Does Medicare still require that patients be homebound for a house call?
Effective January 1, 2019, for services provided in the patient’s home, Medicare does not require that the patient be “Homebound”, nor do there need to be extenuating circumstances to necessitate the home visit. Medicare will pay for home services based on Medical Necessity. Based on the Medicare Carriers Manual, Section 15515, Medicare will pay for home service codes 99341-99350 when they are billed to report an E/M service provided in the home. The physician has to actually be present in the home of the beneficiary. It is not necessary that the patient be confined to the home. A patient’s home may be his/her own dwelling, an apartment, a relative’s home, a home for the aged, a retirement community, a senior citizen facility, or another type of senior living accommodation. (MCM Section 2051.1) Homebound Criteria is no longer a requirement for a house call to be performed.
What’s the difference between 97597 and 11042?
97597 is for the excisional debridement of necrotic tissue either partial or full thickness from within the dermis of the ulcer.
11042 is for the excisional debridement of necrotic subcutaneous tissue from within the ulcer.
Are we required to submit records to CIOXX and EPISOURCE? Do we have to check with our insurance contract to see if required?
Based upon the contract that you have with the Medicare Advantage Plan; this determines whether you are required to submit records.
If we don't submit records to CIOXX and EPISOURSE is there any kind of retaliation or subsequent issues that may occur from them or the insurance company they represent?
If the contract states that medical records need to be submitted and the request is not followed, the provider runs the risk of being eliminated from the Medicare Advantage Plan and the possibility of additional sanctions.
Does 11305 require injectable anesthetic?
No.
Is 11755 a flag for audits with Medicare?
Yes. You need to be sure that an appropriate nail biopsy is performed as opposed to submitting nail clippings.
Do E&M codes ever trigger audits, such as using a high number of level 4s?
Most Medicare audits are based upon trends and patterns. If a provider is billing for something more frequently or is billing for something different than the other providers of the same specialty in the same state, this triggers an audit.
How to know whether to use assisted living or nursing home E&M? Some facilities are mixed or offer both.
This needs to be confirmed by the actual facility.
What happens if records are unavailable or lost during an audit due to a problem such as ransomware attack that is out of our control?
Unfortunately, the provider is always responsible for providing the appropriate documentation to support what was billed in the event of an audit. There needs to be a backup plan in the event that the records cannot be obtained from the original source.
How are you compared to your peers - volume of CPT codes sent or a % of your total claims? Am I at a Lower risk of an audit being a small, less busy practice (50-60 pts a week)
The comparison is not based upon volume. It is based upon the percentage of total claims submitted.
If we are debriding distal tuft calluses - can we bill the 11055 instead of the toenails? Or do we have to include that with the lesser code of 11721?
As discussed in the webinar, the paring of the distal callus is included in the billing of 11721. Please access the specific rule that I provided from MLN.
How to we document medical necessity in patients who have conditions such as dementia who cannot relate loss of protective sensation or other neuropathic symptoms?
When the lower extremity physical examination is performed, as the physician you need to do your best in order to determine the patient’s neurological status. If they have no feeling, this can be determined even if they are overreacting to the touching of their feet.
Is it ok to use G60.3 Idiopathic Neuropathy as a code for routine foot care?
Yes, if the patient has neurological findings/symptoms.
What if a patient has class findings but has no formal diagnosis of diabetes or neuropathy or PVD - especially prevalent in nursing home settings?
The 2 best options depending upon what the class finding are would be G63.0 and/or I73.9.
Is it ok to bill for wound debridements long term (years) if patient is not surgical candidate to address underlying pressure but debridements keep the ulcer controlled?
It is absolutely NOT appropriate to do this. When a wound or ulcer is being debrided, if there is not significant improvement in 1 month, another approach needs to be taken or the patient needs to be sent elsewhere.
Would you say to not bill for follow up visits for 11730 procedures where patient is "fine" even though there is no global?
