by Phillip E. Ward, DPM

Place of Service Codes
Volume 35

Starting October 1, 2003 there will be four new place-of-service codes.  These new codes eliminate a lot of confusion that has been in place for years.

POS 13   Assisted-Living Facility.  Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, seven days a week, with the capacity to deliver or arrange for services including some health care and other services. Paid at non-facility rate.

POS 14   Group Home. Congregate residential foster care setting for children and adolescents in state custody that provides some social, health care and educational support services and that promotes rehabilitation and reintegration of residents into the community. Paid at non-facility rate.

POS 49   Independent Clinic.  A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventative, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. Paid at non-facility rate.

POS 57   Non-Residential Substance Abuse Treatment Facility.  A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. Paid at non-facility rate.

The Question:

What is the correct way to code for an inpatient consult that results in a surgery, for example seeing a patient with osteomyelitis on consultation and doing a bone resection on the same day.

The Answer:

For a Medicare patient you can bill the consultation code based on the level of E/M documentation in the chart (9925X) and add a 57 modifier reflecting that the decision to do the surgery was based on that E/M service and that the surgery was done within 24 hours of the E/M service.

The surgical procedure would be coded as the surgical procedure you actually performed (for example 28820 amputation toe at MTPJ).  This would have a 90-day global. The follow-up inpatient visit and office visits related to the surgery would be covered but not separately billable for 90 days.  Post-op radiographs would be billable.  If the patient developed any other problems during the post op period they could be billed with an E/M-24 indicating a non-related problem during the post-op period.

Billing Orthotics
Volume 30

At the recent AAPPM meeting in Philadelphia, one of the most common billing questions concerned the correct way to bill orthotics.  The answer to the question is to bill specifically for the device you are dispensing.  Many insurance companies will cover “orthotics” but not orthotics related to the feet.  When verifying insurance coverage for an orthotic, make sure you tell the company what code you plan on using.  Often an insurance company will cover a lesser device but not the type of device you want the patient to have.  The orthotic codes are listed below with their descriptors.

L3000     foot insert, removable, molded to patient model, UCB type, each
L3001     foot insert, removable, molded to patient model, spenco, each
L3002 foot insert, removable, molded to patient model, plastizote or equal, each
L3003     foot insert, removable, molded to patient model, silicone gel, each
L3010     foot insert, removable, molded to patient model, longitudinal arch support, each
L3020     foot insert, removable, molded to patient model, longitudinal/metatarsal support, each
L3030     foot insert, removable, formed to patient foot, each

The L3040-L3060 are premolded devices and the L3070-L3090 are nonremovable devices attached to the shoe.

If you are dispensing a device made from an impression of the patient’s foot, then the L3000-L3020 series is appropriate.  If the device is formed directly to the patient’s foot and no model of the foot is made, then the L3030 is the appropriate code.  The take-home lesson is not to allow the insurance companies pay you for a less expensive device than you are dispensing.

The AAPPM DME seminar will be held in Philadelphia in August. Watch for more info coming about this dynamic seminar.

Crystal-Clear Coding Q & A
Volume 27

The Question:

I have a patient that has a painful screw from previous foot surgery. The patient wants it removed. How do I code for it and what documentation is required?

Linda Harr

The Answer:

The correct procedure code would be 20680 (removal of implant deep; e.g. pin, screw, plate). You would bill this code for each pin, screw or plate removed. There has to be a medical necessity for the removal, so the best diagnosis would be 996.4 painful internal fixation.  For medical necessity it must be symptomatic, otherwise it is a non-covered procedure. The chart documentation should include both subjective and objective signs of pain related to the fixation devices.  The date of injury goes along with that diagnosis and would be the date of the original symptoms related to the hardware.

*_*     *_*    *_*

The 2nd Question:

What is the correct modifier for custom molded shoes?  Wasn't it ZX?

Jenny Gilliland, PMAC

The 2nd Answer:

The correct modifier will depend on where you practice and which DME carrier your claims go to.

