Case Presentation

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Case Presentation

• Brian Gardner DPM

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Case

• 45 y/o male presents to clinic 3 weeks s/p R
  Lapidus bunionectomy with new onset pain to L
  heel and an ingrown toenail to the L hallux as
  well. You evaluate the patient and he has very
  painful plantar fasciitis L ft and you perform a
  steroid injection L heel and you also perform an
  avulsion of the ingrown toenail to the L hallux.
  Lapidus appears great on x-ray, but the wound
  has dehisced because the patient got the bandages
  wet and you have to re-suture the wound closed
  in clinic..

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Case

• You appropriatly treated the patient and he goes
  on to have a terrific result but you incorrectly
  billed/ coded this visit and the insurance
  company denied the claim and you did not get paid
  a dime for all the time spent.

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Billing and Coding

• Improper billing/coding can cost you a
  significant amount of money (undercoded, denial
  of claims).
• Improper billing/coding can lead to audits and
  potential legal problems.
• Billing/coding has become much more complicated
  and is always changing.
• You will be expected to know this on day 1 after
  you finish residency although you have never
  received any formal training. Good Luck!

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Billing/Coding

• ICD9 diagnosis codes
• CPT codes
• - Evaluation and management
• - Procedure codes
• CPT codes must correlate with correct diagnosis
  codes.

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New Patient Visit

• 99201 problem focused (10 min)
• 99202 problem focused (20 min)
• 99203 detailed (30 min)

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Established Patient

• 99212 Problem focused (10 min)
• 99213 Expanded problem focused (15 min)
• 99214 Detailed (25 min)

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Office Consultation Codes

• Consultation codes require that the patient be
  referred for a specific problem
• In HPI state that the patient is seen in
  consultation with Dr. ------- for (specific
  problem)
• Must send a copy of note to referring doctor
• Consultations pay more than a new patient visit

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Emergency Room Codes

• 99281 Problem focused
• 99282 Expanded problem focused (low to moderate
  severity)
• 99283 Expanded problem focused visit (moderate
  severity)
• 99284 Detailed (high severity, requires urgent
  evaluation but does not pose threat to life of
  physiologic function)
• 99285 Comprehensive (high severity and pose an
  immediate threat to life or physiologic function)

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Inpatient Consultation CodesInitial Visit

• 99251 Problem focused (20 min)
• 99252 Expanded problem focused (40 min)
• 99253 Detailed (55 min)
• Use these codes for the first initial hospital
  visit whether they be a new or established
  patient to you. Do not use these for follow up
  visits. These codes are for the non-admitting
  physician

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Inpatient Consultation VisitFollow up Visits

• 99231 problem focused
• 99232 expanded problem focused
• 99233 detailed

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Observation Care Discharge

• 99217 This code is used by physician to report
  all services provided to patient (discharge
  instructions, final examination)at discharge from
  observation status .
• Disharge date must be different than initial date
  when beginning observation status.

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Nursing Facility CodesInitial Visit

• 99304 Detailed
• 99305 Comprehensive
• Problem focused codes deleted
• These facilities provide medical services.
  (Skilled nursing care facilities, long term care
  faciliites, rehabilitative and psychiatric
  treatment center.

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Nursing Facility CodesFollow up Visit

• 99307 Problem focused
• 99308 Expanded problem focused
• 99309 Detailed

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Assisted Living Facility(Rest Home)

• New Visit
• 99324 Problem focused (20 min)
• 99325 Expanded problem focused (30 min)
• 99326 Detailed (45 min)
• Established Visit
• 99334 Problem focused (15 min)
• 99335 Expanded problem focused ( 25 min)
• 99336 Detailed (40 min)
• These facilities do not provide medical
  services

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Home Visits

• New Visit
• 99241 Problem focused
• 99342 Expanded problem focused
• 99343 Detailed
• Established visit
• 99347 Problem focused
• 99348 Expanded problem focused
• 99349 Detailed
• Specific regulations on qualifications for home
  visits. (Patient are homebound due to medical
  conditions)

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Telephone Calls

• 99371 simple (report labs/test, coordinating
  medical care with other health care
  professionals)
• 99372 intermediate (provide advice/treatment to
  established patient for new problem)
• 99373 complex lengthy discussion with patient
  /family over complex or serious conditions

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Nail Avulsions

• 11730 Avulsion
• 11732 additional avulsions

• Case
• Avulsion of hallux nail b/l and R 2nd
• 11730 TA (L hallux)
• 11732 T5 (R hallux)
• 11732 T6 (R 2nd)

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Warts

• Case
• Cryotherapy of 4 warts in clinic
• Bill
• 17000
• 17003
• 17003
• 17003

• 17000 Destruction of benign lesion (1)
• 17003 Destruction of benign lesions (2-14)
• 17004 Destruction of Bengin lesions (gt15)

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Global Period

• Surgical Procedure - Any visit/treatment within
  90 days after surgical procedure is considered
  part of surgical fees and cannot be billed.
• Chemical matrixectomys have a 10 day global
  period
• Fractures that are treated nonsurgically can
  also be billed as a global code which is 90 days.
  
• x-rays, fracture boots and casting supplies can
  be billed for during a global period.