There is not an ICD-10-CM code for fine. If the patient is fine. There is nothing to treat. E/M means Evaluate and Manage or Diagnosis and Treat.
If you start a toenail avulsion after the block but mid procedure the patient decides they do not want the procedure anymore, would you not bill for the procedure? How would you bill in that situation?
I would make sure that everything is completely documented within the medical record. In all likelihood, I would bill this as 99213.
Where is the appropriate place to document the amount of time for an E&M code on a SOAP note in an EHR?
It needs to be documented within the part/area of the medical record where the treatment nis indicated.
Does the hallux count as having a DIPJ in reference to billing an 11055 and 11720 on same toe if the callus is on the distal aspect of the hallux?
Of interest is the fact that when the MLN article is accessed, the hallux is not mentioned. Based upon this, I would say no, especially since the hallux only has an IPJ, not a DIPJ and a PIPJ.
How do you bill for toenails that qualify and some that don't on the same patient on the same day if they are all thick toenails?
Your medical record documentation needs to be specific for each toenail to specify which are covered and which are not covered.
With Medicare Advantage plans, such as BCBS, that deny the use of -59 modifiers with covered, routine foot care patients with Q modifiers, for multiple procedures such as 11055 with 11721 or 11055 with 11720 and G0127, would it be correct to use RT and LT modifiers on the toenail codes? CBS seems to pay with the use of RT and LT but never with -59 modifiers.
Absolutely not. The 59 modifier is to be used in the appropriate fashion and if the claim is rejected, it then needs to be appealed. Aetna Medicare Advantage has recently made the correction and now accepts the use of the 59 modifiers.
In the past in Illinois, use of long-term anticoagulants with the asterisk was covered for at risk foot care but using the code Z79.01 in more recent times this code wasn't covered. Should I contact the MAC, NGS?
I would. It should be covered. As I described in the webinar, when the long-term use of anticoagulants is the factor that covers the patient for “At Risk,” Routine Foot Care, the primary diagnosis is the podiatry diagnosis, not the anticoagulant diagnosis. I would first check the LCD and the associated article for Billing and Coding.
If the patient has 50 questions and you take the time to answer all their questions, regardless of pertinency, can you include all that Q&A time? Can you simply say “15 min of Q&A with Pt”?
If you are billing the E/M service based upon Total Time, that is what I would do.
Can a patient send a photo at 10 days s/p phenol 11750 in lieu of visit, as long as the toe looks good no need to come in?
This is probably not a bad idea.
Can you touch on attendings billing these inpatient codes when residents are involved? Do attendings need a separate note?
Not if the attending reviews and signs off on the note.
With the removal of suture codes- are those only if non-surgical sutures? As in- if I put them in in surgery, I cannot bill to take them out.
Correct.
Why wouldn’t you use a XS modifier on 28308 in your example vs the 59?
Either will be appropriate.
How should removal of two neuromas on two separate sites on the same foot be billed? Do I use Modifier 59 on the second line?
28080-RT
28080-LT
If an older physician bills for 99213 office visits due to ingrown slant backs, what should they do with their billing as if there is no cellulitis, it is technically not covered correctly?
If there is inflammation, drainage, etc. it would be covered. Pain alone is not sufficient. It would not be covered.
Can I perform a temporary toenail avulsion on the same toe and border within 8 months?
No. It is not reimbursable.
I am the only podiatrist in a multidisciplinary group. When I see a patient for the first time that has been seen by the primary doctors, can I bill it as a first visit or follow up visit?
An initial E/M service can be billed.
A new patient checks in and spends 20 minutes filling out new patient paperwork. Can this be included in the total time of the office visit to determine the level E/M?
No.
They walk to xray and come back. This takes 10 minutes. Can this be included in the total time spent for E/M determination?
No.
In order to use the ICD10 code onychomycosis, do you HAVE to have a pathology report to support this?
