by Phillip E. Ward, DPM

The Question:
(re: candin treatment for warts)

What code should I use to bill for the injection?

Kathleen McPherson
TTUHSC Dept of Dermatology


The Answer:

The proper code for injections for warts or porokeratoses would be:
 
11900 Injection, skin intralesional, 1-7 lesions (0 day F/U, RVU 1.29)
11901 Injection, skin intralesional, >7 lesions (0 day F/U, RVU 1.55)

Surgical Procedures
(Volume 56)

The Question:

So am I to understand that procedure code 28285 is not just for an arthroplasty ( bone work) but is also for soft tissue ( ie: tenotomy and capsulotomy) correction of hammer digit syndrome?

Fraternally,
R. Shankman, DPM

The Answer:

Yes, if billed the 28285 includes all work done on the digit.
You could attempt to bill each procedure separately, but the correct way to bill it is as a 28285. As an auditor, I would combine multiple digital surgery codes into a 28285 and pay you for that code, not the individual codes (with the exception of a 28270).

Surgical Procedures
(Volume 55)

The Questions

Can you tell me what the following code numbers are for ... 20650, 27687 and 28285?

Susan J. Houck
Oklahoma City, OK


The Answers:

20650  describes the insertion and/or removal of a pin or wire into or out of a bone. This is typical for osseous procedures where you need fixation, such as a hammertoe repair. Medicare considers the insertion of the pin/wire part of the procedure, however some third party payers will pay separately for insertion of a pin/wire. If the pin/wire is percutaneous the removal is considered included in the RVU for the procedure. If a return to the operating room is necessary to remove then pin then it can be separately billable.

27687  Gastrocnemius recession is a procedure used primarily to treat gastroc equinus whereby the gastroc tendon is lengthened typically in a tongue and groove manner. (reference McGlammary Comprehensive Textbook of Foot Surgery).

28285   Hammertoe repair describes the repair of hammered or crooked toe via soft tissue and/or osseous methods.  This code includes just about anything that can be done on the toe with the exception of nail work.  It does not include a MTPJ release 28270 (reference Correct Coding Initiative)

Injection Codes
(Volume 53)

The Question:

Hi Gayle,

Can anyone tell me what injection code they use for injection of sinus tarsai?   We keep getting stumped.   And what is everyone using when they inject cortisone into a neuroma?

Thanks,

Gail Bennett
Spokane, WA

The Answer:

Injection into the sinus tarsi could be coded either as 20550 (injection tendon/ligament) or as 20605 (injection intermediate joint).  Remember to use an appropriate diagnosis with the procedure.  For the 20550 you would need a soft tissue diagnosis (example bursitis 726.79), for the 20605 you would need an joint diagnosis (example arthralgia 719.47).

The injection of a neuroma has been a hot topic of debate over the last year but the APMA Coding Committee and the consensus of the Codingline.com expert panel agree that the appropriate code would be 64450.  Remember to bill for the actual steroid used in the injection by using the J supply codes.

Candin Wart Injection Coding
(Volume 52)

The Question:

Gayle,

Can anyone tell me if they are currently using the "Candin Wart Injection Therapy".  We are considering using this in our office.  We are currently having problems determining how to get reimbursement for this procedure.  The cpt codes are billed as 1-7 (11900), >7 (11901).  We would appreciate any information.

Mbradshaw@sadler.com 
Dr. Pack
Conroe, TX

The Answer:

The 11900-11901 procedures could be used for the injections. another option is to use the regular wart destruction codes 17000-17005. Refer to these codes to ascertain the correct ones to use depending on how many lesions are being treated.

Fracture Care Coding
(Volume 50)

Last week I had to remove the fractured segment of the base of the fifth metatarsal.  The correct way to code this is as follows:

The diagnosis was 825.20 (fracture of other tarsal/metatarsal bone, closed)

Since I removed the base of the 5th metatarsal the appropriate procedure code was 28122 (partial excision, craterization, saucerization, sequestrectomy, diaphyscetomy; bone, metatarsal).

