Coding

“What code would you recommend for the excision of a pressure ulcer? Here is an excerpt from the operative report: “Attention was directed to the left plantar medical foot at the level of the arch where an approximately 3 cm round chronic ulceration with underlying bursa formation was noted. At this time, an elliptical incision was made in a 3:1 fashion running in line with the foot from toe to heel. This incision was deepened through subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures. At this time, dissection scissors were utilized in order to remove the chronic ulceration with underlying bursa. The skin margins were then separated in order to free up and allow for skin closure.”

“I had a patient present to the clinic with multiple, minimally displaced toe fractures. She has Medicare and we are planning to treat all four of these conservatively. When and how do I use CPT code 28510?”

Based upon an article that is posted within The American Institute of Healthcare Compliance website, it is important to note that the OIG is Auditing for Abusive Dermatology Claims. The Office of the Inspector General (OIG) is auditing dermatologists for billing an E/M service on the same date of service that a minor surgical procedure (ie. postoperative global period of 0 or 10 days) is performed. Medicare only covers Evaluation & Management (E/M) services on the same day as a minor procedure if a physician/surgeon performs a significant and separately identifiable E/M service that is unrelated to the decision to perform the minor surgical procedure. In order to bypass the CCI edits or the Correct Coding Initiative edits and bill for the E/M service and the minor surgical procedure/CPT code on the same date of service, the 25 modifier needs to be appended to the E/M service.

Beginning in 2022, if you order Medicare Part B advanced diagnostic imaging services, you must consult appropriate use criteria (AUC) through a qualified Clinical Decision Support Mechanism (CDSM). You must also provide the information to furnishing professionals and facilities, because they must report AUC consultation information on their Medicare claims. When we use “you”, we are referring to physicians, other practitioners, and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to Medicare beneficiaries and billing Medicare Administrative Contractors (MACs).

“I have several healthy Medicare patients that have painful calluses. These patients come to my office, sometimes monthly complaining of painful callouses. I understand that Medicare does not cover the routine trimming of calluses in healthy patients. However, I have been billing CPT 99212-13 with the diagnosis codes of L84 (corns and callous), M77.4X (metatarsalgia). The documented management plan for L84 is discussion of moisturizing the feet, not waking barefoot, etc. and then I debride the callus. The documented management plan for metatarsalgia is discussion of metatarsalgia and surgical options, and then I place felt padding in the shoe, or modify the shoe to take pressure off the callus. My patients rarely follow my advice for moisturizing and not going barefoot; so ultimately, the calluses come back. Is this appropriate billing? The treatment I provide is instrumental in preventing a wound or ulceration from occurring (which I also document). Also, it relieves the patient of pain. Is it appropriate to bill an E/M code in lieu of a procedure code if the procedure is not covered?”

“I am having trouble finding an appropriate code to bill for a procedure to remove tophaceous material at a toe. The location was the left 2nd toe. This was performed in the office and a digital block was utilized to obtain anesthesia at the toe. Using a 3mm dermal curette, approximately 1 mL of tophaceous material was removed and a sterile gauze dressing applied. I planned to use ICD-10 M1A-0721. What CPT would be appropriate in this situation?”

“On February 11, a patient has a transmetatarsal amputation. The patient is a non-compliant, diabetic. The site deteriorates weeks after he leaves the hospital. On March 24, he was readmitted for an infected at the amputation site. On March 26, the remaining 5 metatarsals stumps are removed, and the wound is kept open. How would you recommend coding for the 2nd surgery? What is the code for removing the 5 remaining metatarsal stumps?”

"An in-patient consultation was done and later on the same day an in-patient surgical procedure was performed. Medicare has paid for the consultation code but has denied payment for the procedure stating that “a CPT or a CPT/modifier combo is not compatible with another procedure or CPT/modifier combo provided on the same day according to the CCI.” The codes used were CPT 99222 and CPT 28820 (T6). Any suggestions?”

“I am trying to educate my physician about the documentation requirements for CPT 11721. He doesn’t think it’s important to document the number of nails debrided or even the method of debridement. Is there a resource you can point me to that specifically addresses this?” This was addressed last week. “Since it is stated – CPT 11721: Debridement of nail(s) by any method(s); 6 or more, why would it be necessary to document what instruments were used for debridement since any method would be accepted under this description?” This is part 2.

I am trying to educate my physician about the documentation requirements for CPT code 11721. He doesn’t think it’s important to document the number of nails debrided or even the method of debridement. Is there a resource you can point me to that specifically addresses this?