No. It is based upon physical examination of the affected nail(s).
With the removal of suture and staple codes does it require 79 modifier or left/right foot modifier?
LT or RT modifiers.
When I see inpatients, I typically do some kind of procedure (I&D, amputation). So can you bill the E/M code with modifier "decision for surgery" the day before or after a non-global procedure code? And then subsequent hospital care with those as well?
If the procedure being performed has a postoperative global period of 90 days and the procedure is performed the day of or the day after the E/M service, the answer would be yes. The E/M code would be appended by the 57 modifier.
Teaching family wound care, how can I bill?
You can bill this only if the E/M service is based upon Total Time.
212 or 99213?
Check the Total Time for each of these E/M codes.
Can you bill ulceration on the same toe with onychomycosis distal from DPJ Joint?
Yes.
Can you bill 11720/21 and 11719 if someone has onychomycosis with pain and a disease that qualifies for at risk foot care? I have had instances where the insurance has not paid. I sent the LCD to the insurance company, and they denied paying it again. What is the next step?
11720 and 11719 can be billed for a patient that qualifies for “At Risk,” Routine Foot Care as long as the patient has as covered systemic disease. It would be coded as the following:
11719 - Q-
11720 – 59, Q_
Let’s go the other way. You have performed non-covered rfc, but the patient requests you submit it, so you do. Do you need to be careful what you document; i.e., will these services even be audited and if so, can it be determined that you have in fact performed a covered service (for which you have billed and collected from the patient)?
If an ABN was signed the claim is submitted with the GA modifier appended. If an ABN was not signed the claim is submitted with the GY modifier submitted. An ABN covers your butt.
To clarify, you have developed a satisfactory practice of doing rfc where patients accept that your services are non-covered and sign ABN's. However, you've got a few patients who have second thoughts. Can Medicare request records for audit, and your records in those cases just say something like “routine foot care performed". Other than that is poor documentation, can that be used as ammunition to claim that in fact you may have possibly performed covered care and thus may owe money?
The ABN is the best documentation to have in the event that Medicare requests records for these patients.
HOW DO WE FIND OUT WHAT OTHER PODIATRIST ARE BILLING IN OUR STATES
This can be obtained from your Medicare Administrative Carrier
DO YOU INCLUDE BILLING FOR INJECTABLES J CODES WITH NDC?
Yes.
So, in your example First visit R-PF, second Visit New problem L. and the 3rd visit: No pain. on the R and no pain on the L. So, what happens now? You don't charge? No f/u visit? simple 99213?
No problem, no charge.
Is it correct that if time is used to determine E/M level, that the note must be completed the same day as the day of service in question?
Yes.
If G0127/11719 can be paid by systemic disease with class findings, PCP name/last date of service, why add diagnosis L60.2, L60.3, L60.8 or L60.9?
The CPT/HCPCS Level II code that is billed needs a podiatric diagnosis in addition to the systemic disease diagnosis.
With Medicare do you always have to bill the procedure instead of E/M for the same condition? such as a patient has painful calluses can the visit be billed as E/M instead of procedure code if calluses are trimmed?
Never.
If patient unable to sign an ABN (Alzheimer) but wants bill submitted, can you just submit 11719 or G0127 without systemic diagnosis/class findings and let the bill get rejected and not bill the patient?
Send in the claim appended with the GY modifier.
How to bill for a symptomatic non-mycotic toenail?
A dystrophic toenail is billed with G0127. A non-dystrophic toenail is billed with 11719.
I recently was paid for 99343 from NGS Medicare. When was it deleted?
January 1, 2023.
In the example codes with 11055/11720, why did you use the 59 modifier instead of the XS modifiers?
Either 59 or XS will be correct.
Specifically, difficulty walking must be due to the nail condition, and not just that a patient is using a walker, correct?
Correct.