Debridement
Volume 26

Often a podiatric physician must debride more than one ulcer on a single patient visit.  The problem is how to relay the information that more than one ulcer was involved to the third party payer.  If the debridement were done on multiple toes, then the T modifiers would be appropriate. The RT and LT modifiers would differentiate ulcer care done on separate feet. A 59 modifier would indicate that a separate procedure was performed at a different location.

Volume 25

What is the difference between a 28289 and a 28290?

The 28289 is defined as “Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint”.

The 28290 is defined as “Correction, Hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (eg, Silver type procedure)”.

If the intent of the surgical procedure is to remove the medial emminence and correct a HAV via soft tissue release then the 28290 would be appropriate.  If the intent of the procedure is to correct a limitation of motion at the 1^st MTPJ by removing bone on the dorsal aspect of the joint then the 28289 would be the appropriate code.  Remember to attach the correct diagnosis for the procedures. For the 28289 a diagnosis of hallux limitus/rigidus (735.2) is appropriate.  For the 28290 a diagnosis of HAV (735.0) is appropriate.

Volume 23

Often in podiatric surgery it is necessary to release a contracture at a metatarsophalangeal joint. This procedure should be coded as a 28270 (capsulotomy, MTPJ with or without tenorrhapathy, RVU office 14.13).  If this procedure is done in conjunction with a hammertoe repair (28285, RVU office 13.99) the MTPJ release can be separately coded, as these two procedures are not bundled together in the Correct Coding Initiative.  Most insurance companies will attempt to bundle them together so you should appeal this decision with the CCI as your factual base that they are not bundled together.  The correct way to code the procedures would be as follows:
 *28270-59, diagnosis of contracted joint 718.47
 *28285-Tmodifier-59, diagnosis of hammertoe 735.4

This type of improper bundling by insurance companies should always be appealed, as you will win this appeal most of the time.

Volume 22

In a busy podiatric office there are times when things happen that need to be explained to the insurance company.  An example of this is when, during a global period for a surgery, a situation arises that requires the doctor to take the patient back to the operating room for an additional surgery.  If the insurance company gets the claim without a modifier, they will assume that the claim is part of the original surgery and will not pay additionally for it.  The way to inform them of the situation is by appending the correct modifier.

The 76 modifier means repeat procedure by the same physician
The 77 modifier means repeat procedure by another physician
The 78 modifier means a return to the operating during a global period for a related procedure.
The 79 modifier means an unrelated procedure was performed during a global period

A few examples of how to use these modifiers follow:

A bunionectomy was performed on the right foot on March 1, a bunionectomy was performed on the left foot on April 1. The first bunionectomy would be coded 28296-RT. The second bunionectomy would be coded 28296-LT-76-79.

A bunionectomy was performed on the right foot on March 1. The patient fell and dislocated the osteotomy site had to be taken back to the operating room for fixation. The first procedure would be coded 29296-RT. The second procedure would be coded 28485-78.

A different physician performed a bunionectomy on March 1. In June the patient presented to you for a redo bunionectomy. You would code your service as 28296-77.

Correct use of modifiers will often get the claim paid on the first submission and increase cash flow in the office.

Volume 21

One of the most common errors seen relating to billing is improper linking of procedure and diagnosis codes.  This causes a significant amount of work for the billing office when they receive a denial due to this error.  The best advice to limit this error is diligent review of the super-bill by the doctor before it is given to their staff, as well as examination by the staff to double check.  For example, different diagnosis codes need to be used for office visits and for surgical (procedure) codes, including debridements, casts, injections, strapping.  Surgical codes do not include x-rays, orthotic devices and DME items (L-codes).

A suggestion to help reduce errors with linking is to have the doctor make a list of the most common twenty-five procedure codes and corresponding diagnoses used.  These should be posted at the front desk as well in the billing office.  An example to begin your list is a patient with a calcaneal spur (726.73) and plantar fasciitis (728.71) with an injection given:
 
     99213-25  Dx: 726.73
     20550  Dx: 728.71
     J code Dx:  728.71


Knowledge is power!

- Phillip Ward, DPM