Coding

Understand the new utilization parameters and documentation requirements for CPT Codes 11730 and 11750.

What is a Medicare NCD? An NCD or National Coverage Determination defines coverage for a particular item or service nationwide.

Effective January 1, 2009, the term “decubitus ulcer” was changed to “pressure ulcer.” A six-part staging system for pressure ulcers was put into effect on January 1, 2009, as well. This is what ICD-10 has incorporated to base the series of L89- upon. Classification systems, whether Wagner, University of Texas, etc. for ulcer grading do not apply to pressure ulcers.

Since CPT code 11703 is a targeted CPT/procedure code by Medicare, what do I need to know to make sure that I don’t get in trouble?

What does “Same and Similar” mean when it comes to DME, specifically regarding Ankle Foot Orthoses, aka AFOs?

When is it appropriate to bill for the trimming of a callus and the debriding of a nail on the same toe on the same date of service?

Why can’t an E/M service be billed every time that a procedure is performed on a patient in the office setting? When can an E/M service be billed when a procedure is performed on a patient in the office setting?

Routine Foot Care, which includes trimming or debridement of the asymptomatic dystrophic, mycotic, or normal toenails is covered by Medicare only when the patient has one of the Medicare-specified systemic diseases with clinically significant peripheral complication placing the patient “at risk” for infection and/or injury if a non-professional attempts to trim or debride the nail. However when the nail becomes ingrown, and the surrounding soft tissue is complicated by pain or inflammation, then its care is no longer “routine,” but involves a pathological state. This state is characterized by one or more of the following: pain, inflammation of the nail bed, inflammation of the surrounding soft tissue, infection and/or abscess.

Medical Record Documentation 1. Indicate the size, depth, grade, and appearance of the wound or ulcer. This is done on every encounter.   2. Indicate the type of tissue or material removed from the wound or ulcer. The tissue or material must be necrotic. This is the sole factor that determines the debridement code to bill. The selected debridement code is based upon the deepest level of necrotic tissue that is excisionally debrided from within the ulcer. 3. Chart the location of the wound or ulcer. This is the only time in the entire process that the location is stated.   4. Indicate any anesthesia (or lack of need) used during the debridement. This is imperative for 11043 or 11044. 5. Indicate any associated status factors that may affect treatment

A diabetic patient undergoes a transmetatarsal amputation. Due to the infectious process, the surgeon decides to perform delayed closure at point “X” in the future. When the time arrives to close the surgical site, the appropriate wound closure code is billed appended by the 58 modifier. This confirms a documented “staged, related, pre-planned procedure.”