Medical Coding

“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?”

“A Medicare patient is admitted to the hospital for a foot infection and suspected osteomyelitis of the left, fourth toe. Amputation of the toe is done at the metatarsophalangeal level and billed CPT 28820-T3. However, post-operative x-rays reveal that there is residual bone, presumably from the base of the proximal phalanx that remains. The patient is taken back to surgery a few days later for removal of the residual bone. This was done during the same hospitalization. Would this be coded as CPT 28124-78? Would the -78 modifier not apply since there is no global for the amputation? Could CPT 28124 be billed without a modifier?”

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?”

“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.”