“In a nursing home, if you are rendering a service where the E/M is a systemic condition and separately identifiable, can you bill the E/M code and the procedure? I believe you cannot. My biller and a webinar speaker both feel that you can. Their thought is that as long as you have different diagnoses for the office/nursing home visit and routine foot care, it will be allowable. For example, you could bill E/M 99307, CPT 11056, and CPT 11721 and the diagnosis codes are G20 (Parkinsons), L84 (corns and calluses), I73.89 (PVD), B35.1 (mycotic nails), M79.674 and M79.675 (pain toes). I would put the G20 on the E/M 99307, L84 and I73.89 on CPT 11056 and B35.1 and M79.674, M79.675 on CPT 11721. Any thoughts on this issue would be helpful.”
This nursing home issue keeps raising its ugly head. Whether the patient is treated in a nursing home (Place of Service code 32), the patient’s home (Place of Service code 12) or in the physician’s office (Place of Service code 11), when it comes to treating a patient for “At Risk,” Routine Foot Care, the same rules apply for billing an E/M service in conjunction with the performance of a minor procedure (postoperative global period of 0 or 10 days).
When the E/M service is billed together with the procedure on the same date of service, in order to be reimbursed for the E/M service, the 25 modifier needs to be appended. The 25 modifier is defined as: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.
Now, I may get some negative feedback for what I am going to opine, however, on the Initial Encounter when the patient is seen for the first time for “At Risk,” Routine Foot Care, you must first establish whether or not the patient meets the coverage criteria. In order to achieve this goal, the appropriate levels of history and examination must be performed and documented. The History determines whether or not the patient has a “covered” systemic disease (ie. G20, Parkinson’s disease) based upon the Medicare Administrative Carrier Routine Foot Care LCD, the name of the MD/DO treating the systemic disease and whether or not it is necessary to document the date last seen by the treating MD/DO for the systemic disease within the 6 month period prior to the ”At Risk,” Routine Foot Care encounter. The Examination determines whether or not the patient has the associated complications that have resulted from the systemic disease. In other words, the “Class Findings” that lead the podiatrist to select the appropriate Q modifier (Q7, Q8, Q9) to the CPT/procedure codes (ie. CPTs 11055, 11056, 11057, 11720, 11721, 11719, G0127) that are provided and billed for. Shouldn’t this qualify for an Initial E/M service? I think it does. The Initial E/M service would be appended with the 25 modifier and the CPT/procedure codes would be billed, as well.
On the subsequent encounters when “At Risk,” Routine Foot Care is provided, despite the fact that the same process is performed by the podiatrist, it is inappropriate to bill a subsequent patient E/M service in addition to the CPT/procedure codes that are provided to the patient. Why? Because this is a “one bite of the apple” situation. If the subsequent E/M code (ie, 99307) is appended with the 25 modifier, this is not representative of a ‘Significant Separately Identifiable E/M service.
As far as the coding scenario that is posted. I have a few issues. First of all, I checked two Medicare Administrative Carriers that have an LCD for Routine Foot Care, First Coast Service Options and National Government Services. Parkinson’s disease, ICD-10-CM code G20 was not a covered systemic disease. You need to make sure that your Medicare Administrative Carrier qualifies G20 as a covered entity. Secondly, I am assuming that by billing E/M code 99307, this was not the first time that this patient received “At Risk, Routine Foot Care. If that is the case, then 99307 could not be billed in conjunction with CPT codes 11056 and 11721. Lastly, it would be inappropriate for a DPM to bill an E/M service with the only ICD-10-CM code being linked being the systemic disease. By doing that, it would be assumed that the DPM is treating the patient for the systemic disease and clearly that is not the case. It would be appropriate to link to the E/M service not only the systemic disease ICD-10-CM code, but also the ICD-10-CM codes for the specific issues that the DPM will be addressing (ie. L84 and B35.1).
This is my opinion.
Michael G. Warshaw
DPM, CPC
THE 2021 Podiatry Coding Manual is available in either Book or Flashdrive formats. It has been completely updated including the E/M coding changes for 2021. Many offices across the country consider this to be their “Bible” when it comes to coding, billing and documentation. The price is only $125 including shipping! To purchase, access the website drmikethecoder.com.
Are you in compliance with Medicare concerning your billing, coding and documentation? An audit should never be more than an inconvenience. It should not be a life altering event. Find out your status before you are audited by your Medicare carrier. Drmikethecoder special: Have 5 dates of service audited for $250 (new clients only). Contact drmikethecoder.com for more information.
Read Comments