E/M

“I have a patient who suffered an inversion, ankle injury. This injury resulted in a severe sprain of the lateral ankle ligaments and a fracture of the fifth metatarsal. The initial treatment involved immobilization using a CAM boot. I billed an E/M code and CPT 28470 at the initial visit. Eight weeks later the patient is in clinic, the 5th metatarsal fracture has healed clinically and radiographically. However, the ankle ligaments are clinically symptomatic and the patient is complaining of continued ankle instability. This clinic visit was focused on continued treatment of the lateral ankle ligaments and we are considering an MRI for further evaluation. I know I am still in the global period for CPT 28470, but I am still working on this ankle! Can we bill an E/M for this visit?”

“We have a disagreement among our group regarding radiology billing. If a new patient presents with x-rays, MRI, etc., from an outside source, without a report (or with an inadequate report), can the podiatrist bill for the professional component of reading the imaging studies provided?”

“As a general question, I am wondering if a physician documents that the patient has had symptoms for longer than a year and has failed conservative/other treatment, can this problem be considered as “chronic with exacerbation/progression”? I am referring to the verbiage in the CPT book (page 13, under Stable, chronic illness) regarding the expected duration of at least 1 year and am wondering if it is applicable in this scenario. Also, I know that a diagnosis of osteoarthritis is inherently considered “chronic”, but I am wondering if there are other diagnoses that can be considered ‘chronic’, as well?”

“I think it is time for this topic to resurface. Being a coder/biller for a number of podiatrists around the U.S., I am finding that some are still scheduling “annual diabetic foot exams” as a routine on all of their diabetic patients. They are then performing a “full physical exam” and trying to bill an E/M. Sometimes this coincides with callus or nail treatment, at which time they want to add the 25 modifier. Of course, I am telling them that Medicare does not pay for an “annual diabetic foot exam” and that it is not a benefit and as such should be CASH. Has anything changed?”

“Has anyone else noticed Novitas is not approving E/M codes for treating onychomycosis medically? I saw a patient for evaluation of a discolored toenail. She was concerned it might be a fungal infection and wanted to treat the condition before it worsened. I obtained an H/P, a specimen for culture and discussed treatment options depending on culture results. I billed CPT 99212 with diagnosis code B35.1. The EOB read $0 payment. Code 49 “These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Any advice?”

Based upon an article that is posted within The American Institute of Healthcare Compliance website, it is important to note that the OIG is Auditing for Abusive Dermatology Claims. The Office of the Inspector General (OIG) is auditing dermatologists for billing an E/M service on the same date of service that a minor surgical procedure (ie. postoperative global period of 0 or 10 days) is performed. Medicare only covers Evaluation & Management (E/M) services on the same day as a minor procedure if a physician/surgeon performs a significant and separately identifiable E/M service that is unrelated to the decision to perform the minor surgical procedure. In order to bypass the CCI edits or the Correct Coding Initiative edits and bill for the E/M service and the minor surgical procedure/CPT code on the same date of service, the 25 modifier needs to be appended to the E/M service.

“I have several healthy Medicare patients that have painful calluses. These patients come to my office, sometimes monthly complaining of painful callouses. I understand that Medicare does not cover the routine trimming of calluses in healthy patients. However, I have been billing CPT 99212-13 with the diagnosis codes of L84 (corns and callous), M77.4X (metatarsalgia). The documented management plan for L84 is discussion of moisturizing the feet, not waking barefoot, etc. and then I debride the callus. The documented management plan for metatarsalgia is discussion of metatarsalgia and surgical options, and then I place felt padding in the shoe, or modify the shoe to take pressure off the callus. My patients rarely follow my advice for moisturizing and not going barefoot; so ultimately, the calluses come back. Is this appropriate billing? The treatment I provide is instrumental in preventing a wound or ulceration from occurring (which I also document). Also, it relieves the patient of pain. Is it appropriate to bill an E/M code in lieu of a procedure code if the procedure is not covered?”

"An in-patient consultation was done and later on the same day an in-patient surgical procedure was performed. Medicare has paid for the consultation code but has denied payment for the procedure stating that “a CPT or a CPT/modifier combo is not compatible with another procedure or CPT/modifier combo provided on the same day according to the CCI.” The codes used were CPT 99222 and CPT 28820 (T6). Any suggestions?”

“Can you evaluate and manage onychomycosis without debridement for the purpose of treating onychomycosis for an established patient? This would be in the absence of pain and underlying conditions, specifically with Medicare patients. Is it a covered condition for just evaluation and management? Would tinea pedis be covered as a sole diagnosis for evaluation and management?”

“Based on your experience with the new E/M guidelines, is it possible and appropriate for a podiatrist to bill a level 4 or 5 if the documentation is supported? These higher levels have always been taboo (especially level 5). Some patients are at a higher risk with diabetes, chronic non-healing ulcers and wounds etc. Some patients need amputations. Based on the documentation, I believe achieving these higher levels is possible.”