Crystal-Clear Coding  

by Rick Horsman, DPM, and Scott Schroeder, DPM
 

The Question (from Volume 102):

Rick Horsman, DPM
Olympia, WA

Coding Bledsoe Boots
(Volume 103)

The Question:

Scott Schroeder, DPM
Wenatchee, WA

Coding Procedures with E/M
(Volume 103)

The Question:

Scott Schroeder, DPM

Coding for "Accu-Mold"
(Volume 103)

The Question:

Coding Orthoses
(Volume 103)

The Question:

The Answer:

The Answer:

Rick Horsman, DPM

The Question (from Volume 101):

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

Thank you,

Cindy

The Answer (Another perspective from Dr. Schroeder):

Gayle,
 
I think what Cindy was referring to is the billing for Diabetic shoes and Insoles.  One of the criteria is "Peripheral neuropathy with evidence of callous formation".  To be reimbursed for the shoes and insoles you can put down the diagnosis for a callous (700) but what DMERC is really looking for is the diabetic neuropathy code.  In this case ICD-9:  250.60 or 250.61.  When I bill for the shoes and/or insoles I will use the 250.__ codes alone since when I used other codes in combination it seemed to confuse the matter and we had more denials.  This also holds true with the "History of pre-ulcerative callous" and "Foot Deformity" conditions that qualify a Diabetic patient for Therapeutic shoes. 
 
Scott Schroeder, DPM
Wenatchee, WA

Coding and Review of Systems
(Volume 102)

The Question (from Volume 101):

".... Lately in our office we have the discussion regarding ROS when doing our charting.  We are split, does the ROS have to pertain with why the patient is at the office?  If so how do we ever get the 10 ROS, as needed for some OV? ( I doubt if you can get all for a podiatrist visit.)  If no, do the ROS need to be listed as why?  Such as HEET- positive for contacts?"

Brenda Reed

The Answers:

*_*  Editor's note:  The following is an edited email "discussion" between Drs. Horsman and Schroeder and myself in response to Brenda's questions.   ~ Gayle  *_*


I think Rick will be more up to speed with this one regarding "bullets" needed for office visit levels.  ....They were revamping all of that and I haven't heard the latest.  ... What she really meant was HEENT which stands for head, eyes, ears, nose and throat.

Scott Schroeder, DPM

*_*  *_*

There IS no new E/M bullet information.  The parties have not been able to agree on bullets, etc.  There was a strong move to switch to a series of vignettes/clinical examples, representative of anticipated types of presentations, and the levels of work-up through appropriate. That fell apart, too.
 
So, in the meantime, the 1995 and 1997 E/M guidelines are the best currently available system.

This is a weblink that will provide both the 1995 and 1997 E/M guidelines, which would include the bullets.
 
http://www.cms.hhs.gov/physicians/cciedits
 
Rick Horsman, DPM
Olympia, WA

*_*  *_*

Gayle,
 
The ROS point is "relevant"
 
The ROS must be appropriate for the clinical presentation.
 
The extent of ROS one might generate for an 18 year old healthy male with a new acute ingrown nail is VERY different from that for an 85 year old with a long history of diabetes with renal disease, peripheral neuropathy, and poor circulation, with an otherwise similar presentation.
 
It is NOT relevant or appropriate to generate a huge ROS on the young healthy patient, but very appropriate on the elder patient with multi-system disease.
 
So, the answer to the question is perhaps not as simple as one might like.  However, that being stated, it is my own personal belief that, as a physician specializing in the lower extremity, and dealing with issues of relevance, I can not conceive of ANY way of meeting the necessary criteria for a 99204 new patient visit- for virtually ANY presentation.
 
But since established patient visits must only meet two of the three components for an E/M, I can easily see the ability to meet the criteria for a 99214 established patient visit, although these should be much less frequent than 99213 established patient visits, which are the most frequently-billed E/M services for ALL physicians of ALL types
 
I hope that answers the question.
 
Rick Horsman, DPM

*_*  *_*

Thanks, Rick,

Based on what you've said here, we (readers) could conclude that addressing HEENT would be inappropriate and over-reaching in a DPM's review of systems for an initial visit? 

~ Gayle

*_*  *_*

Precisely.
 
I'm sure there is some rare situation out there in which it is absolutely appropriate for a podiatrist to do a ROS of EENT, but that should be the singular exception.  Some years ago, a doc .... sent me a work-up for a straightforward ingrown nail in an otherwise healthy adult.  The computer-generated note was over 8 pages long.  His question.... does this record support CPT 99205?  He wanted to build up a series of templates macros for every likely presentation, and bill the highest level E/M for everything.  The charting might do it, but it wasn't relevant or medically necessary.  I think Harry [Goldsmith] termed "medically necessary" as matching the level of/intensity of the service to the need.  Low risk things don't need high risk work-ups.
 