I had previously billed the fracture care code for the fracture (28470 closed treatment metatarsal fracture without manipulation) but the fracture did not heal.  Therefore, I had to modify the 28122 with a -78 (return to OR for a related procedure), which would start a new 90 day global period.  I left the patient in the same non-pneumatic orthopedic walker post-operatively that I had used initially to treat the fracture so there was no additional charge for the immobilization.

Radiographs were billed as 73620 (foot radiographs, 2 views).

Fracture Care Coding
(Volume 46)

The Question:

Gayle,

I have a question about coding for a fracture of a metatarsal. How do I go about doing it?

825.25 is the Dx
3 views on the Xray
cast his left foot.
How would I go about billing this? 
Office visit.
Treating the Fx? Cast?
I have no idea how to bill this. 

Thank you ,

Susan


The Answers:

There are 2 ways to code this encounter, assuming a new patient:

Option 1 Code it as fracture care:
9920X -57initial office visit RVU from 0.95-2.52
73630 for the radiographs RVU 0.79
28470 closed treatment of metatarsal fracture W/O manipulation RVU 7.02
(if manipulating use 28475 RVU8.75 instead of 28470)
29425 RVU 2.23, application of BK walking cast
Q4038 pays $29.27, materials for short leg fiberglass cast
subsequent office visits are included
subsequent radiographs are separately billable
subsequent cast application are separately billable
subsequent casting supplies are separately billable

Option 2 Code it as office visits:
9920X -57initial office visit RVU from 0.95-2.52
73630 for the radiographs RVU 0.79
29425 RVU 2.23, application of BK walking cast
Q4038 pays $29.27, materials for short leg fiberglass cast
subsequent office visits are separately billable RVU from 0.56-3.18
subsequent radiographs are separately billable
subsequent cast application are separately billable
subsequent casting supplies are separately billable

The difference is that in Option 1 you are bound to a 90-day surgical global period. You are not bound to that in Option 2.

Heel Surgery
(Volume 42)

Calcaneal surgery can be tricky to code.  The following should help you know your options.

For a retrocalcaneal heel spur (Haglund’s deformity) you can use either 28100 (tarsal osteotomy) or 28118 (ostectomy calcaneous).  

For a plantar heel spur resection the correct code is 28119 (plantar heel ostectomy).   This code includes a 28008 plantar fasciotomy.  

However, the 28119 does not include a 28060 (plantar fasciectomy, partial) or 28062 (plantar fasciectomy, radical). 

Crystal-Clear Coding Q & A 

The Question:

Dear Gayle,

I am looking for some help with a billing code.  The Doctor performed a McBride bunionectomy with a bone biopsy.  He also performed skin wedge closure on a dorsal ulcer. Can I bill for more than the McBride?  If so, any suggestions on which codes I can use.
Thank you for your help in this matter and I do enjoy "FootZine".
 
Debbie Roberts

The Answer:

If the biopsy was done on the first met head it would be included with the bunionectomy and not separately billable.  If the biopsy was done at the site of the ulcer skin closure the closure would be bundled with the biopsy and not separately billable.
So therefore you have:
28292 (with includes biopsy done in the same area) plus 12001 (repair superficial wound)
or
28292 plus 20240 (biopsy bone superficial excisional includes skin closure)

Claim Appeals
(Volume 41)

I am often asked how to appeal a denied insurance claim.  The first question I ask is, why was the claim denied.  The following are the most common reasons for denial and what you need to do to appeal them.

*  Concurrent Care denial
Submit a narrative documenting the necessity of those physicians’ services, which was rendered in addition to the physician overseeing the total patient care.
*  Over-utilization denial
Submit documentation depicting why more than the standard number of services were rendered and why they were medically necessary
*  Services not medically necessary denial
Submit specific diagnosis codes and narrative indicating the patient complaint warranting the services
*  Routine Screening or routine care denial
Submit specific diagnosis codes and narrative indicating the patient complaint warranting the service
*  Surgery within a post-op period of another surgery
Submit corrected claim with the appropriate modifier, -58, -78, -79
*  Visit on same day as procedure denial
Submit corrected claim with the appropriate modifier, -25 or 57

The Best 2 Diagnoses in Podiatry
Volume 40

Often I am asked, “What diagnoses codes can I use to get paid?”.  In my experience there are two diagnoses that help get the claim paid on the first submission. 

