike Prado

The Answer: 

Q modifiers are not required on the initial or subsequent convalescent visits if you are treating a covered podiatric medical condition.  If the sole purpose of that visit is to trim or debride nails or calluses, then the appropriate Q modifiers would apply to the procedure codes.  You should not bill both a visit code and the nail and/or callus debridement codes if the sole purpose of the visit was to perform the procedures.  If there is a separate identifiable diagnosis, then an E&M visit may be charged.  Make sure this is well documented that these are separate conditions.  To make it easier for reviewers I have dictated these as separate problems with a SOAP note for each.  I do this at in the office also.

Scott Schroeder, DPM
Wenatchee, WA

Coding -  Q-Modifiers
(Volume 80)

The Question: 

Hi Gayle,
I want to tell you how invaluable Foot Zine is. My husband and I truly value what you're doing.

Question: Is it necessary to use Q modifiers when billing for an initial or ongoing convalescent hospital or office visit?

Thanks again for your help.

Kate Prado
Dr. Mike Prado

The Answer: 

Q modifiers ONLY have relevance if you are providing routine foot care services upon a patient with applicable risk factors (non-traumatic amputation-Q7; absent pulses-Q8; softer vascular or neurologic signs-Q9).

This is true without regard to site of service, or whether it is for a new or established patient.

If it's not routine foot, don't you DARE use a Q modifier!  Bill it as applicable E/M and/or procedural codes.

Once you use the Q modifier, you have defined your services as routine, and are subject to all the restrictive criteria, documentation requirements, etc.

Rick Horsman DPM

Coding -  "Routine Care"
(Volume 80)

The Question: 

Hello Again Gayle,

One more question.  I see where a colleague of mine billed in this manner for a Medicare patient:

1. 99212  modifier 25
2. 11056  (can you tell me what this is?)  I think it might be debridement of nails 1-5
3. 11721  I think this might be debridement of nails 1-6

Is this within Medicare guidelines?  My colleague bills for subsequent visits on this same patient:
1. 11056 Q8
2. 11721 Q8

Is this ok?  Thanks for your help.  Have a great long week end.

Kate Prado
Dr. Mike Prado

The Answer: 

It is suggested that you review your CPT manual regarding these codes, as these are fundamental, and very commonly used codes.

CPT 99212 is a minimal office visit for an established patient. The 25 modifier indicates that the provider provided some procedural services on the same visit/date of service.

CPT 11056 is trimming of several hyperkeratotic skin lesions. These might be corns, or....
 
CPT 11721 is debridement of 6 or more dystrophic and/or symptomatic nails (depending upon criteria established by the carrier)

When these codes are all used together, correct coding is:
99212-25
11721-59
11056

If they are arguing that this patient warrants these services based upon absent pulses (which is what the Q8 modifier is suggesting).... correct coding is:
99212-25
11721-59-Q8
11056-Q8

Since these are such fundamental and frequent issues, I suggest you review your Medicare carrier's LMRP on routine foot care, as they may have carrier-specific criteria for coverage, documentation, and coding.

Rick Horsman, DPM

The Question:

We see several diabetic patients twice a year for neuropathy but with no other symptoms. What should we code this? Any suggestions. Thanks

Linda Casella
Dr. James Dolan

The Answer:

Rick Horsman, DPM:

The answer to the question is not as self-evident as it might seem...and depends upon the reason for the patient's presentation, and their underlying health insurer.
 
If the patient is non-Medicare, and presents without any symptoms (ulceration, infection, unrecognized injury, painful dyesesthesia, poor balance and stability...i.e. there's a LOT of latitude here), some payers would consider this screening care, and a non-covered service. Correspondingly, the documentation must be quite complete so as to support medical necessity.
 
In my own experience, such nebulous presentations are the exception, not the rule. I would bill it as an appropriate level E/M service.
 