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Postoperative Visit

• 99024 Postoperative visit (no charge)
• If patient is out of global period then an office
  visit can be billed.
• Always good to inform patients of global period
  so that they are aware.

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Modifier 25

• Significant, separately identifiable evaluation
  and management service by the same physician on
  the same day of a procedure or other service

• Case
• New patient with plantar fasciitis comes in and
  you perform a steroid injection.
• EM 99203 (mod 25)
• 20550 Inj tendon/ ligament

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Modifier 24

• Unrelated evaluation and management during a
  postoperative period

• Case
• Pt is 10 days s/p bunionectomy L ft and now
  complains of painful heel pain R ft. You diagnose
  plantar fasciitis but no proocedure perfomed.
• 99213 mod 24
• Do not bill a postoperative visit

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Modifier 79

• Unrelated procedure during a postoperative period

• Case
• Pt is 10 days s/p bunionectomy L ft and now
  complains of painful heel pain R ft. You diagnose
  plantar fasciitis and perform a steroid
  injection.
• 99213 mod 24,25
• 20550 mod 79

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Modifier 79

• Case
• Patient with metatarsal fracture comes in and you
  treat it conservatively and code it as a global
  code. At week 3 the patient steps down hard on
  the fracture and now it is significantly
  displaced and you take the patient to the OR to
  fix.
• 28485 (ORIF met) mod 79

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Modifier 59

• Distinct Procedural Service
• Place 59 modifier on procedure that has the
  least amount of reimbursment

• Case
• Established patient. You perform a steroid
  injection for neuroma and trim a painful callus.
• 64450 inj nerve
• 11055 trim 1 callus (mod 59)

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Modifier 57

• Decision for surgery

• New diabetic pt presents to clinic and needs a
  emergent ID in OR.
• 99203 mod 57
• If modifier 57 is not used then Insurance carrier
  may include office visit as part of surgical fee
  and you will not get reimbursed for office visit.

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J Codes

• Case
• You perform a steroid injection to R plantar
  fascia consisting of ½ cc of celestone and ½ cc
  0.5 marcaine
• 20550 inj tendon/lig
• J 0702 (½ cc celestone)

More than 3 injections must be justified by the
clinical record indicating a logical reason for
failure of the prior therapy and why further
treatment can reasonably be expected to succeed.
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Diabetic Codes
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Mycotic Nails

• Nails can be treated regardless of whether or not
  there is any underlying systemic condition
  (diabetes, PVD) if there is pain or infection
• Documentation must state that there is evidence
  of mycosis to the nail and pain/ infection
• The term Debridment should only be used when
  treating dystrophic/mycotic nails but not a
  nondystrophic nail
• The term Trimming can be used for dystrophic and
  nondystrophic nails

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Routine Foot Care

• Routine foot care is the debridement /trimming of
  toenails and the paring/cutting of corns/calluses
  in the absence of localized pain or infection.
• Routine foot care can be provided by a physician
  for patients with underlying systemic conditions
  that would be at increased danger for infection
  and injury if a non-professional performed these
  services
• Routine foot care can be provided every 61 days

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Systemic Conditions that Might Qualify for
Routine Care

• Diabetes
• Chronic thrombophlebiits
• Multiple Sclerosis
• Arteriosclerosis obliterans
• Buergers disease (Thromboangitis obliterans)
• Peripheral neuropathies
• Pernicious Anemia
• Quadraplegia/Paraplegia
• Malabsorption (celiac disease, topical sprue)
• Patients that are immunocompromised or on
  anticoagulants do not qualify for routine care
• These conditions require that the patient be
  seen and treated by PCP within the past 6 months.
  You must document approximate date of last visit
  with PCP and PCPs UPIN number.

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Q Modifiers

• Q7 Class A finding (amputation)
• Q8 Two class B findings
• Q9 One class B finding and two class C

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Conditions that do not Require a Q Modifier

• Neuropathy
• Quadraplegia/Paraplegia
• Multiple Sclerosis
• Chronic Thrombophlebitis

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Billing for Ulcer Care

• 11040 Debridement of skin partial thickness
• 11041 Debridement of skin full thickness
• Debridement of skin and subcutaneous tissue

• Size of ulcer does not matter
• Can only bill for the debridement of up to 4
  ulcers per visit
• Must place a modifier to specify the area of
  debridment (LT left, RT right). If ulcer is on a
  digit, specify which digit T5.

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Billing For Ulcers

• Clinical records must document indications for
  debridment (necrotic /fibrous devitialized
  tissue)
• Specific level/depth of debridment must be
  documented.
• Size, depth and location must be documented

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Billing for Hyperkeratosis

• Procedure code
• 11055 trim callus 1
• 11056 trim callus 2-4
• 11057 trim callus gt 4

• Diagnosis code
• 700 callus/corn
• 757.39 porokeratosis
• Must also be associated with 729.5 (pain in
  limb)
• Doesnt need to be associated with other
  medical conditions (diabetes)

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Diabetic Shoes

• L3250 Custom Shoes
• Medicare covers one pair of shoes and 3 inserts
  per year (Private Insurance does not cover
  diabetic shoes)
• Must be diabetic with neuropathy
• Must have PCPs note documenting diabetes
• Bill for Each shoe (L3250 x 2)

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References

• CPT 2007 Professional Edition. American Medical
  Association.
• Noridianmedicare.com