Coding

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

“I am part of a recovery audit from CMS for using a modifier 59. Cotiviti Healthcare has been hired by CMS to review my use of modifier 59. They stated that my operative report supports documented Charcot reconstruction and the use of application of external fixator (CPT 20692) but modifier 59 was inappropriately used since both procedures were performed at the same session. Should I have used a different modifier in this situation? Is application of an external fixator (CPT 20692) not considered a separate procedure if it is performed at the same session as other reconstruction procedures?"

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

“In the summer of 2021, when the delta variant was near its peak, I attempted a house call visit to review laboratory results and discuss treatment options. The family of the elderly patient did not want anyone in the house and recommended leaving the results and instructions at the front door. Lab results, my interpretation of the results, prescription and instructions were left at the front door as instructed. This, of course, required driving to the patient’s residence to accomplish this. How could this scenario be billed to Medicare?”

What E/M code would you bill for initial evaluation at an “inpatient” acute care facility in a long term, rehabilitation unit? What “place of service” would you use?

“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?”