CPT

“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 just received a letter from Cigna insurance. As of August 13, 2022, they will require the submission of office notes with claims submitted with Evaluation and Management/E and M codes (ie. 99212, CPT 99213, CPT 99214) appended by modifier -25 when a minor procedure is also billed the same day by the same physician. The E/M will be denied if documentation is not received. The claim can be sent electronically with attachment indicator and notes should be faxed. Is this happening with other insurance companies? The amount of paperwork for a small office is crazy and along with continued decreasing reimbursements, higher prices for supplies, shortages, etc. The insurance companies are making greater profits than ever. The insurance premiums have increased and out-of-pocket patient billing has become more significant. The system is not right. What can we do? How do we fight back? Please don’t say take cash rather than insurance, it’s not practical in many circumstances. Any thoughts?”

“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?”

“My partner prefers to inject the subtalar joint under fluoroscopy. What would be the best procedure code to bill for an injection of the subtalar joint and does the use of fluoroscopy change things?”

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

“A Medicare patient is admitted to the hospital for a foot infection and suspected osteomyelitis of the left, fourth toe. Amputation of the toe is done at the metatarsophalangeal level and billed CPT 28820-T3. However, post-operative x-rays reveal that there is residual bone, presumably from the base of the proximal phalanx that remains. The patient is taken back to surgery a few days later for removal of the residual bone. This was done during the same hospitalization. Would this be coded as CPT 28124-78? Would the -78 modifier not apply since there is no global for the amputation? Could CPT 28124 be billed without a modifier?”

“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?”