Billing and coding

[beargrillz]

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I’m a resident that’s looking for input on billing and coding. I’m in a program that has a small group of doctors, but it’s hard to learn billing and coding for surgery and clinic because it seems so variable from provider to provider. It’s hard to determine what is legit and what is fraud. What are some good resources?

Examples of billing that seems confusing:

1. Nail care - some doctors trim any nail that walks through the door and others seem to evaluate each patient for underlying diseases and only “debride” thickened nails. I have seen both office visits and nail/callus debridement codes used differently for various patients. There doesn’t seem to be any correlation for which patients are treated and what codes are used

2. Taking patients to the surgery center for ingrowns and billing for I&D’s. I assume this is not ever correct, but I see it weekly so how does it keep happening?

3. From what I can tell, an Austin bunionectomy has a single CPT code but I have never once seen this listed as a single CPT code when that is the only procedure performed. There is normally a mix of tendon lengthening or some other codes mixed in.

4. Tons of hardware removal cases. Everything from bunions to hammertoes, where the hardware is removed after the osteotomies heal. I would not personally do this, but am curious to see if this is something that is blatantly wrong or does it fall into the magical grey area of “doctors opinion” for removing the hardware although it doesn’t seem to have a real need to be removed.

5. Fracture care: For the patients that are conservatively treated, I’ve seen fracture codes used but was informed that these codes have a 90 day global. Does it make sense to use these codes or just do several E&M’s throughout the recovery period? Or is it fraudulent to choose the E&M’s over the fracture codes?

6. Grafts: Some grafts are applied in clinic while some are applied in the OR. What is the deciding factor for where they are applied? Are they always covered if applied in the OR?

7. What exactly is a “slant-back”? I’ve been told that if you cut back a portion of a mild I growing nail, it’s covered via 11765. I’ve read enough online that makes me think this is not legal. Others say that you can’t bill for any mail surgery unless you use local anesthesia. So if a patient comes in with a very mild ingrown, all you can do is offer them the procedure and nothing else?

Sorry for the stupid questions. This doesn’t seem like it should be this confusing but I feel like everything I learn about billing and coding does not seem to be how it is done “in the real world.” I also don’t understand how this could be so common if it is fraudulent.

 

[air bud]

I’m a resident that’s looking for input on billing and coding. I’m in a program that has a small group of doctors, but it’s hard to learn billing and coding for surgery and clinic because it seems so variable from provider to provider. It’s hard to determine what is legit and what is fraud. What are some good resources?

Examples of billing that seems confusing:

1. Nail care - some doctors trim any nail that walks through the door and others seem to evaluate each patient for underlying diseases and only “debride” thickened nails. I have seen both office visits and nail/callus debridement codes used differently for various patients. There doesn’t seem to be any correlation for which patients are treated and what codes are used

2. Taking patients to the surgery center for ingrowns and billing for I&D’s. I assume this is not ever correct, but I see it weekly so how does it keep happening?

3. From what I can tell, an Austin bunionectomy has a single CPT code but I have never once seen this listed as a single CPT code when that is the only procedure performed. There is normally a mix of tendon lengthening or some other codes mixed in.

4. Tons of hardware removal cases. Everything from bunions to hammertoes, where the hardware is removed after the osteotomies heal. I would not personally do this, but am curious to see if this is something that is blatantly wrong or does it fall into the magical grey area of “doctors opinion” for removing the hardware although it doesn’t seem to have a real need to be removed.

5. Fracture care: For the patients that are conservatively treated, I’ve seen fracture codes used but was informed that these codes have a 90 day global. Does it make sense to use these codes or just do several E&M’s throughout the recovery period? Or is it fraudulent to choose the E&M’s over the fracture codes?

6. Grafts: Some grafts are applied in clinic while some are applied in the OR. What is the deciding factor for where they are applied? Are they always covered if applied in the OR?

7. What exactly is a “slant-back”? I’ve been told that if you cut back a portion of a mild I growing nail, it’s covered via 11765. I’ve read enough online that makes me think this is not legal. Others say that you can’t bill for any mail surgery unless you use local anesthesia. So if a patient comes in with a very mild ingrown, all you can do is offer them the procedure and nothing else?

Sorry for the stupid questions. This doesn’t seem like it should be this confusing but I feel like everything I learn about billing and coding does not seem to be how it is done “in the real world.” I also don’t understand how this could be so common if it is fraudulent.

Great questions. Will try when I have some time. Will be some good info coming from other attendings on here. Also sounds like this hardware removal thing is total junk if they are taking to a sx center they have an interest in. Painful or infected hardware gets removed.. and that is very rare.