The first is 729.5 (pain in limb).  This is an excellent diagnosis for the E/M service done on the first time you see the patient for a new problem.  This code would be the primary diagnosis and the specific condition diagnosis would be the diagnosis for any procedure done.  For example a new patient is seen for heel pain and we evaluate them, do radiographs and inject.  The E/M would be coded 9920X with diagnosis of pain in limb (729.5).  The radiographs would have the same diagnosis.   The injection would have the diagnosis of plantar fasciitis or heel spur syndrome.

The second diagnosis is 998.83 and is often used when the patient is outside the global period for a procedure but still is having problems.  You would bill the E/M unmodified with the nonhealing surgical wound diagnosis (998.83).

Crystal-Clear Coding Q & A
Volume 40 

The Question:

How can I bill insurance, be it Medicare or other ins for an E&M code for complication during post op period?  I can not seem to find a modifier that will work.
Thanks for you help and the very informative newsletter.

Cindy Bryce, PMA

The Answer:

Any complication related to a procedure that occurs in the global period is considered part of the global and not separately billable unless a return to the OR is required in which case modify the procedure with -79 (return to OR for related problem during global period).

If there arises a problem unrelated to the procedure then -24 (unrelated E/M service during global), -78 ( unrelated procedure during global period)

Crystal-Clear Coding Q & A 
Medicare Coding
Volume 39

The Question:

If Medicare is primary are you not suppose to fill in 11 A-D on the HCFA 1500 form? We do paper claims in our office. Medicare said this has been in effect for I year now. They say no, only put the word NONE in box 11. Now if Medicare is not their primary then you fill in the boxes 11 A-D. Have you heard of this?
Thank you,

Phyllis

The Answer:

No, you do not need to put anything in box 11 except "NONE" if Medicare is primary.

Consult and Surgery
Volume 37

Often in podiatry we encounter a situation similar to the following:
A patient was seen in the office and it was determined that he had an ulcer which probed to bone.  Radiographs indicated bony degeneration and a diagnosis of osteomyelitis was made.  The podiatrist contacted the patient’s PCP and later that day the patient was then admitted to the hospital by their PCP and a podiatry consult ordered.  The consult was done and the patient was booked for an amputation.  The amputation was performed the next day.  Inpatient follow-up care was rendered until discharge.  Thereafter the patient is followed in the office by the podiatrist until the surgery site is completely healed.  How should the podiatric services be coded?

1. The initial office contact with the patient would be coded as a 9920X new patient or 9921X established patient, depending on the level of history, exam and medical decision making.  736XX would be billed for the radiographs.

2. The inpatient consult would be coded as a 9925X-57, depending on the level of history, exam and medical decision making.  The 57 indicates the decision to do the surgery was made as a result of the consult.

3. The surgery would be coded with the appropriate CPT code.  Let’s assume it was a digital amputation at the MTPJ.  This would be coded 28820.

5. The professional component of the radiographs taken in the hospital will probably be billed for and paid to the radiologist at the hospital unless the podiatrists reads the films first in which case the podiatrist would bill 736XX-26 where the 26 indicates only the professional component is being billed.  The hospital would bill the technical component for the radiographs.  This includes any intraoperative radiographs.

6. The follow-up visits in the hospital and in the office would be included in the global for the surgery and are not separately billable unless some other problem exists, in which case the appropriate code would be 9921X-24.  Here the 24 indicates that a separate unrelated problem was addressed during the post-op period.

7. Radiographs taken in the office post-op are separately billable and would be billed as 736XX.

Crystal-Clear Coding Q & A 
Volume 37

The Question:

What would be appropriate coding for the custom fabrication of a toe crest
from a silicone based compound such as Berkoplast or Accumold? I have
considered L3030, L3100 and also L3003. Thank you.

Robert D. Phillips, DPM

The Answer:

There is no specific code for a custom crest pad.
L3100 is not appropriate because it describes a hallux splint
L3003 is not appropriate because it specifically states silicone gel
L3040-L3090 are not appropriate because they specify arch
L3030 may be appropriate as nothing in the descriptor would eliminate it's use however
We use the CPT code CASH for this device in my office

Knowledge is power!

by Phillip E. Ward, DPM