If the patient is Medicare, the same issue applies... with the added complexity of the LOPS provisions. In my own opinion, the level of care provided in accordance with LOPS is a lesser standard of care than my patients are expected to receive, and I would avoid its use.
 
With an understanding regarding appropriate reasons for patient presentation, I would carefully document and support the appropriate E/M. Remember, neuropathic patients may not "hurt", but have abundant reason and medical necessity for evaluation, medical management, and education. Particularly in the presence of significant neuropathy, the patient may be in the worst position to determine when to seek medical care...But it will all fall to the quality of your medical documentation.

Coding - Getting Up To Speed
(Volume 75)

The Question:

Hi Gayle,

I am returning to practice after a 6 year absence.  I am absolutely mystified as to get a handle on correct coding.  Can you recommend a way to get up to speed quickly on the myriad of modifiers and codes we need to know?  Thanks for your great work!

Dr. Mike Prado

The Answer:

Scott Schroeder, DPM:

I would recommend you spend some time with a local Podiatrist's billing person.  It is going to be very important for a practitioner to understand how to code correctly (not just the office staff!).  It will eliminate much frustration for a practice and speed up payments.  McVey has coding seminars around the country.  I know Dr. Ward has spoken for them in the past and it would be great finding one of the seminars that is put on by a Podiatrist.  Codingline is another source of great information.  To get up to speed the fastest I would first visit a local Podiatrist's office and meet with their staff.

Coding Hammertoe Corrections
(Volume 75)

The Question:

Question.  I am still learning the electronic claims billing and would like to know how to code for hammertoes.  Two were done on one foot and one on the other.  Thankyou.
 
Debbie McGovern
David McGovern D.P.M.

The Answers:

Rick Horsman, DPM:

Each toe operated is separately billable, but you must indicate to the insurance plan that they are indeed separate. This is done via digit-specific T modifiers:
 
T1 for the left 2nd
T2 left 3rd
T3 for left 4th
T4 for left 5th
 
T6 for right 2nd
T7 for right 3rd
T8 for right 4th
T9 for right 5th
 
So, if the doctor operated upon the left 2nd and 3rd, and the right 3rd and 5th, coding would be:
 
28285-T1
28285-T2
28285-T7
28285-T9
 

Scott Schroeder, DPM:

In billing hammertoes the T modifiers should be used to indicate which toe has been operated on.  TA= the left hallux, T1=2nd left, T2=3rd left, T3=4th left, T4=5th left T5=Right hallux, T6= 2nd right, T7=3rd right, T8=4th right and T9 5th right.
 
If you were billing the second and third left toes and the fourth right one ideally you should be able to bill 28285-T1, 28285-T2, and 28285-T8 with your ICD-9 code being 735.4 for a hammertoe.  Unfortunately, some insurance companies still want the -59 modifier on the second and third procedures, so you would bill 28285-T2, 28285-T3-59, and 28285-T8-59.  This is the way we do it in our office and we have had very few problems.

The Answers:

Rick Horsman, DPM:

CPT /HCPCS offers two codes:
L4360 Pneumatic walking brace.... they don't care if it's hinged or not, or gel-padded or not. Medicare allowance is about $283.74.
L4386 NON-pneumatic walking brace.  Again, they don't care if it's hinged or not, or padded with gel or not.  Medicare allowance is about $127.20
L2112 is a prefab tibial fracture cast orthosis.  Fortunately, they did choose a "prefab" code (many offices try to use the custom made code, which is really fraudulent)... but this is NOT what these devices represent.
If in doubt, they should contact SADMERC, and get specific direction regarding appropriate coding for such devices.
I must state that manufacturer's reps are outrageously wrong in suggesting HCPCS codes.... But remember....if they are wrong, but you bill it that way.... YOU have a problem; NOT them.
The alternative is L2999, unlisted lower extremity orthosis.  The disadvantages of that code should be self-evident

Scott Schroeder, DPM:

In regards to Jenny's question about cast boots, the HCPCS code that best describes the boots she is using is L4386.