 

[NobodyDPM]

Seems there are a lot of shenanigans going on where you are.

1. If you want to bill nail care legitimately, patient should have "class findings" as per Medicare guidelines to get the nail care covered. And you should bill for Mycotic Nail care. Dystrophic nail care pays $10. Healthy nails can only be billed, and covered as an ancillary to Mycotic Nail care if patient has "class findings". Too much to go into with class findings, but if you do a Google search, you should find it quickly.

2. That's just silly. Just trying to get more money, and if the doctor is a partner at the surgery center is trying to line his or her pockets.

3. Correcting a bunion is one CPT code. The doctors you are with are trying to "unbundle" the procedures, and that is a HUGE red flag for audit. Avoid doing that at all costs. Unbundling is B-A-D. Again, people just fishing for a few more dollars. Just no worth it.

4. I personally would never remove hardware unless it was painful or infected. I can tell you, that in the last decade, I've only removed a handful of painful bunion screws, and only a few hammertoe fixation methods, that other doctors placed. Ankle and Calcaneal hardware is a different story, but again, if it's not painful, you're only fishing for dollars.

5. That's a bit of a grey area. If you are removing the cast, taking and reading x-rays, and applying a new cast, that would warrant an E&M visit. If you're not doing that, well, you can read between the lines.

6. Grafts can be tricky business. If you want to apply them in the office, your practice has to buy them and then bill to get reimbursed for them. In the past, that has been a losing proposition all the way around, but lately there has been a resurgence and people are applying grafts in the office and getting paid. So much so, that it will likely be audited and scaled back. If you apply a graft in the OR, you can bill for applying the graft itself, and are more likely to et paid for the procedure alone, rather than the procedure and the product. In the office, you are billing for both. I don't do enough wound care anymore to warrant delving into this in the office.

7. A "slant back" is basically a nail avulsion without using any anesthesia so it's not as involved. You're basically just trimming the distal nail back to the patient's tolerance. Technically, to bill an 11765, you need to administer some form of anesthesia. But, you know, Podiatrist try to get away with stuff. Especially in Nursing Homes.

Feel free to ask more questions.

 

[dtrack22]

Seems there are a lot of shenanigans going on where you are.

I was going to say, the OPs post looked like a laundry list of things you shouldn’t do because most of them seem fraudulent.

NobodyDPM covered them well. There are a lot of shenanigans going on there.

 

[heybrother]

Pretty sure I agree with everything nobody said above.

1. Nail care - some doctors trim any nail that walks through the door and others seem to evaluate each patient for underlying diseases and only “debride” thickened nails. I have seen both office visits and nail/callus debridement codes used differently for various patients. There doesn’t seem to be any correlation for which patients are treated and what codes are used

Calluses as far as I can tell are ONLY covered with a Q ie. Q789. I've some some presenters get even tighter on the Q coding ie. the right foot has vascular findings and the left doesn't - they would say only bill the the affected foot.

I have to explain to my office over and over that calluses on commercial insurance ie. Blue Cross are still supposed to be self pay. If you look up insurance guidelines for most major commercial insurance they have sheets spelling out that routine care is uncovered.

Patients are going to regularly ask for nails/calluses to be trimmed while there for other services - you will have to decide for yourself if you will do it or and if you'll demand extra reimbursement.

Nails are theoretically covered under 2 pathways - a systemic Q pathway or a pain/limitation to ambulation/infection pathway.

The systemic pathway uses 4 codes for nails - 11719 (which I don't know how to get paid under because I don't know what ICD-10 code to use but is worthless), 11720 (mycosis), 11721 (mycosis), and G0127 (dystrophic but I think you have to use onychogryphosis ICD-10 - dystrophy ungium or whatever doesn't pay).

The pain pathway only pays on mycotic nails that meet the above. I personally do not use this process but supposedly you can only get paid for nails that are mycotic and painful so even if you trim 10 nails its only the nails that were painful that count. I personally see this pathway as dangerous because (a) it will fill you up with people who are just there to get their nails cut and don't actually have risk factors or a reason to be there(b) I personally cut a bunch of nails in residency where the nurse note says - "no pain" - seems like an audit risk.

Some people use the pain coding for nails if a patient presents for plantar fasciitis and also asks for their nails to be cut. Then they have a separate diagnosis and procedure.

