“For Medicare, it has been well established that debridement for callouses is not covered when class findings are not present. But what about that patient that complains of pain from a callus. If you evaluate the painful callus and manage the painful callus, would it not be appropriate to bill a low level E/M code? This patient does not want surgery but this is a recurring problem. Can the E/M be billed each time the patient is seen?”
It amazes me how often E/M coding is discussed in different shapes and forms. The current issue is whether or not the evaluation and management of a painful callus can be billed with a “low level E/M code.”
Yes, it is true. The debridement of CALLUSES is not covered unless the patient qualifies for “At Risk, Routine Foot Care. In order for the “Paring or cutting of benign hyperkeratotic lesions (eg. corn or callus) (Please access the definitions of CPT codes 11055, 11056, 11057), the patient via a lower extremity physical examination needs to have “Class Findings” and a covered, systemic disease. This service is only reimbursable every 61 days. The only exception to this rule is specific to the Medicare Administrative Carrier Noridian Healthcare Solutions. This Medicare Administrative Carrier has an additional policy that reimburses for the paring or cutting of a symptomatic hyperkeratotic lesion (ie. callus). Class Findings and a covered systemic disease are not required. The covered service, as for “At Risk,” Routine Foot Care,” is only reimbursable every 61 days.
The big question is: If you evaluate the painful callus and manage the painful callus, would it not be appropriate to bill a low level E/M code? This patient does not want surgery but this is a recurring problem. Can the E/M be billed each time the patient is seen?
Let’s first take a look at what specifically an E/M service is:
E/M is NOT a synonym for an office visit.
It is a 2 part process:
1.“E” stands for EVALUATION. Using a Medically Appropriate History and/or Examination and *Medical Decision Making, you formulate a WORKING DIAGNOSIS. This shows MEDICAL NECESSITY.
2. “M” stands for management. Using the working diagnosis, you now have to do something about it. In other words, you have to TREAT THE PROBLEM. Diagnosing a problem is not sufficient.
3. *Total Time can be used in lieu of Medical Decision Making in order to determine the most appropriate level of E/M service as long as the total time is appropriately documented within the medical record for the date of service in question.
And, if that is not enough,
4. ALL CPT (Procedure) codes have an inherent E/M component.
5. In order to bill an E/M service and a CPT code on the same date of service, whether it is an initial encounter or a subsequent encounter, you must through your
documentation demonstrate the thought process that was used to extract the E/M component from the CPT code to make the E/M service significant and
separately identifiable.
6. You can NEVER, EVER bill an E/M code in lieu of the appropriate CPT code.
So, the answer to the 2 part Big Question:
1. If a patient is seen by a DPM for the first time/initial encounter for this specific problem and has, for example, a painful, hyperkeratotic lesion overlying the medial aspect of the interphalangeal joint of the great toe or has a painful, hyperkeratotic lesion beneath the head of the 2nd metatarsal of the foot, the result of an elongated metatarsal or the result of a prominence on the plantar aspect of the metatarsal head. What would be the correct approach to justify billing the E/M service? The affected foot should be X-rayed, probably with a lesion marker identifying the hyperkeratotic lesion and its relationship to the osseous deformity. It would then be appropriate to discuss the various treatment options available to effectively treat the underlying issue that has resulted in the hyperkeratotic lesion, both conservatively and surgically. This would certainly justify billing the appropriate level of E/M service. This is a one time scenario. It would not be appropriate to X-ray the patient every time they returned with the “painful, hyperkeratotic lesion.” It would not be appropriate to discuss the etiology of the lesion and the treatment options with the patient every time they returned to see the podiatrist with the same painful, hyperkeratotic lesion and bill another E/M service to justify the paring of the hyperkeratotic lesion.
2. An E/M service cannot be billed each time that the patient is seen. See # 6 above.
Last point: If every CPT code has an inherent E/M component, specifically CPT codes 11055, 11056, 11057 and these services are statutorily NOT COVERED for a particular patient, the E/M service itself is a non-issue. It is a non-covered service and the patient would need to pay out of pocket aka cash.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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