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.”

“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?”

“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?”

“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.”