“Has anyone else noticed Novitas is not approving E/M codes for treating onychomycosis medically? I saw a patient for evaluation of a discolored toenail. She was concerned it might be a fungal infection and wanted to treat the condition before it worsened. I obtained an H/P, a specimen for culture and discussed treatment options depending on culture results. I billed CPT 99212 with diagnosis code B35.1. The EOB read $0 payment. Code 49 “These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Any advice?”
So, a patient presents to the office with a “discolored toenail.” The patient was evaluated for a fungal infection and wanted to have it treated before it exacerbated. Apparently a medically appropriate history and examination were performed as well as obtaining a nail specimen for a fungal culture to be performed. The various treatment options were discussed with the patient depending upon the results of the fungal culture. Based upon 1 self-limited or minor problem and a minimal risk of morbidity from diagnostic testing or treatment, E/M code 99212 was billed. The health insurance carrier is Novitas. I am assuming that this is a Medicare patient. The ICD-10-CM code that was billed was B35.1 (Onychomycosis). Novitas did not reimburse for the service based upon the premise that what was performed was a routine exam or screening procedure done in conjunction with a routine exam. What gives?
Let’s take a look at this scenario. Certainly, it would have been better if in addition to having the “discolored toenail,” there were other manifestations of a fungal nail infection present, as well. Such findings indicating a fungal infection would include the thickness of the nail, the actual discoloration, the texture of the nail, the presence of subungual debris and malodor. In addition, it would have enhanced the findings if a secondary diagnosis was present as well, specifically pain in the affected toenail (M79.674, M79.675), difficulty in walking, not elsewhere classified (R26.2), secondary infection due to the thickness of the fungal nail (L03.031, L03.032). Thirdly, I believe that the documentation for the date of service in question would also have been enhanced with a greater likelihood of reimbursement if the toenail in question, was a secondary issue with the primary issue being a systemic disease that is a covered entity by Novitas which qualified the patient for “At Risk,” routine foot care with the presence of Class Findings.
The bottom line is that there was not a definitive diagnosis of onychomycosis. A specimen for a fungal culture was submitted with the possibility that the result would be positive. The “discolored toenail” was not supported by secondary findings, nor was it highlighted by a covered systemic disease with Class Findings. Unfortunately, the information that was presented in the above post gave the impression that what was actually performed on this date of service did appear to be a screening examination. I really do not think that if an appeal was filed and the documentation for the date of service in question was submitted that the result would be an overturning of the decision that was originally made by Novitas.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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