Keep in mind that nails without calluses are worthless visits. You can use the Medicare fee schedule lookup to figure out the value but I routinely get paid less than $30 if a patient presents for a few nails and has a Medicare advantage plan. Yes, I could make it a 11720 and a G0127 possibly but with bad insurance worthless and worthlesses little brother still pay crap. This pays about $50 on straight Medicare.

2. Taking patients to the surgery center for ingrowns and billing for I&D’s. I assume this is not ever correct, but I see it weekly so how does it keep happening?

In some sort of bizarre world of Fraud. I was reading over at IPED about people's billing practices and there's all sorts of stupid things people do. That said the above is egregious. 99.9% of patients should have their 11730/11750 done in the office. I'll take it a step further - I've done over 700 nail surgeries in the past 2 years with a huge slap in the face from Covid. None were done in a surgery center. I can recall 3 specific cases where a surgery center would have brought value and all were ultimately done in clinic and grateful.

I've said this before but I'm pretty certain the Incision and Drainage codes require an INCISION. Call me crazy but my avulsions also take about 1 minute to perform after leaving them to get numb so I can't imagine taking them somewhere.

3. From what I can tell, an Austin bunionectomy has a single CPT code but I have never once seen this listed as a single CPT code when that is the only procedure performed. There is normally a mix of tendon lengthening or some other codes mixed in.

There's 1 code. This will ultimately blow up in someone's face. That said, I'm becoming increasingly certain that only hospital employed people can get away with this. Private practice and commercial insurance will be caught electronically...

4. Tons of hardware removal cases. Everything from bunions to hammertoes, where the hardware is removed after the osteotomies heal. I would not personally do this, but am curious to see if this is something that is blatantly wrong or does it fall into the magical grey area of “doctors opinion” for removing the hardware although it doesn’t seem to have a real need to be removed.

There's probably no indication. Random thing, if you listen to the billing people they will argue hardware removed over your current surgery site shouldn't be billed. That's another talk and another battle and obviously sucks.

Supposedly most of the time you can't even bill hardware removal unless its greater than 6 months. I haven't looked up the rules on that personally but my residency people claimed rules like that were put in place a long time ago to address doctors pulling everything out afterwards. Hardware removal is like custom orthotics - I think this is something doctors push patients into. Oh you don't want that hardware left in do you!?

5. Fracture care: For the patients that are conservatively treated, I’ve seen fracture codes used but was informed that these codes have a 90 day global. Does it make sense to use these codes or just do several E&M’s throughout the recovery period? Or is it fraudulent to choose the E&M’s over the fracture codes?

So you have the right to choose fracture care vs E&M. Historically, the math grossly favors doing E&M instead of the fracture care codes. What I now realize is the fracture care codes were being used to make surgical coding more profitable. A patient presents with metatarsal fracture 2-4. #2 requires ORIF and 3-4 are not displaced. You'd bill the conservative care codes on those - they indicated a the billing conference a few years ago that door closed. That was probably free BS money on top of the surgery.

Last of all - when they upped the E&M codes they really didn't up anything else that E&M was apart of so its likely massively more profitable to bill E&M.

6. Grafts: Some grafts are applied in clinic while some are applied in the OR. What is the deciding factor for where they are applied? Are they always covered if applied in the OR?

The deciding factor is billing - I don't know how they determine it but some of the grafts are so expensive/not reimbursed/etc that they can't be used in clinic. Jokingly, I wouldn't fret about grafts too much because all of this is going to get shut down in the future.

Everywhere I go people are non-stop talking about billing Medicare for grafts. Was just at a conference and one of the graft companies is only used for Medicare. People are telling ridiculous stories of making $400-7000 a graft blah blah with weekly applications.

7. What exactly is a “slant-back”? I’ve been told that if you cut back a portion of a mild I growing nail, it’s covered via 11765. I’ve read enough online that makes me think this is not legal. Others say that you can’t bill for any mail surgery unless you use local anesthesia. So if a patient comes in with a very mild ingrown, all you can do is offer them the procedure and nothing else?

Its a form of podiatry mental calisthenics in which a toenail is painful or ingrown and therefore you deserve to be paid more.

People want their nails trimmed all the time. Most of this technically falls under routine care. Consider also that diabetics complain about their ingrowns all the time and the debridement of these is simply part of the 1172x series.

You trim out that nail extra deep for them and tell them to soak. Maybe you offer them an antibiotic. Best case here we're in 99212, maybe 99213 territory if you want to talk up the paronychia and your future plans. But what does a podiatrist do - turns trimming down a border into a $100+ code.

