Medical Coding

“What code would you recommend for the excision of a pressure ulcer? Here is an excerpt from the operative report: “Attention was directed to the left plantar medical foot at the level of the arch where an approximately 3 cm round chronic ulceration with underlying bursa formation was noted. At this time, an elliptical incision was made in a 3:1 fashion running in line with the foot from toe to heel. This incision was deepened through subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures. At this time, dissection scissors were utilized in order to remove the chronic ulceration with underlying bursa. The skin margins were then separated in order to free up and allow for skin closure.”

Based upon an article that is posted within The American Institute of Healthcare Compliance website, it is important to note that the OIG is Auditing for Abusive Dermatology Claims. The Office of the Inspector General (OIG) is auditing dermatologists for billing an E/M service on the same date of service that a minor surgical procedure (ie. postoperative global period of 0 or 10 days) is performed. Medicare only covers Evaluation & Management (E/M) services on the same day as a minor procedure if a physician/surgeon performs a significant and separately identifiable E/M service that is unrelated to the decision to perform the minor surgical procedure. In order to bypass the CCI edits or the Correct Coding Initiative edits and bill for the E/M service and the minor surgical procedure/CPT code on the same date of service, the 25 modifier needs to be appended to the E/M service.

"An in-patient consultation was done and later on the same day an in-patient surgical procedure was performed. Medicare has paid for the consultation code but has denied payment for the procedure stating that “a CPT or a CPT/modifier combo is not compatible with another procedure or CPT/modifier combo provided on the same day according to the CCI.” The codes used were CPT 99222 and CPT 28820 (T6). Any suggestions?”

“I am trying to educate my physician about the documentation requirements for CPT 11721. He doesn’t think it’s important to document the number of nails debrided or even the method of debridement. Is there a resource you can point me to that specifically addresses this?” This was addressed last week. “Since it is stated – CPT 11721: Debridement of nail(s) by any method(s); 6 or more, why would it be necessary to document what instruments were used for debridement since any method would be accepted under this description?” This is part 2.

“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.”

“I have great difficulty getting paid for CPT 28308 when a hammer toe repair is performed at the same time. The billing scenario generally will look like this: CPT 28308 (2nd metatarsal osteotomy) -RT CPT 28285 (2nd hammertoe repair) -T1 -59 We never get paid for CPT 28308 in this scenario. Does anyone have any suggestions? We link the acquired deformity of bone diagnosis to CPT 28308.”

Under reciprocal billing arrangements, a patient’s absentee physician may submit a claim and receive payment for services arranged to be provided by a substitute physician on an occasional basis. The regular physician should identify the service as substitute physician services and bill with the Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement).

“We have had more than one claim where Blue Cross Blue Shield of Oklahoma is paying for CPT 28122 but denying CPT 28306, despite the use of the 59 modifier. Our question is why wouldn’t CPT 28306 be allowed instead of CPT 28122 as it is far more work? We are trying to determine how to appeal this.”

“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?”