Medicare

“I documented a women’s size 10.5 shoe measurement in my Medicare note and then ordered the shoes from my diabetic shoe supplier. The supplier mailed me a pair of men’s 8.5 shoes since they are essentially the same size as a woman’s 10.5. In an audit, would Medicare have a problem with the size discrepancy, since I have to document that I dispensed a men’s 8.5 rather than the originally fitted women’s 10.5?”

“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?”

Beginning in 2022, if you order Medicare Part B advanced diagnostic imaging services, you must consult appropriate use criteria (AUC) through a qualified Clinical Decision Support Mechanism (CDSM). You must also provide the information to furnishing professionals and facilities, because they must report AUC consultation information on their Medicare claims. When we use “you”, we are referring to physicians, other practitioners, and facilities ordering advanced diagnostic imaging services and/or furnishing Part B advanced diagnostic imaging services to Medicare beneficiaries and billing Medicare Administrative Contractors (MACs).

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?

Here’s a fun fact that is wreaking havoc in practices with a large volume of patients over 65, especially where facility work (SNFs, assisted living, nursing homes) is involved: Enrollment in Medicare Advantage Plans has DOUBLED over the past decade It has been reported so far in 2021 that approximately 43% (up from 39% in 2020; see graph below) of the 63 million individuals who “have Medicare” actually receive their benefits via an Advantage Plan. And just when you thought you were finished updating patient insurance information in January and February, if those Medicare Advantage patients decide that the plan they chose was not the right fit and they want to go back to traditional Medicare, they have until March 31st to do so.

“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?”

“I often provide wound care for hospice patients and append the GW modifier. However, I recently read that it would be hard to defend this as the wound(s) and wound process is likely related to the patient being deconditioned and malnourished due to their hospice qualifying condition. I am looking for clarification regarding this, should I stop performing wound care services to hospice patients?”

“In the past, it has been postulated that a doctor had the option of using a fracture code or using E/M codes to bill for fracture care. With the upcoming changes to E/M reimbursement, it would seem that billing using E/M codes might make for sense for fracture care. Are there any thoughts on these changes upcoming for 2021?”

“This past summer, one of my patients who was suffering from a diabetic foot ulcer was admitted to a skilled nursing facility (SNF) following a hospital discharge. During her admission to the SNF, I continued to care for her in my office, including ulcer debridement and radiographs. Medicare is denying payment for her ulcer debridements (CPT 97597) as well as the technical component of her radiographs (CPT 73630-TC) on the grounds that “all SNF Part A inpatient services are paid under a prospective payment system (PPS)” and that “services that are considered within the scope or capability of SNFs are considered paid in the PPS rate.” In other words, Medicare considers the care that I rendered to be bundled with the payment to the SNF for admission, and therefore the SNF should have been doing it themselves, and that if I want payment I need to bill the SNF since they–in Medicare’s view–outsourced the ulcer care to me. While I fully expect the SNF to balk at any requests for payment from me, and I believe it might still be worth my time to appeal to an Administrative Law Judge, I would like to know if anyone has experienced this? In the future, if I am going to care for the ulcers of my patients when they are admitted to SNFs, is there anything I can arrange with the SNF or with the patient to ensure I am compensated for their care?”

“I am reading conflicting information regarding the dispensing of a post-operative/cast shoe. Medicare never seems to pay for this but commercial carriers usually do. I am reading that this shoe is NOT separately payable when it is dispensed in conjunction with a surgical procedure code. You cannot have the patient sign an ABN and charge the patient for the shoe. Please clarify the dos and don’ts of using the L3260 HCPCS code.”