Coding

“I have an unusual situation that I am trying to figure out how to code. I had a patient return to the office in the global period after I preformed a 1st metatarsophalangeal joint (MTPJ) arthrodesis. Although, the alignment of the fusion looks good, one of the non-locking screws advanced out of the bone and plate and started to tent the skin at the incision site at three weeks post operative. She is neuropathic and denied any trauma to the area. I removed the screw in the office with local anesthesia. Can I bill for unplanned screw removal in the office?”

“I have a patient who suffered a Lisfranc injury that resulted in nondisplaced fractures of the 1st, 2nd and 3rd metatarsal bases. There was no disruption of the alignment of the midfoot. We decided that conservative treatment was the most appropriate option for the patient and this injury. She was casted using fiberglass. I am planning to code this treatment as CPT 28470 Closed treatment of metatarsal fracture; without manipulation, each. I was using the APMA Coding Resource Center and noticed that there is “MUE 2″ for this code. Does this affect how many metatarsal fractures that I can bill for during this treatment?”

“My group takes “call” at our local hospital, and this necessitates seeing patients in the emergency room (ER) on occasion. We are not all in agreement regarding what E/M codes should be used in this scenario. We have come up with different encounters: 1. A patient seen in the ER. The patient is then discharged to follow up for outpatient care. 2. A patient is seen in the ER and then admitted for continued medical treatment. 3. A patient is seen in the ER and is taken straight to the operating room for surgical treatment. What E/M code series would you recommend using for these different scenarios? Thank you for the help!”

“Do you have any advice on coding for a return to the operating room within the 90-day postoperative global period for revision of the prior procedures that were performed? The patient had a 1st metatarsocuneiform joint (MTCJ) fusion and 2nd toe, proximal interphalangeal joint (PIPJ) fusion for a hammertoe. Post op x-rays demonstrated excellent fixation and alignment. The patient returned 2 weeks later and had obvious abnormal clinical changes to position of the fusions. X-rays showed loss of position correction at the 1st MTCJ fusion and the 2nd toe fusion as the two-component implant had disengaged and dislocated. The patient didn’t recall any injury. This required a return to the OR for revision of the fusion of both joints done three weeks post operative. The 1st MTCJ plate and screws were removed, the joint realigned and a new plate/screw construct applied. The 2nd toe PIPJ was opened, and the two-component implant re-engaged for alignment correction. Is the following coding scenario 28740 -78, CPT 28285 -78 correct to bill?”

Do I need to have a referral to provide Routine Foot Care to a patient in a Nursing Home?

“What is the proper CPT code for percutaneous capsulotomy and tenotomy of metatarsophalangeal joint?”

“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?”

“After watching some E/M presentations, it was suggested that hospital consultations should be billed with CPT 99252-CPT 99255. When we billed these codes, our EMR system and our clearing house rejected the codes. They are saying effective 1/1/2010, CMS has announced that they will reject these codes. Are we billing the right codes?”

“How do you code for a fracture of the tibial sesamoid? Is it any different if you considered it to be a symptomatic, bipartite tibial sesamoid? What about an avascular necrosis of the tibial sesamoid?”

“I am not sure when I should and can bill for an E/M when seeing patients for wound care. Is it reasonable to bill an E/M code if the patient returns for follow up for their ulcer and it is 100% healed? Occasionally hyperkeratotic tissue is present and sometimes I debride the callus to confirm the ulcer has healed. I always spend time on these visits educating the patient on ulcers and the diabetic foot. Would it be appropriate to code for an E/M at this visit since the vast majority of the time is spent counseling the patient prior to discharging them from care?”