“My documentation for qualified, routine foot care is similar for most patients as little changes in 3 months. But, yes, I do look for changes and make the note reflect such. And I try to make sure notes are not exact copies of previous notes. My notes have plenty of bullet points for an E/M code on each visit. I am primarily charging procedure codes only (CPT 11056, CPT 11721, etc). Can I still bill at least one E/M code per year even when there are no substantive changes as I continually monitor vascular, neurologic and dermal changes each visit? Must I have a new or different diagnosis to bill an E/M code?”
by Michael R. Lowe, Esq., Brian Evander, Esq., and Jacob Lowe
February 03, 2025
By tahlia@tldsystems.com
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Often, health care providers do not even realize how marketing arrangements can violate the Anti-Kickback Statute and other state marketing/brokering laws. It is completely natural for health care providers to market; they need to get business and establish referral relationships with other practitioners. With this, health care professionals often rely on marketing companies, MSOs (management services organization), pharmaceutical companies, or referral entities that represent that an agreement is compliant with such statutes a provider will not have checked by an attorney.
“I know things have changed a little for removal of retained hardware and I am seeking clarification for a scenario. A patient has previously had an Austin Akin bunionectomy. It healed uneventfully. Years later, she has developed pain at the retained screw in the metatarsal. There is a k-wire noted in the proximal phalanx. X-rays showed complete healing at the osteotomies. The patient would like to have both implants removed despite only one of them hurting today. How would the changes in CPT coding apply to this situation? Thank you for the help.”