If you are consulted but did not admit the patient, can you bill an initial hospital care E&M the first time you see them or since you didn’t admit are all visits considered subsequent hospital care?
Initial can be billed the first time that you see the patient in the hospital as a consult. Subsequent visits are billed as subsequent.
Is there a need to be concerned with a CBR that was received for my retired partner? It was regarding an INPT billing and was informational.
It is just a heads up to make you aware of the potential for excessive billing of a CPT code above the state and national average.
For inpatient encounters, if you have planned time off and have someone (not in your group) covering for you when you leave can they bill a 99222/3 for an initial encounter as it will be their first time seeing the inpatient even though you had billed that same code already on admission and initial consultation
Yes, depending upon the health insurance carrier.
If you are billing based on medical decision making, can you still list how much time was spent in evaluating patient and discussing plan of care?
You can, but there is no reason to do so.
If you do self-audits in your group and realize a wrong foot was documented or mistake was made, can you do an addendum at that time?
Absolutely.
Are we still using associate place of service codes when billing E&M codes?
Yes.
What type of audits are they doing if nothing is noted on the request?
Subsequent letters will inform you.
We were denied "at risk codes" with appropriate modifiers last year. Did these Q codes change?
No. Check your Medicare Administrative Carrier’s LCD and call the carrier and ask to speak to a supervisor.
Can we use a "pain" code and bill for paring calluses (11055) or trimming nail (G0127) codes in patients who are NOT "at risk"? So not using Q codes.
The only Medicare carrier that accepts this is Noridian.
If you do not use an electric grinder to deride nails at a home visit for lack of vacuum for nail dust, then what procedure code is used for manual debridement?
The same CPT code can be billed.
Can we bill 10021 AND 20612,59 for ganglion cyst aspiration on L foot?
Only CPT code 20612 would be appropriate.
If an estb heel pain pt returns and not better and you tape the same foot and send in a Rx for steroids same issue, how would you code?
Based upon the documentation, only CPT code 29540 can be billed. The E/M service is not considered significant and separately identifiable. The same problem is being treated by the CPT code and the E/M code.
How would you bill for a pt that has neuropathy for nail care?
Based upon the documentation, if not a diabetic, I would probably use ICD-10-CM code G63.
After a 10060, you can schedule all you want for a visit within the 10-day global period, but what if the patient no shows or cancels? Is there any special way to document that we schedule for a visit, but the patient decided to no show?
Document it.
For the 11050 series, what about using L85.1? How does the L85.1 vs L84 compare in terms of frequency of use or appropriateness to use?
You use the ICD-10-CM code that is most appropriate for the situation at hand.
If I perform a 11750 and see patient for a follow up 2 weeks later, can I bill office visit?
Considering that the patient should have been seen within the 10-day postop global period one time, I would opine no.
Which modifier is used on the ABN for Medicare orthotic?
GA.
Does 99211 cover the patient being seen by a medical assistant for a replacement of a splint or dressing?
If a covered service, the answer would be yes, as long as the provider/DPM is present within the office.
Have you dealt with the issue of Aetna Medicare not covering services E.g., 11057 and 11720 and only covering one service?
Yes, but this issue is being corrected by Aetna and is coming to an end.
Are we required to provide records that's not paid by carrier?
This is based upon the contract that has been signed with the carrier.
If you are an associate and later buy the [practice with a new ID and tax Number, can you bill the same patients as NEW E and M s?
If you personally have seen the patient(s) previously within the last 3 years, absolutely not.
Example of a podiatric condition with unknown consequences? If I place a patient on a medication and review all morbidity ....is that a 99204/99214?
Two of the three elements of Medical Decision Making must be met at the appropriate levels in order to determine the correct E/M code to bill. I would urge you to access the Table of Elements of Medical Decision Making that was presented.
What is the hype w/ billing E&M based on time? Does it pay more for the equivalent time?
When you read the definition/description of each E/M code, essentially you are reimbursed the same. Medical Decision Making is more straight forward and cleaner than Total Time.
