Coding

“If a patient refuses to pay their bill due to a high deductible, is it possible to request the insurance company (i.e. Anthem) to delete the claim? That way, the patient will still be responsible for paying their deductible amount elsewhere.”

“I have great difficulty getting paid for CPT 28308 when a hammer toe repair is performed at the same time. The billing scenario generally will look like this: CPT 28308 (2nd metatarsal osteotomy) -RT CPT 28285 (2nd hammertoe repair) -T1 -59 We never get paid for CPT 28308 in this scenario. Does anyone have any suggestions? We link the acquired deformity of bone diagnosis to CPT 28308.”

Under reciprocal billing arrangements, a patient’s absentee physician may submit a claim and receive payment for services arranged to be provided by a substitute physician on an occasional basis. The regular physician should identify the service as substitute physician services and bill with the Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement).

“Can you evaluate and manage onychomycosis without debridement for the purpose of treating onychomycosis for an established patient? This would be in the absence of pain and underlying conditions, specifically with Medicare patients. Is it a covered condition for just evaluation and management? Would tinea pedis be covered as a sole diagnosis for evaluation and management?”

“We have had more than one claim where Blue Cross Blue Shield of Oklahoma is paying for CPT 28122 but denying CPT 28306, despite the use of the 59 modifier. Our question is why wouldn’t CPT 28306 be allowed instead of CPT 28122 as it is far more work? We are trying to determine how to appeal this.”

“We are inquiring about the use of the Q7 modifier when billing nail and callus debridement with Medicare. We are aware of the changes to the LCD with diagnosis codes. When billing nail debridement CPT 11721 and callus debridement CPT 11056, we are submitting diagnosis codes Z89.412 and Z89.422, (acquired absence of toe) with a Q7 modifier to show “non-traumatic amputation of a foot or an integral skeletal part of the foot.” Now we are being told by Medicare that per the LCD, we cannot bill those diagnosis codes even with a Q7 modifier. Should we be billing with a different modifier?”

“I am curious when and how to bill G0127 or G0247 instead of CPT code 11721 when performing Routine Foot Care.”

“I recently saw a new patient with Oxford insurance for a tinea problem. A prescription was given and options for additional treatments were discussed. We billed his insurance for an initial office visit. The visit was allowed by insurance and the payment was applied to his deductible. He was billed by us. He checked with Oxford and is now telling us that “preventive” care is not subject to the deductible and would like me to resubmit to Oxford telling them that the visit was for “preventive” care. My opinion is that “preventive” care does not really apply to a specialist and that I could not undo what I already submitted. Can we bill for “preventive” care and, if so, is it possible to resubmit the claim?”

“Based on your experience with the new E/M guidelines, is it possible and appropriate for a podiatrist to bill a level 4 or 5 if the documentation is supported? These higher levels have always been taboo (especially level 5). Some patients are at a higher risk with diabetes, chronic non-healing ulcers and wounds etc. Some patients need amputations. Based on the documentation, I believe achieving these higher levels is possible.”

“I often provide wound care for hospice patients and append the GW modifier. However, I recently read that it would be hard to defend this as the wound(s) and wound process is likely related to the patient being deconditioned and malnourished due to their hospice qualifying condition. I am looking for clarification regarding this, should I stop performing wound care services to hospice patients?”