CPT Codes

“I have a simple question for which I have not been able to find the correct answer. I have a Medicare patient whom we took to the operating room to remove 3 skin lesions. Two were removed from the left foot and one was removed from the right foot. We used code CPT 11421 and are planning on billing the following way: CPT 11421 – 50 (2 units, one lesion on the LT and one the RT) CPT 11421 – LT (the other lesion on the LT) I checked CCI edits and it says I do not need to use a 59 modifier but I feel like I should. Some people have said to use XS modifier. Some have said to bill one code 3 units and others to bill 11421 3 times. What’s the correct answer?”

“My clinic is at the local hospital. I send X-rays to the radiology department. They are eventually read by a radiologist. However, I actually evaluate the x-rays and interpret them myself. Can I bill that component of the radiology fee? And if I do, will it affect radiologist reimbursement?”

“I have a rheumatoid patient with a grossly deformed interphalangeal joint with significant osseous malformations leading to a chronic ingrown toenail on the hallux fibular border. I have ruled out any infection, osteomyelitis, or neoplasm. The bone is grossly hypertrophic and needs excision along with the nail structures on the fibular border. There also may need to be some plastic closure performed. What are the appropriate ICD10 and CPT codes reflective of this scenario?”

“I have been getting denials from BCBS, First Care, Aetna, and UHC on claims billed out with diagnosis codes M72.2, M71.571, M71.572, M77.31, and M77.32. Has anyone else had this problem lately? The NDC number and the description are on the claim. The claim is going out as follows: CPT 99213 25, CPT 20550 RT, CPT 20550 LT, J0702 x 2 units, J1030 x 2 units.”

“I have a patient who has Blue Cross insurance. He came in for a matrixectomy on February 8th and returned on February 15th for follow up. I billed CPT 99213 using M79.673 and T81.40XA for the follow up and the claim was denied. Is there another code or modifier that I should include?”

“Is a plantar keratosis debridement (CPT 11055) at the first metatarsal head considered bundled with nail debridement (CPT 11720)?”

“We had a patient that was dispensed an ankle foot orthoses (AFO) about 4 1/2 years ago. This device broke and he was having difficulty walking without it. We dispensed a new AFO and it was denied as the original wasn’t 5 years old. We had a very long telephone conversation with Medicare along with the patient and his attorney. Unfortunately, Medicare wouldn’t budge as they said he should have gone back to the provider of the original brace, even though it was in another state. We did have an ABN, but the patient said that he’s not going to pay for the replacement. We are working with him now to at least get our lab costs. Unfortunately, appeals don’t always work. We requested a peer-to-peer, but after several months we have not heard anything as they are too backlogged! I suspect that there are other stories like this out there. I wish we could just tell patients what it costs and they hand over their credit cards.”

“I have an adult patient who suffered from posterior tibial tendon dysfunction. A local surgeon addressed this by placing a subtalar joint arthroereisis implant. This had a very positive effect on the structure of the foot and reducing the symptoms at the posterior tibial tendon. Unfortunately, 5 months after the procedure, she is now having symptoms at the subtalar joint and would like the implant removed. There has been no movement of the implant and no breakage of the implant. With the 2022 CPT changes, does the removal of this implant count as an “implant” or “foreign body?”

“We suddenly started getting denials the fourth quarter of last year for a handful of Blue Cross Blue Shield and United Health Care plans for CPT 97597. After a little investigation, the code seems to be tied to physical therapy and is triggering the denials. Is there a modifier that we are failing to use? Has anyone else seen this problem?”

“I saw a patient with a history of chronic onychocryptosis. On this date of service, he presented with a red, swollen, tender right great toe. I performed an E/M and diagnosed paronychia L03.031 for which I took a culture for a gram stain and culture and sensitivity. I discussed the problem with the patient, prescribed an oral antibiotic and gave him instructions. I billed CPT 99213-25 for this. During the same visit, I addressed hypergranulation tissue L92.9 of the same toe. I treated it by excising the tissue and cauterizing the area with silver nitrate. I billed CPT 17250. I was told that HMO Blue of Massachusetts retracted the office visit due to an audit and that there are no appeal rights. Insurance states that “there are no other issues managed and treated aside from the procedure. Therefore the documentation does not support a separate E&M level of service.” I would appreciate any insights you have on this situation, especially when I am informed that I have no appeal rights.”