Please give specific podiatry examples of level 4 moderate. Please include decision regarding minor surgery as well as diagnosis or treatment significantly limited by social determinants of health.
The number one example is when the decision for surgery is made, and the patient is scheduled to have elective surgery performed. The number two example is when the patient comes back to the office, the labs, etc. are reviewed with the patient and the patient signs the necessary paperwork.
Social determinants of health are described and defined within the presentation.
We can bill suture removal even if we perform the surgery?
No.
If we see a patient the day they are discharged, then we would not bill the inpatient code (i.e. 99232)?
Correct.
In a multispecialty group with orthos, if one of them has seen the pt in the clinic but I have not would I bill established or new? I thought it was based on tax ID and not specialty.
Since the specialty is different, an Initial E/M code can be billed.
Can you add things to the notes after getting the audit request for these grafts, for example go back add lot # or units wasted?
Absolutely not.
Does the pt need to be seen 1 time after 11750 within in the 10-day global also just like I&D?
That is what is expected.
Will an auditor take into account MDM as well as time? Do commercial insurances follow Medicare guidelines?
If both MDM and Total Time are documented, MDM is what is used. Most commercial insurances follow Medicare’s guidelines as long as it supports their position.
That is, can commercial insurance be billed on time or MDM? How do we specify whether the level of code is based on time or MDM? Simply state that in the record?
Correct on both issues and questions.
The xray in this case could be associated w a bone deformity if present--M77.31 or M19.071?
Yes.
Can you bill for debridement of a fungal nail on the hallux AND debridement of a medial pinch callous on the same hallux in contradistinction to a thick nail on second digit with a distal clavi?
Yes.
You debride a thick second digit toenail and a distal callous on the same toe and there is an ulceration under the callous. How do you code this and bill for it?
In reality, both the ulcer and the toenail can be treated and billed.
What cpt replaced 99335?
I would suggest that you access the presentation. All of the changes are listed. The presentation can be obtained. From CME Online. See the Home or Residence Services E/M codes that went into effect on January 1, 2023.
If we do the sx we cannot bill to remove sutures in a post op visit?
Correct.
If billing for date last seen for at risk foot care, can you document the date that patient provides you or do you need to contact treating MD?
If you trust the patient, use the date that the patient provides especially if they are accessing the date on their cell phone, etc. If not, contact the treating PCP.
On EM codes if you're performing a CPT code, but the EM is an ongoing problem and not acute can you bill the EM?
Only the CPT code can be billed if the CPT code and the E/M code are addressing the same issue.
On I&D if there is an abscess on both hallux does this cover 10601 - more than one abscess?
Yes.
Can an NP be substituted instead of DO or MD for RFC and Therapeutics shoes?
No.
Is it appropriate to bill the following combinations of ICD-10 & CPT codes:
(1) I73.9, L60.3 w/CPT 11719, 11720 w/mod Q8, 59
(2) I73.9, L60.0 w/CPT 11719, 11720 w/mod Q8, 59
(3) E11.40/51, L60.0 w/CPT 11719, 11720 w/mod Q8, 59
(4) E11.40/51, L60.3 w/CPT 11719, 11720 w/mod Q8, 59
ICD-10 B35.1 would not be included in any of the examples above.
These are the most appropriate:
11719 – Q8 (I73.9, L60.9), 11720- 59, Q8 (I73.9, B35.1)
11719- Q8 (E11.40 or E11.51, L60.9), 11720 – 59, Q8 (E11.40 or E11.51, B35.1)
Can I use the 99304/305/306 for any new pt I see there? I heard this was for "admitting doctors" which didn't make sense to me.
The answer is yes, based upon the medical record documentation.
If you see a patient with a wart, can you bill an E/M and 17110?
Only if this is the initial encounter with the patient for this specific problem.
