Coding

“I have a simple question for which I have not been able to find the correct answer. I have a Medicare patient whom we took to the operating room to remove 3 skin lesions. Two were removed from the left foot and one was removed from the right foot. We used code CPT 11421 and are planning on billing the following way: CPT 11421 – 50 (2 units, one lesion on the LT and one the RT) CPT 11421 – LT (the other lesion on the LT) I checked CCI edits and it says I do not need to use a 59 modifier but I feel like I should. Some people have said to use XS modifier. Some have said to bill one code 3 units and others to bill 11421 3 times. What’s the correct answer?”

“My clinic is at the local hospital. I send X-rays to the radiology department. They are eventually read by a radiologist. However, I actually evaluate the x-rays and interpret them myself. Can I bill that component of the radiology fee? And if I do, will it affect radiologist reimbursement?”

“I am in practice and would like to figure out a different way to contain and manage my routine foot care. It is approximately 15% of my practice. I would like to designate one morning a week as a routine foot care clinic. I am considering making this a cash only clinic: $50 for toenails and $50 for calluses. Is this possible? I am a Medicare provider and have contracts with most insurance companies. I was hoping to model my cash clinic on what some nurses in the area have done. They visit a nursing home and offer residents $25 for routine foot care and do not work with any insurance companies or Medicare. Any thoughts on this cash model, routine foot care clinic would be appreciated.”

“I have a rheumatoid patient with a grossly deformed interphalangeal joint with significant osseous malformations leading to a chronic ingrown toenail on the hallux fibular border. I have ruled out any infection, osteomyelitis, or neoplasm. The bone is grossly hypertrophic and needs excision along with the nail structures on the fibular border. There also may need to be some plastic closure performed. What are the appropriate ICD10 and CPT codes reflective of this scenario?”

“I have been getting denials from BCBS, First Care, Aetna, and UHC on claims billed out with diagnosis codes M72.2, M71.571, M71.572, M77.31, and M77.32. Has anyone else had this problem lately? The NDC number and the description are on the claim. The claim is going out as follows: CPT 99213 25, CPT 20550 RT, CPT 20550 LT, J0702 x 2 units, J1030 x 2 units.”

“I’m trying to determine the coverage of diabetic shoes for a patient who has had one foot/leg amputated. Somewhere in my brain I seem to remember that Medicare will cover a pair of shoes so the amputee can wear the shoe on his prosthetic. Does this also apply to heat moldable inserts? Can we dispense them for the shoe that will be used on the prosthetic leg? I would appreciate any thoughts on this situation. I have read the LCD and associated article but can’t seem to fully understand how this works.”

“Is the debridement of a plantar keratosis (CPT 11055) at the first metatarsal head considered bundled with nail debridement (CPT 11720)?”

“I just received a letter from Cigna insurance. As of August 13, 2022, they will require the submission of office notes with claims submitted with Evaluation and Management/E and M codes (ie. 99212, CPT 99213, CPT 99214) appended by modifier -25 when a minor procedure is also billed the same day by the same physician. The E/M will be denied if documentation is not received. The claim can be sent electronically with attachment indicator and notes should be faxed. Is this happening with other insurance companies? The amount of paperwork for a small office is crazy and along with continued decreasing reimbursements, higher prices for supplies, shortages, etc. The insurance companies are making greater profits than ever. The insurance premiums have increased and out-of-pocket patient billing has become more significant. The system is not right. What can we do? How do we fight back? Please don’t say take cash rather than insurance, it’s not practical in many circumstances. Any thoughts?”

“I have a patient who has Blue Cross insurance. He came in for a matrixectomy on February 8th and returned on February 15th for follow up. I billed CPT 99213 using M79.673 and T81.40XA for the follow up and the claim was denied. Is there another code or modifier that I should include?”

​​​​​​​“I have a Medicare patient that has healed a neuropathic ulcer (L97.522, E11.62) at the plantar base of his 5th metatarsal. He needs paring of the hyperkeratotic tissue, frequently with hemorrhagic changes, every four weeks or he re-ulcerates at this location. Should this be coded as: CPT 11055 using a GY modifier every other visit? Debriding devitalized tissue CPT 97597 or am I evaluating and managing an ulcer CPT 9921X?”