Coding

“Here’s the scenario: patient has a chronic ulcer left foot that comes in for regular debridements/wound care. Two weeks ago he has a full thickness ulcer and osteomyelitis at the 2nd toe right foot and I performed a partial amputation of the toe in the office. He comes in for postop check five days later and everything is fine. At his 2nd postoperative visit, I notice a new punctate ulcer plantar 2nd toe with exposed bone and progressing osteomyelitis. I did a prep and debrided the bone at this visit (Yes, authorization was submitted for a more proximal amputation at a future appointment.) I also debrided the wound on his left foot. The question I have is with a multiple modifier order/rule for the debridedment of the ulcer left foot. I billed the visit out as follows: CPT 11044-78,T6 CPT 11042-59,79,LT Should the order of the modifiers with the CPT 11042 be -59,79 or -79,59 (or does this matter?) I have seen coding recommendations that say that the 1st modifier should be the “pricing” modifier and the 2nd modifier should be the “procedure” modifier but I am not sure of this.”

“I am trying to get a handle on the 2021 E/M changes. The question I have is about the defining pathology/diagnosis as “acute” versus “chronic.” This is critical in the portion of the medical decision making. What do the guidelines tell us about these definitions?”

“In the past, it has been postulated that a doctor had the option of using a fracture code or using E/M codes to bill for fracture care. With the upcoming changes to E/M reimbursement, it would seem that billing using E/M codes might make for sense for fracture care. Are there any thoughts on these changes upcoming for 2021?”

“We have billed CPT 11730 for all 10 nails using the appropriate toe modifiers. Anthem Blue Cross paid for five of the toes but is denying the other five. The denial comes back with CO-222 (Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific.) Please advise.”

“I am excising a wound on top of the foot (not on the bottom) and opening up to expose a Brodie abscess of the cuboid. Following this, I will be curetting the abscess from the bone to promote bleeding of the bone and filling it with an allograft bone putty impregnated with antibiotics. I am considering using these following CPT codes 28107 and CPT 15999. Is CPT 15999 correct to use for a wound on top of the foot? "

“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 past summer, one of my patients who was suffering from a diabetic foot ulcer was admitted to a skilled nursing facility (SNF) following a hospital discharge. During her admission to the SNF, I continued to care for her in my office, including ulcer debridement and radiographs. Medicare is denying payment for her ulcer debridements (CPT 97597) as well as the technical component of her radiographs (CPT 73630-TC) on the grounds that “all SNF Part A inpatient services are paid under a prospective payment system (PPS)” and that “services that are considered within the scope or capability of SNFs are considered paid in the PPS rate.” In other words, Medicare considers the care that I rendered to be bundled with the payment to the SNF for admission, and therefore the SNF should have been doing it themselves, and that if I want payment I need to bill the SNF since they–in Medicare’s view–outsourced the ulcer care to me. While I fully expect the SNF to balk at any requests for payment from me, and I believe it might still be worth my time to appeal to an Administrative Law Judge, I would like to know if anyone has experienced this? In the future, if I am going to care for the ulcers of my patients when they are admitted to SNFs, is there anything I can arrange with the SNF or with the patient to ensure I am compensated for their care?”

“Can someone please clarify the postoperative global period for a percutaneous flexor tenotomy for flexible hammertoes? I thought the postop global for CPT 28010 was ten days. I discovered that it is 90 days! Is it really the same as a bunion correction? I performed an in office flexor tenotomy successfully on one foot and now the patient requests correction for the other foot. I understand how a longer global period would discourage so called “serial surgeries” for higher reimbursements for multiple procedures on one foot. But on the opposite foot as well?”

“All the nails were trimmed in length with a sterile nail nipper. The leading edges were debrided with the nail bur and electric podiatry drill. The debris under the edges of the great toenails was derided with the sterile curette. Is this nail trimming (CPT 11719) since we DID NOT debride the entire nail (just edges and under toe) or can we bill as CPT 11721?”

“A friend of mine is encouraging me to change how I bill for my Lapidus bunionectomy. I typically bill this using CPT code 28297. I am being told that I should think about billing this “alternatively” as: 1) CPT 28740 2) CPT 28292 Thoughts on this?”