“I saw an established patient who returned to the office for “At Risk,” Routine Foot Care. The patient also had a new complaint of heel pain. I obtained X-rays of the foot and gave a steroid injection into the heel. Can I bill for the “At Risk,” Routine Foot Care and those additional treatments as well?”
So, an established patient is scheduled to be seen for “At Risk,” Routine Foot Care. The patient had a NEW complaint of heel pain at the same encounter. In other words, this is an established patient with a new problem. In addition to the performance of “At Risk,” Routine Foot Care, the affected foot with the heel pain was X-rayed and a steroid injection was administered into the painful heel. The big question is: “Can The E/M service, Routine Foot Care, the X-rays and the injection be billed for?” Well, yes.
Clearly, since this is an established patient with a new problem, an established patient E/M service can certainly be billed for. A medically appropriate history, a medically appropriate examination and medical decision making of low complexity all need to be performed and documented. Based upon this premise, this would qualify and support a significant and separately identifiable E/M service.
The E/M service would qualify E/M code CPT 99213 to be billed. As far as the X-rays are concerned, I am assuming that 3 views of the affected foot were obtained, and a written report was provided by the physician. This would support the billing of CPT 73630 appended by the LT or the RT modifier depending upon the affected foot. Since this is a Global X-ray study (Technical and Professional Components), an additional modifier is not needed. With respect to the steroid injection, assuming that the plantar fascia was injected, the appropriate CPT code to bill is CPT 20550 which is defined as the following: Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”). This would also be appended by the LT or the RT modifier depending upon the affected foot.
What about the coding scenario?
CPT 99213 – 25 (The 25 modifier is appended to the E/M code to document that the E/M service was significant and separately identifiable) – The ICD-10-CM code to be linked would be M72.2, plantar fasciitis.
CPT 73630 – RT/LT (M72.2)
CPT 20550 – RT/LT (M72.2)
The appropriate “At Risk,” Routine Foot Care CPT/HCPCS Level II codes appended by the appropriate “Q” modifier and the 59 modifier depending upon the NCCI edits would additionally be billed.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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