Now, this is fact.... there is a local ENT who refers me patients for management of tinea and onychomycosis.  He read somewhere some years ago that some/many? patients who have mycotic infections in the lower extremities can develop an "id" reaction, resulting in chronic dermatitis in the ear.  It doesn't respond to anything other than effective treatment of the mycosis.  Now, in THAT instance, ROS of EENT might actually be relevant (and I did NOT make that up).
 
Rick

Coding Resection of Bone
(Volume 102)

The Question: 

Hi, I have a question.  I have noticed one of our Drs coding his own CPT codes.  And when we do not get the same thing we second guess our training.  For instance .. one of our procedures is metatarsectomy of the 2nd right toe and debridement of wound.

The op note states that there is a floating fragment of the 2nd metatarsal likely secondary to osteomyelitis related fracture, presents for debridement of the wound and necrotic bone.   He later goes on to say that the fragment was removed and was sent for culture, the bone bed and the granulation tissue with in it was also swabbed for bone bed.  The granulation tissue was sharply debrided, with ronguers back to bleeding ossified bone, which req debridement of two additional cm of the shaft of the metatarsal, 

The Dr codes are 28140.

We choose metatarsectomy as the approach, would that be correct?  We do get an unlisted code for the procedure but the Dr debrides done to bone.  

Clearly confused.

Tausha, RHIT

The Answers: 

Based upon what was stated, I think that partial resection of bone, metatarsal (CPT 28122) is a more accurate code for the services performed, rather than metatarsectomy.
 
Rick Horsman
Olympia, WA


I concur with Rick.

Scott Schroeder, DPM
Wenatchee, WA

Coding Hospital Visits
(Volume 102)

The Question: 

Gayle,

Quick question, I had a doctor who did an in hospital office visit.   We coded it 99221 with a place of service of 21.  Medicare denied,  can you give us a heads up on what code would work better?  
 
Thanks,

Alice

The Answer: 

I would recommend 99231 (Subsequent Hospital care - 15 minutes). 
If this was an initial in-patient consult 20 minute - 99251.
Place of Service - 21 appears correct.
 
Scott Schroeder, DPM

Coding Debridement of Verruca
(Volume 102)

The Question: 

Hi,
 
What exactly is the correct coding for a debridement of a verruca?  I used to bill 11000 for a 709.8 but Medicare is now saying that is the wrong diagnosis code.
 
Thank you for any help you can furnish me.
 
Sincerely,
 
Esther
Miami, Florida

The Answers: 

*_*  Editor's note:  This answer also takes the form of an edited email "discussion" between Drs. Horsman and Schroeder and myself in response to Esther's question.   ~ Gayle  *_*


In our region if a verruca is painful we utilize 11040 with the diagnosis code combination of either 700 or 701.1 (callous/hyperkeratosis) and 729.5 (pain).

The reason being you would be debriding the hyperkeratosis associated with the verruca.  If you are using a chemical agent or curretting the verruca in toto 17000 would be appropriate.  You would follow your region's guidelines for treatment of painful lesions which typically should cover verruca.
 
Scott Schroeder, DPM

*_*  *_*

For Medicare, the answer to this question depends upon your state of residence, and the corresponding policies regarding debridement of lesions.
 
Both Scott and I practice in Washington State, for whom the Medicare carrier is Noridian.

I am currently preparing for a day-long seminar on coding issues in the Noridian states, so had the opportunity to update my knowledge based upon most current Noridian policies
 
CPT coding differs depending upon method of treatment of the verruca.
Within all the Noridian states, these are the permitted codes for treatment of a verruca:
 
If it is "shaved":  CPT 11305 series
If it is excised (and closed with suture):  CPT 11420 series
If the lesion is "destroyed".. an interesting term...this includes use of an acid, cyrotherapy, chemotherapy, use of a laser, currettement... the coding is the CPT 1700 series
 
But that's for Noridian states. You must look at the Medicare LCDs (formerly called LMRPs) for management of painful skin lesions, etc., for the state of Florida.

For the record.... CPT 11000 is absolutely the wrong CPT code for a verrucae...... IF it was paid by Florida Medicare in the past, it must have been in error.
 
Rick Horsman, DPM
Olympia, WA

*_*  *_*

Taking a closer look at the diagnosis code used, if one adheres to the rule to use the most accurate and appropriate diagnosis, and the lesion is a verruca.... ICD-9 709.8 "epithelial hyperplasia, vesicular eruption, or menstrual dermatosis" would be a real stretch.... Maybe they transposed the numbers.  I personally have never used that code for anything; and in fact, have never ever seen it used in any of the claims I have reviewed.

Rick Horsman, DPM

*_*  *_*

The recommended Dx code to use in conjunction with CPT for most forms of treatment, aside from the examples that Scott gave, would still be 078.19 then?

~ Gayle

*_*  *_*

Yup.
 
I'm hoping that the other stated code was either a misprint or transposition.  To volitionally and knowingly come up with such a code for a verruca would be very troublesome, and prompt an auditor to look very, very closely.
 
Rick Horsman, DPM