Billing

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 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.”

“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.”

“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?”

“We are having difficulty with a denial when combining CPT 28320 and CPT 20680. CPT 20680 is being rejected as unbundling. According to CCI edits, CPT 28320 is a Column 1 code and CPT 20680 is a Column 2 code and they are allowed. The surgeon removed hardware from a prior surgery performed by a different surgeon not associated with the practice then repaired a non-union and applied new fixation. Is the removal of prior hardware actually included in CPT code 28320? If not, what modifier should be used if it is the same incision/surgical site as the non-union repair?”

Medicare has released updated articles to reflect the annual ICD-10 update. These updates are effective on October 1 and change the coding and documentation requirement for many services we provide.