Crystal-Clear Coding  

by Phillip E. Ward, DPM

Top Ten Reasons for a Claims Denial
(Volume 74)

10. Incorrect insurance company billed
   * Copy insurance card front and back
   * Identify where to send the claim
   * Separate CPT from DMERC for Medicare
   * Does the staff know which plans you participate in

9. Inappropriate use of modifiers
  * Use digital and class findings modifiers
  * Use with E/M visit -25, -57
  * Use during global days -24, -58, -76, -78, -79
  * Use with multiple procedures -51, -59

8. Not using CCI correctly
  * Use the CCI
  * Do procedures on different visits
  * Follow list of codes in Federal Register

7. Misunderstanding health plans medical policies
  * Use the LMRPs for Medicare
  * Commercial carriers - some states have a law that states the carrier must disclose their policies to all providers upon request
  * X-rays - are you registered to take radiographs for that insurance company

6. Poor coding technique - CPT and ICD-9 do not agree
  * Doctors get to know your codes
  * Primary ICD-9 must match the CPT code
  * Superbill interpretation - did you code for what was done

5. Data entry errors
  * Garbage in garbage out
  * Train data entry people vigilantly
  * Each demographic/registration form is a potential $100 bill; make sure the necessary info is there
  * Get spouse information when possible
  * Ask for insurance card every visit to check for any changes

4. Inappropriate bundling by health plan claim processing software
  * Appeal with CCI data

3. Not using clinical knowledge to assist in the coding and billing process
  * Have physician help with any clinical aspects or questions on appeals

2. Missing data on the claim form
  * Missing demographics
  * Missing referring doctor UPIN #
  * Missing referral authorization #
  * Missing (to and from date) hospital inpatient/outpatient data

1. Insurance companies are just stingy bastards
  * They deny for a reason
  * They live and make their money on the float
  * Their hope is that you will not appeal the claim in a timely manner so they win
  * They win: they keep your money
  * How we win: we learn their game and play it better than they do!

This week's question was edited for clarity.  See link to Audit Sheet Document below.

The Question:

From Eileen B

re Medical Decision-Making

Hello - I have a coding question pertaining to evaluation and Management services.

I am doing a self study course and am struggling with the medical decision making component.

I have taken a medical terminology class and am able to identify a disease by definition but do not know how to come to a conclusion for the different levels of the medical decision making component in reference to the severity of the disease, such as self limited or life threatening.

How would I know if a condition is one in which the body can correct itself or something more severe or even life threatening? The way I see it this is something only a doctor would know, yet in all the documentation I can find on medical coding it appears this is the responsibility of the Medical Coder to extract this information from the medical documentation and assign a certain level of medical decision making.

Please help me as I am very frustrated because I am able to get the concept of all other components of e/m coding but just can't get passed the MDM component.

Eileen B

The Answer:

Download Audit Sheet Doc 

Download free MS Word Viewer   Here

Coding Hallux Limitus
(Volume 70)

The Question:

Can anyone tell me if I am using the correct code for hallux limitus correction (with osteotomy and screw fixation)--28289?
Thanks for any info!!!

Stacy Davis, PMA

The Answer:

28289 is only for the cheilectomy, not for the osteotomy.  A cheilectomy refers to the work involved in removing the osteophytic spurring around the MTPJ.

You should use the 28289 plus the 28306 for the osteotomy (which will include the fixation, but the screw itself could be separately reimbursable depending on the insurance company).

Coding Green-Waterman Procedure
(Volume 67)

The Question:

From:  Chris Dysart
re:      Green-Waterman Procedure

I'm looking for the CPT code for a Green-Waterman Procedure.  Which code
should I be looking at, 28296?

Thanks!
Chris Dysart
Carle Clinic Coding Analyst
217-326-8284

The Answer:

Green-Waterman is I believe a correction of HAV with a metatarsal head osteotomy. This would be coded as a 28296.

Coding Warts
(Volume 64)

The Question:

Gayle, please help. Anthem has recently started to reject the paring of plantar warts. What code can we use to be reimbursed for this.
Thanks,

Linda Casella, PMA
Exeter, NH

The Answer:

We have had success using benign neoplasm of skin (216.7) as the primary diagnosis and pain in foot (729.5) as the secondary diagnosis with the wart destruction codes (17000-17004)

Evans-Calcaneal Bar/Tarsal Coalition
(Volume 62)

The Question:
 
I'm needing some help on getting a CPT code for a surgery? Do you know anyone who can help on my search for: Evans Calcaneal navicular bar!!
Please Help or help me in the right direction.
Thank you for your help in my search :-)

Krissy
Hillsboro, OR

The Answer:

Evans-calcaneal bar is a diagnosis.   It is describing a tarsal coalition (755.67).