And that's why we can't have nice things. A podiatrist showed me a proposal suggesting Novitas is going to make 11730/11750 have a lifetime use of "1" in the future. That will be awesome, but probably not a big surprise with the above sort of behavior.

Anyway, also what nobody said - nail surgery procedure codes are supposed to document anesthesia used (or I guess neuropathy).

My suspicion - if you are routinely passing a nail nipper down the side of a toe and routinely billing something beyond 99212, 11720, etc you are probably doing something ...different.

 

[DYK343]

I’m a resident that’s looking for input on billing and coding. I’m in a program that has a small group of doctors, but it’s hard to learn billing and coding for surgery and clinic because it seems so variable from provider to provider. It’s hard to determine what is legit and what is fraud. What are some good resources?

Examples of billing that seems confusing:

1. Nail care - some doctors trim any nail that walks through the door and others seem to evaluate each patient for underlying diseases and only “debride” thickened nails. I have seen both office visits and nail/callus debridement codes used differently for various patients. There doesn’t seem to be any correlation for which patients are treated and what codes are used

-I 100% refuse to do this. Its just not worth it. If they qualify (class findings as above) then I do it. I find it to be more rare than common for someone to truely qualify for nail debridements.

I have had a lot of patients leave my office unhappy with me because I wont cut their fraudulent nails. My ONLY negative reviews are over this issue and I do not believe its fair but it is what it is. I had a guy storm out cussing and screaming a couple weeks ago. All because another DPM used to do it. That makes me a terrible doctor apparently.

DPMs in my area are booked out 3+months with nothing but a bunch of nail care. Any new patient that wants to be seen for fracture, ingrown, acute stuff they end up in my office because I refuse to be booked with nails all day long. As others said once you see the reimbursements (and the headache involved) its just not worth it. Yes you can crank out 8 nail care patients an hour but thats just a misserable way to live.

2. Taking patients to the surgery center for ingrowns and billing for I&D’s. I assume this is not ever correct, but I see it weekly so how does it keep happening?

Yeah thats obviously fraudulent.

3. From what I can tell, an Austin bunionectomy has a single CPT code but I have never once seen this listed as a single CPT code when that is the only procedure performed. There is normally a mix of tendon lengthening or some other codes mixed in.

Austin is 1 CPT code
I bill doublecut bunionectomy for austin/akin.
I bill lapidus as lapidus (not TMT fusion or worse transverse/multi joint fusion because you threw a screw across the 1st/2nd met).

4. Tons of hardware removal cases. Everything from bunions to hammertoes, where the hardware is removed after the osteotomies heal. I would not personally do this, but am curious to see if this is something that is blatantly wrong or does it fall into the magical grey area of “doctors opinion” for removing the hardware although it doesn’t seem to have a real need to be removed.

Yeah this is fraud. And really crappy cases. Why would anyone WANT to do this? Its not worth the money. Hardware removals are probably my least favorite cases. Some of my most frustrating days in the OR have been trying to get a stripped screw out of a locking plate. Staple removals can be even worse. Especially if you dont have the right device to get the thing out.

5. Fracture care: For the patients that are conservatively treated, I’ve seen fracture codes used but was informed that these codes have a 90 day global. Does it make sense to use these codes or just do several E&M’s throughout the recovery period? Or is it fraudulent to choose the E&M’s over the fracture codes?

I always just bill E&Ms. I dont think ive ever billed the 90day fracture global code. I know people that have billed this for each digital fracture and ran up the bill though.

6. Grafts: Some grafts are applied in clinic while some are applied in the OR. What is the deciding factor for where they are applied? Are they always covered if applied in the OR?

Not worth the struggle in clinic as above. Employed at a wound healing center sure but your private office? No.

7. What exactly is a “slant-back”? I’ve been told that if you cut back a portion of a mild I growing nail, it’s covered via 11765. I’ve read enough online that makes me think this is not legal. Others say that you can’t bill for any mail surgery unless you use local anesthesia. So if a patient comes in with a very mild ingrown, all you can do is offer them the procedure and nothing else?

Only bill with local anesthesia. This scam has been around forever. Google podiatry nail care fraud and you will see the ones that are sitting in jail or paid massive fines.

Sorry for the stupid questions. This doesn’t seem like it should be this confusing but I feel like everything I learn about billing and coding does not seem to be how it is done “in the real world.” I also don’t understand how this could be so common if it is fraudulent.

