Matrixectomy Follow Up

“I have a patient who has Blue Cross insurance. He came in for a matrixectomy on February 8th and returned on February 15th for follow up. I billed CPT 99213 using M79.673 and T81.40XA for the follow up and the claim was denied. Is there another code or modifier that I should include?”

So, a patient had a matrixectomy performed on one of his toes. The correct CPT code to bill for this procedure is CPT code 11750 which is defined as the following: Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal. This procedure is classified as a minor surgical procedure with a postoperative global period of 10 days.

What exactly does that mean? For a Global Period of “10,” the Global Period includes the actual day that the procedure is performed and the next 10 consecutive postoperative days. Thus, in reality, “10” really means “11.” Therefore, it is expected that for the next 10 consecutive days that follow a matrixectomy postoperatively, when the patient is seen for a visit related to the procedure that was performed, the visit or encounter is directly related to the procedure that was performed and is not separately reimbursable.

There are three exceptions to the above rule.

1. 1. UNRELATED E/M SERVICE DURING POST-OP PERIOD – 24 modifier: Use this modifier (only on an E/M code) when you perform an Evaluation and Management service during the follow-up period of an unrelated surgical procedure. You are entitled to bill for an E/M service performed during the follow-up period if that service is not related to the original surgical procedure. In this case, add the -24 modifier to the E/M service code. Make sure you reference this service code to the appropriate unrelated diagnosis on the billing claim.
2. 2. UNPLANNED RETURN TO THE OPERATING/PROCEDURE ROOM BY THE SAME PHYSICIAN FOLLOWING INITIAL PROCEDURE FOR A RELATED PROCEDURE DURING THE POSTOPERATIVE PERIOD – 78 modifier, also known as the “Complication Modifier”: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier -78 to the related procedure.
3. 3. UNRELATED PROCEDURE BY THE SAME PHYSICIAN DURING THE POST-OPERATIVE PERIOD – 79 modifier: Use when performing an unrelated procedure or service during the post-operative period of another surgical procedure.

The patient was seen 1 week/7 days postoperatively and a Level 3 E/M service, CPT 99213 was billed linked to two ICD-10-CM codes, M79.673 (Pain in unspecified foot) and T81.40XA (Infection following a procedure, unspecified, initial encounter and treatment). Clearly, not one of the three exceptions to the global policy rule applies to this postoperative encounter. Therefore, reimbursement was not made.

Additionally, I have a problem with the ICD-10-CM codes that were used despite the fact that the E/M service was not reimbursable. ICD-10-CM code M79.673, Pain in unspecified foot, is not only “unspecified,” which defeats the entire purpose of using ICD-10-CM, but the procedure was performed on a toe not on a foot. The much more appropriate ICD-10-CM code to use would have been either M79.674, Pain in right toe (s) or M79.675, Pain in left toe(s). ICD-10-CM code T81.40XA, Infection following a procedure, unspecified, initial encounter and treatment, is once again not specific enough. A much better ICD-10-CM code to use would have been T81.41XA, Infection following a procedure, superficial incisional surgical site, Initial encounter and treatment.

The above are my opinions as to why I believe BCBS denied the postoperative visit claim that was billed.

Michael G. Warshaw

DPM, CPC

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