“I have several healthy Medicare patients that have painful calluses. These patients come to my office, sometimes monthly complaining of painful callouses. I understand that Medicare does not cover the routine trimming of calluses in healthy patients. However, I have been billing CPT 99212-13 with the diagnosis codes of L84 (corns and callous), M77.4X (metatarsalgia). The documented management plan for L84 is discussion of moisturizing the feet, not waking barefoot, etc. and then I debride the callus. The documented management plan for metatarsalgia is discussion of metatarsalgia and surgical options, and then I place felt padding in the shoe, or modify the shoe to take pressure off the callus. My patients rarely follow my advice for moisturizing and not going barefoot; so ultimately, the calluses come back. Is this appropriate billing? The treatment I provide is instrumental in preventing a wound or ulceration from occurring (which I also document). Also, it relieves the patient of pain. Is it appropriate to bill an E/M code in lieu of a procedure code if the procedure is not covered?”
I hate to be the bearer of bad news and negativity, but billing an E/M service in lieu of what is, in reality, statutorily non-covered Routine Foot Care is a big, big problem. At face value, this appears to be a pattern of events that can only lead to trouble.
The billing of an E/M service such as 99212 or 99213 using the ICD-10-CM codes L84 (corns and calluses), M77.4X (metatarsalgia) to qualify for coverage is not appropriate if all that is done is the trimming or the paring of the lesions. That being said, if this patient is a new patient and on the initial encounter a medically appropriate history and examination are performed and the two diagnoses, L84 (corns and callous) and M77.4X (metatarsalgia) are identified, certainly a discussion with the patient regarding a management plan for metatarsalgia such as biomechanical and surgical options would qualify to be classified as Medical Decision Making and certainly lead to billing an appropriate level of Initial E/M service, probably 99202. However, moisturizing, padding and trimming of hyperkeratotic lesions is not a billable option and if this is linked to the billing of an E/M service in the future, this definitely creates a very, uncomfortable situation.
The only Medicare Administrative Carrier that does pay for painful, hyperkeratotic lesions is Noridian Healthcare Solutions, LLC. The LCD of note is L34243 – Treatment of Ulcers and Symptomatic Hyperkeratoses. The associated article regarding Billing and Coding should be accessed, as well. Even if the provider practices in a state that has Noridian healthcare Solutions, LLC as the Medicare Administrative Carrier, if the coverage criteria is met, the symptomatic/painful hyperkeratotic lesions can only be addressed (ie. trimmed/pared) once every 60 days, the same as “At Risk,” Routine Foot Care and Symptomatic Mycotic Toenails. Obviously, the treatment of these lesions is not covered if the time frame is less than 60 days.
Here are some general statements regarding E/M services:
1. ALL CPT (Procedure) codes have an inherent E/M component.
2. In order to bill an E/M service and a CPT code on the same date of service, whether it is an initial encounter or a subsequent encounter, you must through your documentation demonstrate the thought process that was used to extract the E/M component from the CPT code to make the E/M service significant and separately identifiable.
3. You can NEVER, EVER bill an E/M code in lieu of the appropriate CPT code.
4. If the service is statutorily not covered, you can NEVER, EVER bill an E/M service in lieu of the patient signing an ABN and paying for the service provided out of pocket.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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