Coding Pearls

In 2019, the OIG performed an audit of claims that were billed by podiatrists for E/M services. The audit examined whether podiatrists’ claims for E/M services billed with the 25 modifier, which indicates that the E/M service was significant and separately identifiable from a minor surgical procedure billed on the same date of service, one that has a postoperative global period of 0 or 10 days, complied with Medicare’s guidelines. One hundred (100) claims were sampled, and it was found that forty-four (44) claims did not comply with Medicare’s guidelines. The OIG estimated that $39.6 million of the $222.5 million paid by Medicare during the audit period was inappropriate. It was found that during the audit period, CMS’s oversight may not have been sufficient to prevent improper payments.

I have a patient with diabetic peripheral neuropathy and foot ulcers. I have been debriding the ulcers every two weeks, and we have billed out CPT 11042. Cigna has denied our latest two claims and the EOB says, “Procedure code is invalid for DOS and global.” There is no global for CPT 11042 and there should not be a procedure code invalid for any DOS with these claims. Any thoughts on what to do next?

“I know with Medicare and Medicaid you bill any DME the date of dispensing. I am curious about commercial insurance plans. Can you bill the day you cast for devices?”

Can the use of an interpreter (ie. different language spoken, hearing impaired) increase the level of E/M service based upon time?

Acceptable methods for handwritten signatures are: 1. A legible full signature 2. A legible first initial and last name 3. An illegible signature accompanied by signature log or attestation statement 4. Initials over a printed or typed name 5. Electronic signature

“Need advice on codes and modifiers.... My associate removed painful hardware from a previous Lisfranc dislocation repair (only removed the hardware from the 1st met-cuneiform joint, not the other tarsometatarsal joints), and redid a 1st met - med. cuneiform arthrodesis with new hardware. He also did a sliding calcaneal osteotomy with fixation. He did a 1st proximal phalanx osteotomy. All on the right foot. Highmark insurance in PA was the health insurance carrier.

“My business partner and I have different opinions regarding this issue and I’m having trouble finding a succinct and primary source document. When performing nail care and callus care for a high-risk patient, can you bill for both when the callus is located on the tip of the toe? It is my understanding that the skin is a separate structure than the nail and thus they are separate diagnoses and CPT codes, but my business partner states he heard a lecture that stated not to charge for calluses that occur on the same toe as a nail that is trimmed or debrided. This seems to be an LCD-dependent decision as I have not been able to locate anything in CMS policy that states either way. Can someone point us in the right direction with primary source reference?”

“I have a patient with a nonhealing pressure wound on his right ankle and his right heel. I applied a skin graft substitute to both sites. I used a single piece and shared it between the two sites. The ICD-10 code I used for the ankle is L89.513. The ICD 10 code I used for the heel is L89.613. For the application codes I utilized CPT code 15271-RT for L89.513 and CPT code 15275-RT for L89.613. The NCCI Edits does not show any conflict, but I am wondering whether a -51 is necessary. I also used the correct Q code for the product.”

What Is This Code? When Is It Used? Is it Appropriate to be used in Podiatry?

“I was consulted on a patient in the hospital with a large 5th metatarsophalangeal joint ulceration. There was osteomyelitis of the proximal phalanx and metatarsal head. I performed the resection and subsequently performed a delayed closure several days later. The closure left an area open due to soft tissue deficit. This necessitated post operative wound care. I initially billed CPT 28810 and then subsequently CPT 13160. I billed CPT 11042 weekly post operatively, until the wound healed. The private insurance states that all the CPT 11042 billings are considered part of the global.”