“I have recently done bunionectomies on two separate patients with Anthem and received denials. One was a combination of an Austin procedure and an Akin procedure. I billed CPT 28299 -RT. On another patient, I did an Austin procedure and I billed CPT 28296 -RT. Both claims were denied for “inappropriate use of modifier.” I have called the customer service twice and even sent a corrected claim and removed the modifier but claim was still denied. Has something changed with Anthem that I don’t know about?”
This is certainly not the first time that this issue has come up. The fact that Anthem Blue Cross Blue Shield is involved does not surprise me at all. The first patient had an “Austin-Akin” procedure performed on the right foot. This would be appropriately coded using CPT code 28299 which is defined as: Correction, hallux valgus [bunionectomy], with sesamoidectomy, when performed, with double osteotomy, any method. Since it was performed on the right foot, it would be correctly appended by the RT modifier. The second patient had an “Austin” procedure performed on the right foot. This would be appropriately coded using CPT code 28296 which is defined as: Correction hallux valgus [bunionectomy], with sesamoidectomy, when performed, with distal metatarsal osteotomy, any method. Since it was performed on the right foot, it would be correctly appended by the RT modifier.
Since bunionectomies/hallux valgus corrections are performed on the first metatarsal and the metatarsals are considered to be part of the foot, not part of the toe, you would think that the most appropriate anatomical modifier to append to a hallux valgus correction/bunionectomy that was performed on the right foot would be RT. Most health insurance companies with apparently very few exceptions agree with this premise. It appears that Anthem Blue Cross Blue Shield is one of the few that don’t. I don’t have a good explanation to support their decision to reject the hallux valgus correction/bunionectomy codes that were appended by the RT modifier, but they pay for the reimbursement so I guess this is the choice that they made.
When the corrected claims were resubmitted without an anatomical modifier appended to the CPT/procedure codes, I understand why reimbursement was not achieved based upon the fact that the claim lacked specificity. So, how should the claims be billed? Here is my suggestion:
Procedure #1: CPT 28299 – T5
Procedure #2: CPT 28296 – T5
Yeah, I know that this makes no sense, but I have seen commercial health insurance carriers reimburse for procedures that were clearly performed on a metatarsal, but the CPT codes were appended by a digital/toe modifier.
This is my opinion.
Michael G. Warshaw
DPM, CPC
GREAT NEWS!!!
THE 2022 Podiatry Coding Manual is now available in either Book or Flashdrive formats. It has been completely updated including the E/M coding changes. Many offices across the country consider this to be their “Bible” when it comes to coding, billing and documentation. The price is still only $125 including shipping! To purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for $125 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, FL 32757
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