When another competing podiatrist calls you to update you about your patient, can I bill a consultation E/M code?
No.
Debriding a diabetic ulcer of a toe with the patient having dry gangrene stable of the other toes you are leaving alone, I should use both the gangrene as the primary diagnosis and the secondary diabetic ulcer icd10 code?
Since the toe with the ulcer is not affected by dry gangrene, the primary diagnosis would be E11.621 and the secondary diagnosis would be L97.xxx.
In hospital setting, inpatient, I thought time-based coding had been removed. The hospital coders have asked us to bill only on the basis of MDM. Is it not true?
No. It is your choice.
If you see a patient in ER and take the pt to surgery the same day, can you bill or will you get paid for surgery and 99254?
If you see the patient in the ER, I would bill 99284-57 and the appropriate CPT code for the surgery that is performed.
Can you bill for the dispensing and fitting of off-loading padding such as those for sesamoiditis, hallux limitus or hallux valgus? If so, how on the same day as E/M?
It would be included in the E/M service.
In Dr. Washsaw's coding manual, does he have alternative modifiers that could be used in lieu of modifier 59?
Absolutely!!
Long ago I could use 10060 if I performed a "slant-back" to an ingrown toenail. Is this correct?
Absolutely not.
If you are contracted to a nursing home, how do you know if the appropriate asterisk information will be documented on the billing form submitted by the home?
It is on the provider to make sure that the billing and coding are appropriate.
We were audited and fined for not billing enough callous trims in relation to others in our state. We did the callous trimming, however, did not bill the patient when not covered and we were fined.
This is why it is always important to know the guidelines and rules before an issue occurs.
You mention that lack of a DP pulse in one extremity and lack of a PT pulse in one extremity; they absent pulse for each must be in the same extremity to use B1 and B3. We used to be taught the opposite. Have the regulations changed? I did not see an indication in the regulations where this is specified.
Please access my book or the presentation for the most up to date, accurate information regarding this issue.
If patient lacks a DP pulse on the right only and a PT pulse on the right only and the patient has 6 keratoses, but all on the left foot - is this billed 11057-Q8? Is there somewhere in writing that says this would not be billable?
It is billable.
Sometimes I get overlaps from 2 'advantage’ plans asking for the same time period--any problem with providing the same notes to both. Pt has had both insurances during the time period requested.
This should not be a problem.
A letter is received which states that a physician is an 'outlier' on some code. No request for comment is made. How should this be addressed?
You need to be aware and change the way that you bill in order to decrease the number of times that the code in question is excessively billed. You are being given a heads up to amend the way that you are billing.
11720Q8, 11055Q8, 11730TA are performed. Please comment on the modifiers used for that same DOS.
11730 – TA
11055 – Q8
11720 – 59, Q8
In the event that the patient returns for 11730 during the 8-month period for the same border then we should use the modifier relating to return within sx period?? What should be done if 11730 was billed within the 8-month period since the implementation of the new shut-out period (same border, same toe). What was the date??
CPT code 11730 cannot be billed within 8 months on the same toe, same border. The opposite border can be billed.
Scenario. If I'm on call at the hospital, and I've been consulted at the ER or on the floors on a specific date to evaluate a specific patient seen before but may have seen a different specialist on the same DOS. How would I bill the E/M? Initial or subsequent?
Initial.
If pt has dm and pvd, do I need to list last MD visit since I can use pvd on its own?
If you are using PVD as the covered systemic disease, the date last seen is not required.
Nail and callous debridement is every 61 days??
If the patient meets the qualifications, this is the minimum amount of time that must pass.
It appears that all of our local prosthetic stores have rejected Medicare Therapeutic shoes for DM patients. Is the DM therapeutic shoe program dead or did they make it very difficult to reimburse?
The Medicare Therapeutic Shoe Program for diabetics is still ongoing. The rules need to be specifically followed. This is specifically described in detail in my book.
Read Comments