Medical Billing

“I performed a partial 1st ray amputation that included the hallux and part of the 1st metatarsal. The site did not heal, and a new infection developed at the amputation site. The result is a return to the operating room for a right trans-metatarsal amputation. For the subsequent surgery, I used Modifier 78. After all, this was an unplanned return to the operating room. I evaluated the patient post operatively and I am wondering which date should I be using for the 90-day global period?”

“Since the global period for a toe amputation is now zero days, does that mean I bill for removing sutures in the office when I do a follow up visit in 14 days? Billing for this, seems very uncomfortable to me.”

“My practice involves a lot of wound care and I frequently take patients to the operating room for a debridement involving a wound and bone with osteomyelitis. I always code this type of procedure as CPT 11043 and CPT 11044. I feel that this is justified because I am debriding the soft tissue structures (CPT 11043) but also the bone (CPT 11044). I was discussing this with a colleague and she suggested that this might not be appropriate.”

“What code would you recommend for the excision of a pressure ulcer? Here is an excerpt from the operative report: “Attention was directed to the left plantar medical foot at the level of the arch where an approximately 3 cm round chronic ulceration with underlying bursa formation was noted. At this time, an elliptical incision was made in a 3:1 fashion running in line with the foot from toe to heel. This incision was deepened through subcutaneous tissues with care being taken to identify and retract all vital neurovascular structures. At this time, dissection scissors were utilized in order to remove the chronic ulceration with underlying bursa. The skin margins were then separated in order to free up and allow for skin closure.”

“I had a patient present to the clinic with multiple, minimally displaced toe fractures. She has Medicare and we are planning to treat all four of these conservatively. When and how do I use CPT code 28510?”

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?”

“I am having trouble finding an appropriate code to bill for a procedure to remove tophaceous material at a toe. The location was the left 2nd toe. This was performed in the office and a digital block was utilized to obtain anesthesia at the toe. Using a 3mm dermal curette, approximately 1 mL of tophaceous material was removed and a sterile gauze dressing applied. I planned to use ICD-10 M1A-0721. What CPT would be appropriate in this situation?”

“I am trying to educate my physician about the documentation requirements for CPT 11721. He doesn’t think it’s important to document the number of nails debrided or even the method of debridement. Is there a resource you can point me to that specifically addresses this?” This was addressed last week. “Since it is stated – CPT 11721: Debridement of nail(s) by any method(s); 6 or more, why would it be necessary to document what instruments were used for debridement since any method would be accepted under this description?” This is part 2.

I am trying to educate my physician about the documentation requirements for CPT code 11721. He doesn’t think it’s important to document the number of nails debrided or even the method of debridement. Is there a resource you can point me to that specifically addresses this?