Sounds like an interesting situation but not unexpected given podiatrys reputation. BIlling IS hard. Its really hard and we dont have much training in it but its something youre going to have to learn and learn quickly. I recommend you buy the 2022 CPT book that should be coming out and study it. All the codes are in there and its usually (not always) straight forward which codes to use.

You will quickly learn that surgery really doesnt pay all that well. Actually it doesnt pay well. I laugh when I see some of my reimbursements that also include 90 day global. Declining reimbursements are likely leading to increased fraud (Or vice versa - increased fraud lead to decreased reimbursements!)

Make an excel doc with all the common codes you will use broken down by procedure. It saves time as a cheat sheet.




Other professions, especialyl surgical, HAVE to have the same fraud issues as DPMs right? We cant be alone.

 

[dtrack22]

billing people they will argue hardware removed over your current surgery site shouldn't be billed. That's another talk and another battle and obviously sucks.

As in, removal before surgerizing? Like taking out hardware from an Austin before fusing the 1st MPJ?

If that’s the case then the billing people are probably using the “same incision” verbiage as a carte blanche to not submit a claim and have to deal with sending chart notes or appealing. At least that was an excuse I got from a biller once when I billed HWR and some other procedure in the same case. I asked her what would happen if I performed two metatarsal osteotomies (“each” can be billed separately) through one incision and she looked at me dumbfounded and then said I would have to describe that they were separate procedures. I then asked why I couldn’t dictate the hardware removal and fusion (I think it was a fibula malunion repair) as separate procedures and didn’t get a good answer. I’m not sure she was quick enough or knew enough to at least tell me it was the same bone where the metatarsal examples weren’t. But it felt like a cop-out by a biller as opposed to a well documented, hard and fast rule. There’s probably more discussion out there on hardware removal specifically. But you should only remove metal that is causing complications. Don’t be a TFP.

Supposedly most of the time you can't even bill hardware removal unless its greater than 6 months.

That sounds made up. How would any insurance company even track that? They document all of the hardware you have in your body and then refuse to pay all HWR CPTs unless it’s reviewed?

so its likely massively more profitable to bill E&M.

Not necessarily. It depends on the location of the fracture and if you’re accurately billing most follow up e&m’s (if you don’t bill the closed treatment code). A closed Tx code for a lesser toe fx should pay double a 99212. So you bill 99203-57 and 28515 and then for their one follow up bill a 99024. You will make more money than a 99203 and a 99212 follow up. Even if you bring them back twice, the fracture code still probably wins out. That is assuming you are billing a level 2 visit which is typically all f/u fracture care visits are. You need 2 level 3 follow up visits to outproduce the fracture care CPTs typically. If you’re billing 2 level 3’s within the first 90 days of most closed fractures then you are probably committing some amount of fraud along the way

I billed closed treatment of a calc fx and found out the wRVU is only like 2.4. But that’s more than the maybe 99213 and 99212 visits I would otherwise bill in the first 90 days after the initial e/m.

 

[heybrother]

Appreciate the feedback - especially because your feedback previously pointed out a situation where Medicare and insurance were different.

I have personally been paid for both a 1st MPJ fusion and a hardware removal at the same site so perhaps I'm in violation of this. It was on commercial insurance though.


Hardware Removal:

https://www.cms.gov/files/document/chapter4cptcodes20000-29999final112021.pdf

10. There are CPT codes (20670 and 20680) for removal of internal fixation devices (e.g., pin, rod). These codes are not separately reportable if the removal is performed as a necessary integral component of another procedure. For example, if revision of an open fracture repair for nonunion or malunion of bone requires removal of a previously inserted pin, CPT code 20670 or 20680 is not separately reportable.

Similarly, if a superficial or deep implant (e.g., buried wire, pin, rod) requires surgical removal (CPT codes 20670 and 20680), it is not separately reportable if it is performed as an integral part of another procedure.

Hardware Time Table
This was one of those things that I was told repeatedly - and I can't find anything to support it anywhere. Here's how I would implement it if I were insurance - I'd try to deny hardware removals performed by the original surgeon on same extremity as the original procedure. That said, I have nothing to back this up after trying to come up with a bunch of queries and it doesn't appear to be in the Medicare MSK document either.

Fracture Care Values
I think you've summed up part of the issue - depending on how these are billed or followed up people's mileage may vary. I have known people who would follow a non-displaced 5th metatarsal tuberosity/avulsion-notAJones fracture with 99213s and x-rays forever saying surgery is still on the table etc etc because they wanted to see it "fill in" even though the patient was in normal shoes, no tenderness on exam, no pain with walking. I haven't sat down/or calculated the values in a long time - the people I worked with (who also apparently made up the 6 months thing above) seemed to be confident that E&M was better money both in visits and in danger of the patient coming back over and over again. I'll have to look it up myself since it seems like the recent E&M change should be changing the math on this ie. the E&M contribution of procedures didn't get modified like the codes themselves did.

