Medical Billing

“If a Medicare patient is seen in the emergency department and then surgery is performed later that day or night, can the emergency department consult be billed with a modifier -57 along with the surgery? We have been under the impression that, at least in the office, the visit to decide to do the surgery is included in the surgical fee. Are we correct and does this apply to the encounter in the emergency department too?”

“I have been getting insurance denials for subsequent billing of CPT code 11042 after one has been previously performed. Regardless of what level of tissue is debrided, my biller is saying I can only bill CPT code 11042 every 60 days. The biller is telling me that if I debride any level of tissue within those 60 days, I should bill CPT code 97597 until 60 days have passed. Then after 60 days, I can bill CPT code 11042. This does not seem appropriate. Should we appeal?”

“We have had an influx of phone calls that are burdening our clinical hours. We have been flooded with questions that pertain to patient care, clarification of orders and home care instructions. Is there a way to bill for these calls? Each call can take 20-45 minutes for our medical assistants to complete. And we are trying to manage a full clinic at the same time.”

Can I bill for using intraoperative fluoroscopy (C-arm) to assist in hardware placement before, during and after the procedure? The images are all taken while in the operating room. If so, do I need a modifier for the code? Can I use the same CPT for the surgery with the code for the intraoperative x-ray or does it require a different CPT code? Thank you!

“The NCCI edits talk about having calluses on toes 2-5 that are proximal to the distal interphalangeal joint (DIPJ). However, what about the hallux? We have diabetic patients with class findings that meet the criteria to debride hallux toenails. Occasionally, these patients also have a callus at the medial interphalangeal joint (IPJ). Payment is being denied on appeal due to the rule about not being a separate toe or proximal to the DIPJ. However, the hallux does not have two joints – just the IPJ. Is the IPJ thus considered the most distal joint? And debriding calluses either plantar to the IPJ or medial to the IPJ is included in the code?”

“I was working at the local wound care clinic last week when this scenario presented itself. The patient was referred from the emergency room for follow for a wound. His wound was a deep wound at the medial malleolus of the right ankle. The posterior tibial tendon was right there, as clear as day. There was necrotic and fibrotic tissue around the tendon. I debrided the area, including the tendon, and all surrounding non-viable tissue. The patient had a superficial wound at the right hallux. Here are my questions: 1. Can we bill CPT 11043 and CPT 11044 in a wound care center? 2. Are we allowed to bill more than one wound debridement during the same visit? 3. Can I bill an E/M for the hallux wound, if only debrided the ankle wound?”

“We had a patient present with a fracture of her foot. The debate in the office is the ICD-10-CM definition of “subsequent care” as it refers to trauma. We saw the patient, diagnosed a fracture and chose to treat the fracture with conservative care. Would those follow up visits be considered “subsequent care” or “initial care” while we follow through with the initial treatment for the fracture?”

“I have a patient with a nonhealing pressure wound on his right ankle and his right heel. I applied a skin graft substitute to both sites. I used a single piece and shared it between the two sites. The ICD 10 code I used for the ankle is L89.513. The ICD 10 code I used for the heel is L89.613. For the application codes I utilized CPT 15271-RT to the L89.513 and CPT 15275-RT to the L89.613. The CCI does not show any conflict, but I am wondering whether a -51 is necessary. I also used the correct Q code for the product.”

“A new patient was seen with heel pain. X-rays were taken at an outside facility, and I independently interpreted these and reviewed the labs. Based on medical decision making, I believe I should be coding CPT 99204. The patient had one new, acute problem (previously undiagnosed) and I independently interpreted tests. To me this is a no brainer, but my office staff argues that they believe it should be CPT 99203. Thoughts?"

“My billing team and I have a difference of opinion. If we apply more than one graft, they have been using modifier -76. It is getting paid, but I am not sure that is the appropriate use of the modifier. I just assumed we bill for total units. However, each graft has a unit number. So, if we bill double the units, we need a way to alert the insurance company as to why the units are doubled. This is why we started using the 76 Modifier. Any input would be appreciated.”