“I am a young physician and the practice that I am currently at codes almost all routine foot care patients as the following: 1. Tinea ungium B35.1, 2. Peripheral Vascular Disease (PVD) I73.9, 3. Pain in left toe. Documentation is all the same: “All nails are thickened, discolored, and painful with subungual debris” with CPT 11721. Basically, there is no individual nail documentation and all nails are always painful with PVD. This includes younger, disabled patients who present with some thickened nails. I was under the impression that you have to document individual nails and that pain alone is a qualifying diagnosis for nails, if used as the secondary code. My question is: wouldn’t coding only CPT 11721, with pain and PVD to all toes all the time raise red flags?”
Based upon the above post, it appears that most if not all encounters for “At Risk” Routine Foot Care are being billed the same way. Is this potentially problematic? You bet it is! This is almost like asking the health insurance carrier the following question: “Can you please audit me?”
Assuming that the health insurance carrier is traditional Medicare, although I am sure that Medicare Advantage plans and commercial health insurance carriers take a similar position, as a general rule, Medicare audits a physician based upon two premises: trends and patterns. If a physician is billing for something more frequently or more often than the other physicians of the same specialty in the same state or is billing for something differently that the other physicians of the same specialty in the same state, this creates a trend or a pattern and is quite likely to trigger an audit. The position of the health insurance carrier, primarily traditional Medicare is: why is this podiatrist billing for this particular CPT code linked to the same ICD-10-CM codes more often than the other podiatrists in the same state? Audits are how they investigate this and whether they are CERT, RAC or TPEs, all make the same assumption in advance. Since this podiatrist is billing this CPT code more than most of the podiatrists in the state, he/she must be billing incorrectly or fraudulently.
In the above post, “At Risk,” Routine Foot Care is being addressed. CPT 11721 is being billed continuously linked to the same ICD-10-CM codes, B35.1, I73.9, M79.675. How can all if not most of these patients that qualify for “At Risk” routine foot care have the same issues necessitating the exact same procedure to be performed? I can tell you right now that one of the most audited CPT codes in podiatry is CPT 11721: Debridement of nail(s) by any method(s); 6 or more. When it comes to “At Risk” Routine Foot Care, it is mandatory for each patient to be evaluated individually in order to determine the covered systemic disease that qualifies the patient for coverage, what are the appropriate podiatric findings and diagnoses, what are the Class Findings that are present in order to determine the most appropriate Q modifier to append to the CPT code(s) that are billed. The codes in question are CPT 11055, CPT 11056, CPT 11057, CPT 11721, CPT 11720, CPT 11719, G0127.
I would urge any podiatrist that is performing and billing for “At Risk” Routine Foot Care to access the local coverage determination (LCD) for Routine Foot Care and the associated article for Billing of Routine Foot Care in the state where they practice. These two pieces of information need to be read and followed. These are the rules. When a physician signs a contract with the Medicare Administrative Carrier in the state where they are practicing, it states right in the contract that you agree to follow the rules. These are the rules. Follow them! For example, in the state of New York, the Medicare Administrative Carrier is National Government Services or NGS. The LCD is L33636. The Associated Article is A57759.
One last point. When it comes to “At Risk” Routine Foot Care, pain in the toes, ICD-10-CM codes M79.675 (Pain in the left toe(s)) and M79.674 (Pain in the right toe(s)) should not be used as linked ICD-10-CM codes to CPT 11721 or CPT 11720. These two ICD-10-CM codes are used in the appropriate fashion for the coverage of symptomatic mycotic toenails in the otherwise healthy patient.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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