 

[DYK343]

I've always billed a HWR with whatever procedure I'm doing (ex 1st MTPJ fusion with Austin screw removal).
I guess ive been billing wrong?


I remove my own hardware maybe once a year for elective reasons and 2-3 a year for non elective reasons.

Usually its someone elses im taking out. I have to take the time to get a medical records release on file, find old op reports from a hospital hours away, bug the hospital 3x to actually send them, contact a rep to make sure I have the proper driver. Its all a pain in the ass. I dont trust the synthes "universal" screw driver removal kit. Its burned me before with incorrect driver sizes. I wont open the patient up unless I know I have the right driver there. If I did a fusion on top of that its still all part of the procedure?

 

[king22]

5. That's a bit of a grey area. If you are removing the cast, taking and reading x-rays, and applying a new cast, that would warrant an E&M visit. If you're not doing that, well, you can read between the lines.

The fee for taking an X-ray includes the reading component. If the treatment changes because of x-ray findings, then an E&M would be warranted. If you're simply continuing the current course of treatment and re-applying the cast, there is no E&M.

 

[king22]

Grafts are tricky. Some can be applied in your office/clinic, others have to be done in the OR. Often the Rep will be able to tell you what sites of service are allowed. Keep in mind, they are constantly changing. They can be profitable if you are keenly aware of your reimbursements (some products get reimbursed well below cost, some well above). You also need to know the coverage guidelines like the back of your hands (since their use definitely puts your on the payers radar) I do a lot of wound care in my offices so I happen to use a decent amount of grafts. I've been audited only once (by BCBS) for them and I passed it.

Here are my little tidbits on graft use

1. Know how much each payer reimburses relative to the cost of the product. Again, sometimes they reimburse much lower than the cost of the product

2. Know the coverage guidelines, especially medicare, and adhere to them. Make sure your documentation touches on everything in the coverage guidelines

3. Don't get greedy- don't use a graft that is 10x bigger then the wound in order to get a better reimbursement.

4. Make sure you keep a meticulous tissue log. That's how guys have been dinged in the past.

5. Be very weary of reps promoting "new" products, especially when they are showing you ridiculous reimbursements (like medicare paying $5,000 for a graft that costs your $500)

 

[NobodyDPM]

3. Don't get greedy- don't use a graft that is 10x bigger then the wound in order to get a better reimbursement.

Yep. Excellent point. This was the scam many were running back in the day. They would get a huge graft, and bill for the graft itself every time they applied a small piece of it. Very not kosher.

 

[NobodyDPM]

I've always billed a HWR with whatever procedure I'm doing (ex 1st MTPJ fusion with Austin screw removal).
I guess ive been billing wrong?

If you are removing hardware, as well as performing a 1st MPJ Fusion, and you code the procedures with separate ICD-10 codes and CPT codes, then technically, you should get paid for both. That being said, many insurances will not cover both, as they will say that both procedures were performed through the same incision. Which is total BS in my eyes, I personally think you should get paid for both, as they are separate identifiable problems, and two distinct procedures with different diagnoses for each. If you are getting denials on one of the two, to me, it would be worth fighting for. YMMV.

 

[DYK343]

If you are removing hardware, as well as performing a 1st MPJ Fusion, and you code the procedures with separate ICD-10 codes and CPT codes, then technically, you should get paid for both. That being said, many insurances will not cover both, as they will say that both procedures were performed through the same incision. Which is total BS in my eyes, I personally think you should get paid for both, as they are separate identifiable problems, and two distinct procedures with different diagnoses for each. If you are getting denials on one of the two, to me, it would be worth fighting for. YMMV.

Majority of my patients are medicare. I have not been declined to date.

 

[HardRoadPaved]

If you are removing hardware, as well as performing a 1st MPJ Fusion, and you code the procedures with separate ICD-10 codes and CPT codes, then technically, you should get paid for both. That being said, many insurances will not cover both, as they will say that both procedures were performed through the same incision. Which is total BS in my eyes, I personally think you should get paid for both, as they are separate identifiable problems, and two distinct procedures with different diagnoses for each. If you are getting denials on one of the two, to me, it would be worth fighting for. YMMV.

