Coding

Since CPT code 11703 is a targeted CPT/procedure code by Medicare, what do I need to know to make sure that I don’t get in trouble?

What does “Same and Similar” mean when it comes to DME, specifically regarding Ankle Foot Orthoses, aka AFOs?

When is it appropriate to bill for the trimming of a callus and the debriding of a nail on the same toe on the same date of service?

Why can’t an E/M service be billed every time that a procedure is performed on a patient in the office setting? When can an E/M service be billed when a procedure is performed on a patient in the office setting?

Routine Foot Care, which includes trimming or debridement of the asymptomatic dystrophic, mycotic, or normal toenails is covered by Medicare only when the patient has one of the Medicare-specified systemic diseases with clinically significant peripheral complication placing the patient “at risk” for infection and/or injury if a non-professional attempts to trim or debride the nail. However when the nail becomes ingrown, and the surrounding soft tissue is complicated by pain or inflammation, then its care is no longer “routine,” but involves a pathological state. This state is characterized by one or more of the following: pain, inflammation of the nail bed, inflammation of the surrounding soft tissue, infection and/or abscess.

Medical Record Documentation 1. Indicate the size, depth, grade, and appearance of the wound or ulcer. This is done on every encounter.   2. Indicate the type of tissue or material removed from the wound or ulcer. The tissue or material must be necrotic. This is the sole factor that determines the debridement code to bill. The selected debridement code is based upon the deepest level of necrotic tissue that is excisionally debrided from within the ulcer. 3. Chart the location of the wound or ulcer. This is the only time in the entire process that the location is stated.   4. Indicate any anesthesia (or lack of need) used during the debridement. This is imperative for 11043 or 11044. 5. Indicate any associated status factors that may affect treatment

A diabetic patient undergoes a transmetatarsal amputation. Due to the infectious process, the surgeon decides to perform delayed closure at point “X” in the future. When the time arrives to close the surgical site, the appropriate wound closure code is billed appended by the 58 modifier. This confirms a documented “staged, related, pre-planned procedure.”

Physical Therapy: For Calendar Year 2022, the combined outpatient physical therapy and speech language pathology cap is 2,150.00. Physical Therapy is a covered service when that service is medically reasonable and necessary to restore a patient’s level of function that was lost or reduced due to injury or illness. To substantiate medical necessity, there must be a written indication in the medical record regarding the expected improvement. Prior to treatment, a physician must certify the Medical Necessity for the therapy and establish a “Plan of Treatment.”

Minor Surgery: Any CPT code that has a Global Period of “0” or “10” days is classified as a Minor Surgical Procedure. Major Surgery: Any CPT code that has a Global Period of “90” days is classified as a Major Surgical Procedure.

Can an Unlicensed Individual Perform Nail Debridements Under the License of a DPM and Can the Service be Billed to Medicare?