Medical Billing

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?

“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.”

“I saw a patient with a history of chronic onychocryptosis. On this date of service, he presented with a red, swollen, tender right great toe. I performed an E/M and diagnosed paronychia L03.031 for which I took a culture for a gram stain and culture and sensitivity. I discussed the problem with the patient, prescribed an oral antibiotic and gave him instructions. I billed CPT 99213-25 for this. During the same visit, I addressed hypergranulation tissue L92.9 of the same toe. I treated it by excising the tissue and cauterizing the area with silver nitrate. I billed CPT 17250. I was told that HMO Blue of Massachusetts retracted the office visit due to an audit and that there are no appeal rights. Insurance states that “there are no other issues managed and treated aside from the procedure. Therefore the documentation does not support a separate E&M level of service.” I would appreciate any insights you have on this situation, especially when I am informed that I have no appeal rights.”

“The patient is a 47 year old with a soft tissue mass over the distal fibula. It appears to be a gouty tophus and x-rays show no bone involvement. What would be the proper code for surgical debridement/excision of this mass?”

”We’re having a debate on coding for the diagnosis of primus varus versus the diagnosis of hallux valgus. When measuring angles, most patients have both a first intermetatarsal angle greater than 9 degrees (for primus varus) and a hallux abducto valgus angle greater than 15 degrees (for hallux valgus). Would we bill for both diagnosis codes? These are the diagnosis codes we use when billing our Lapidus bunionectomies.”

“We have been finding that, just recently, United Healthcare has a problem with the combination of CPT 64450 and CPT 76942. They are paying the CPT 76942. We have appealed with medical records and CPT 64450 still being denied. We have resubmitted with a 59 and are waiting on response. Is anyone else experiencing the bundling of these two codes?”