-22 modifier but get ready for the claim to also get denied or hang in purgatory. Sadly this topic has been covered extensively by the APMA coding people. It is not appropriate to bill removal of hardware at the same site as the fusion.

 

[NobodyDPM]

-22 modifier but get ready for the claim to also get denied or hang in purgatory. Sadly this topic has been covered extensively by the APMA coding people. It is not appropriate to bill removal of hardware at the same site as the fusion.

The APMA coding people that don't practice, but run a Practice Management seminar? Those APMA coding people?

 

[DYK343]

-22 modifier but get ready for the claim to also get denied or hang in purgatory. Sadly this topic has been covered extensively by the APMA coding people. It is not appropriate to bill removal of hardware at the same site as the fusion.

Thats crazy. I did a midfoot revision fusion recently. Revision of someone else's work. It took me twice as long to get the prior hardware out than to put new hardware in and prep joints. Makes no sense. The two incisions to remove the hardware were the two for revisional fusion. But coming in at an angle to get that small (stripped) locking plate out located directly under the DP neurovascular bundle was not easy.

My billers do most of the billing for me. I just indicate what I think I did and they usually submit what I put down. If they disagree they email me. Like I said above to date I have not been denied but we are contracted with medicare/medicaid at my MSG group and most of our patients (90ish%) are medicare.

 

[G0dFather]

I find it to be more rare than common for someone to truely qualify for nail debridements.

So the overwhelming majority of podiatrists in the US are committing fraud ? cut out your underhanded sly remarks already, we get it you are a "real foot doctor" that treats "fracture, ingrown, acute stuff" ... cool story bro/sis

 

[G0dFather]

I’m a resident that’s looking for input on billing and coding. I’m in a program that has a small group of doctors, but it’s hard to learn billing and coding for surgery and clinic because it seems so variable from provider to provider. It’s hard to determine what is legit and what is fraud. What are some good resources?

Examples of billing that seems confusing:

1. Nail care - some doctors trim any nail that walks through the door and others seem to evaluate each patient for underlying diseases and only “debride” thickened nails. I have seen both office visits and nail/callus debridement codes used differently for various patients. There doesn’t seem to be any correlation for which patients are treated and what codes are used

2. Taking patients to the surgery center for ingrowns and billing for I&D’s. I assume this is not ever correct, but I see it weekly so how does it keep happening?

3. From what I can tell, an Austin bunionectomy has a single CPT code but I have never once seen this listed as a single CPT code when that is the only procedure performed. There is normally a mix of tendon lengthening or some other codes mixed in.

4. Tons of hardware removal cases. Everything from bunions to hammertoes, where the hardware is removed after the osteotomies heal. I would not personally do this, but am curious to see if this is something that is blatantly wrong or does it fall into the magical grey area of “doctors opinion” for removing the hardware although it doesn’t seem to have a real need to be removed.

5. Fracture care: For the patients that are conservatively treated, I’ve seen fracture codes used but was informed that these codes have a 90 day global. Does it make sense to use these codes or just do several E&M’s throughout the recovery period? Or is it fraudulent to choose the E&M’s over the fracture codes?

6. Grafts: Some grafts are applied in clinic while some are applied in the OR. What is the deciding factor for where they are applied? Are they always covered if applied in the OR?

7. What exactly is a “slant-back”? I’ve been told that if you cut back a portion of a mild I growing nail, it’s covered via 11765. I’ve read enough online that makes me think this is not legal. Others say that you can’t bill for any mail surgery unless you use local anesthesia. So if a patient comes in with a very mild ingrown, all you can do is offer them the procedure and nothing else?

Sorry for the stupid questions. This doesn’t seem like it should be this confusing but I feel like everything I learn about billing and coding does not seem to be how it is done “in the real world.” I also don’t understand how this could be so common if it is fraudulent.

The more you learn about billing and coding overtime the more you will notice that you need to keep downcoding your billing ....

 

[Feli]

Agree with other who say there's a lot of shady stuff going on at OP's program.... no doubt.

Try APMA Coding Resource subscription. It costs around $500 per year (depending if you're APMA member) but it saves a ton of time getting the right codes versus googling and searching every day for codes and descriptions that might be correct... which you will be doing daily, at least for the first few years. You can use it to view, review, and make your own superbill sheet. You can also make a list of favorite surgery codes. You can copy or summarize some of the CPT descriptions into your EMR templates. It works great, esp for surgery coding of stuff you don't use often.