The surgical procedure to repair this would be resection of tarsal coalition 28116 (ostectomy, resection of tarsal coalition  -  RVU 17.66).  If an additional osteotomy were performed it would be coded as 28300 (osteotomy calcaneous  -  RVU 25.89); 28302 (osteotomy talus  - RVU 23.18); 28304 (osteotomy tarsal bone  -  RVU 20.47); or 28305 (osteotomy tarsal bone with autograft  -  RVU 25.81), whichever code is most specific for what was actually performed.

The Question:

Is there another CPT code that can be used for orthotic fittings except 97504. We are a hospital based outpatient clinic in a rural area. We supply prefabricated splints and braces for orthopedic patients on a one visit status. Do we have to charge an evaluation of the patient to provide them with the doctor prescribed brace?

Jean Bohl, OTR/L
Audrain Medical Center
Healthworks, Out Patient Rehabilitation Department
711 E. Jackson
Mexico, MO 65265


The Answer:

You can bill 97116 Gait training each 15 minutes
or the
97504 orthotic fitting.
or the
99XXX code for outpatient consult if you meet the requirements of a consult.

The Question:

From:  Penny Hildebrand  
re:      Mold Casting codes

Ma'am,
 
I have been having some difficulty finding a definitive answer to the use of 2 codes when coding for orthotic appliances.  I found your site online but wasn't sure if I could ask you coding questions or not!  Do you know of someone I could contact with a couple of questions regarding the use of 97504 & S0395?  Any assistance you can provide would be deeply appreciated!

Penny L Hildebrand, CPC
Coding Auditor, HCRS
Keesler AFB

*_*   This reply sent to Penny in December   *_*

Hello Penny,

You are welcome to ask coding questions here.  We have a coding guru, Dr. Phillip Ward, who answers coding questions for our subscribers.  I will forward your questions to him, but there won't be another issue of FootZine until after the Holidays.  In the meantime, you may want to review some of the coding information already on the web site (see the link of the left side of the home page for "Coding").   

~ Gayle   *_*

The Follow-up Questions:

From: Penny Hildebrand  
re:     mold casting codes

Wow!  That was quick service!  I have checked the site but the questions I have aren't addressed.  I have been auditing the Orthotic Lab which provides quite a few foot orthotics and keep getting conflicting information from my supposedly "expert" sources!  I'm not altogether sure Dr. Ward will have the answers I'm seeking but here goes!

I was told that when the L codes include a custom fitting or fitting and adjustment in the code that you cannot use 97504 to account for the time they take to customize the appliance. 
Sometimes they perform casting also to create a mold (this is where I question the use of S0395).  They make the appliances here but usually start with a pre-existing appliance to customize so I don't think they would be considered the manufacturer.  Maybe I'm wrong on this one?

I have checked the CCI edits and every other site I can think of to try to determine where my sources came up with the information they provided me but cannot find anything to substantiate it. Yours is the only site I could even find that addressed any coding issues regarding the appliances!

If all of this is beyond his expertise, I want you to know that I still very much appreciate the effort!
 
Happy Holidays!
Penny Hildebrand, CPC

The Answer:

97504  (orthotic fitting and training, lower extremity, each 15 minutes) can be used on the day of dispensing of an orthotic in addition to the L code for the device itself.  It is to be billed in increments of 15 minutes.  Rarely should would it take longer than 15 minutes of the physicians time to instruct the patient about the use of the orthotic.
 
S0395  (impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic) is not to be used when modifying an OTC device.  It is to be used to code for the foot impressions when somebody else is making the orthotics.  You can use the S0395 code in addition to the L codes for the orthotics if you are not the manufacturer of the custom devices.

Unna Boots
(Volume 60)

The Question:

Having a real hard time finding medicare code for unna boot ie; paste bandage, zinc...is there such a code?

-CMKWILL

The Answer:

The code for the application of an Unna boot is 29580.  There is no code for the supply itself.

Knowledge is power!

by Phillip E. Ward, DPM