Billing

“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?”

“My partner prefers to inject the subtalar joint under fluoroscopy. What would be the best procedure code to bill for an injection of the subtalar joint and does the use of fluoroscopy change things?”

“For Medicare, it has been well established that debridement for callouses is not covered when class findings are not present. But what about that patient that complains of pain from a callus. If you evaluate the painful callus and manage the painful callus, would it not be appropriate to bill a low level E/M code? This patient does not want surgery but this is a recurring problem. Can the E/M be billed each time the patient is seen?”

“What procedure codes represent the treatment of an abrasion? Are we restricted to E/M codes?”

“I received notice I am being selected for a TPE (targeted probe & education) review by Novitas Medicare. I practice in New Jersey. I have gone over the LCDs and the “educational” materials they sent. My documentation seems to be aligned with what they want. Any advice for working with them to have this resolved as soon as possible? Any things to avoid? Should I have someone other than myself act as a liaison between Medicare and me?”

“Is there a foolproof way to deal with the “Medicare doesn’t cover orthotics” issue? Is there an article that explains to the irate patient on the difference between functional orthotics and diabetic insoles and what is covered by Medicare? In this scenario, we typically explain to the patient that orthotics for plantar fasciitis are not covered. We have them sign an ABN and we can easily send the L3000 into Medicare with the GY modifier. We can share this with the patient and they can see that it is not covered. However, what can we do when the patient calls Medicare themselves and are told that orthotics are covered?”

“We had a patient that was dispensed an ankle foot orthoses (AFO) about 4 1/2 years ago. This device broke and he was having difficulty walking without it. We dispensed a new AFO and it was denied as the original wasn’t 5 years old. We had a very long telephone conversation with Medicare along with the patient and his attorney. Unfortunately, Medicare wouldn’t budge as they said he should have gone back to the provider of the original brace, even though it was in another state. We did have an ABN, but the patient said that he’s not going to pay for the replacement. We are working with him now to at least get our lab costs. Unfortunately, appeals don’t always work. We requested a peer-to-peer, but after several months we have not heard anything as they are too backlogged! I suspect that there are other stories like this out there. I wish we could just tell patients what it costs and they hand over their credit cards.”

“I have an adult patient who suffered from posterior tibial tendon dysfunction. A local surgeon addressed this by placing a subtalar joint arthroereisis implant. This had a very positive effect on the structure of the foot and reducing the symptoms at the posterior tibial tendon. Unfortunately, 5 months after the procedure, she is now having symptoms at the subtalar joint and would like the implant removed. There has been no movement of the implant and no breakage of the implant. With the 2022 CPT changes, does the removal of this implant count as an “implant” or “foreign body?”

“We suddenly started getting denials the fourth quarter of last year for a handful of Blue Cross Blue Shield and United Health Care plans for CPT 97597. After a little investigation, the code seems to be tied to physical therapy and is triggering the denials. Is there a modifier that we are failing to use? Has anyone else seen this problem?”

“On all of our patients that qualify for routine foot care with the diagnosis of I70.203 Atherosclerosis we send an “Atherosclerosis Letter” to the patient’s treating doctor with our findings and ask them to sign if they agree with our findings. 99% of the time the doctors send the letter back signed. We have always done this in accordance with the routine foot care LCD that in the past stated that we had that letter or documentation from the treating physician in our patient’s chart “in a timely manner.” Recently we have had some doctors sending back the letter, disagreeing with our findings. We have already billed the services from their initial visit knowing or thinking that we will have that documentation for the next appointment in 9 weeks. This led me to research the LCD again, and I am unable to locate the verbiage that was used before about the patient’s other treating doctors agreeing and signing anything. It merely states that we have our findings in the note and the other doctor’s name on the claim to Medicare. Do we need that letter agreed to and signed from the patient’s other doctor? Do other offices also send this “letter” to get that info? Any input is greatly appreciated.”