In basic ethics terms, it's just the old "you still have to look at yourself in the mirror" thing. It goes like this:
If you'd order the MRI even if you didn't work for the hospital or the ortho group that owns the MRI machine and gives you perks or favoritism to order the studies, then order it. If you wouldn't order it and it won't change your decision making, then don't.
If you think 2 screw fixation on Lapidus is the best, then do it. If you're using 2 screw even though you think it's subpar and just to help a surgery center you own shares in, then don't and pick what you'd want if you had the procedure on your own foot.
If you think Spenco are the best OTC insoles or Gordon urea is best cream for the associated patient situation, then recommend them. If you think those suck and would be doing them just because your practice owner wants you to sell them or he gives you a percent of the sale, then don't.
If you are sending a biopsy for legit medical info, do it. If you are doing it so you send more to a path lab that you own shares or get a percent of or get rep dinners from, then don't.
If you believe the ultrasound injects are more accurate or more informational or etc, then go ahead and do them. If you think they're junk that is just for billing and you would never buy an ultrasound if your office didn't already have one that they pushed you to use for everything remotely reasonable, then don't.

...all you really need to do is practice the way you would if you didn't have any ties to any OTC stuff, imaging, surgery center, lab, DME, reps, etc etc. That is ethics in a nutshell. Most docs don't live in a nutshell. You will figure it out.

I will add more sometime if I get bored...
I do what some consider 'unbundling' since surgery pays squat... but I also do much more complex or RRA or revision etc surgery that a lot of the ppl who might be criticizing the coding don't or can't even do, so there is a gray area for sure. There is also a mod you can add for complex/revision surgery, but it is minimally impactful and often denied.
I also do the 90d fracture global codes occasionally when I think I won't see the patient again or when they have high copay per visit (so putting them in global helps them), but in the vast majority, it's best to do E&M each time. Can try to add more later or PM me if you don't get enough good replies here.

 

[DYK343]

So the overwhelming majority of podiatrists in the US are committing fraud ? cut out your underhanded sly remarks already, we get it you are a "real foot doctor" that treats "fracture, ingrown, acute stuff" ... cool story bro/sis

Maybe its my patient population? Healthy active upbeat culture? 90 year olds look like they maybe push 65?
I run a MSK practice. Nothing wrong with that and I'm not the only one who does.
Natch does the same thing.
Calm down with the personal attack there.

 

[G0dFather]

I run a MSK practice. Nothing wrong with that and I'm not the only one who does.

There IS nothing wrong with it, we all do "MSK" ... very easy to run a practice like that btw targeted google ADs , targeted facebook ads and zoc doc galore and your office will fill up with "non medicare" young " MSK" patients btw... but you seem to always point out the how negative RFC is or how its fraudulent, etc... when it is the essence and roots of podiatry ....its what comes to mind in the average american's head when they hear the word foot doctor or podiatrist and there is nothing wrong with it... as a matter of fact 11721 is the most billed code in ALL of medicine LOL

Calm down with the personal attack there.

LOL at "attack"... just calling you out on what i noticed as a common pattern in your posts

 

[dtrack22]

I would gladly attach a 22 modifier for a case where I’m removing hardware to indicate that the hardware removal added extra time/work, above and beyond what the main CPT pays for. I’d even be happy to document how much extra time it added and only charge for that extra time. But they won’t pay you for that. The whole claim will get denied, or they’ll pay you $0 more, or some tiny amount.

Let’s say my fusion takes me 40 min of tourniquet time and reimburses $700. I have to take hardware out that adds 10 minutes to my tourniquet time. That’s a 25% increase in time spent on the case so I’ll take my $700 and ask for an additional $175 (25% of $700) for the hardware removal using the 22 modifier. That’s how they want you to bill it (at least the 22 modifier part), but they won’t actually pay for it. If they did it would probably cost them more than the deep hardware removal code and the main CPT billed separately. I guess by committing fraud I’m actually saving the system money. So you’re welcome CMS.

 

[DYK343]

There IS nothing wrong with it, we all do "MSK" ... very easy to run a practice like that btw targeted google ADs , targeted facebook ads and zoc doc galore and your office will fill up with "non medicare" young " MSK" patients btw... but you seem to always point out the how negative RFC is or how its fraudulent, etc... when it is the essence and roots of podiatry ....its what comes to mind in the average american's head when they hear the word foot doctor or podiatrist and there is nothing wrong with it... as a matter of fact 11721 is the most billed code in ALL of medicine LOL


LOL at "attack"... just calling you out on what i noticed as a common pattern in your posts

There IS nothing wrong with it, we all do "MSK" ... very easy to run a practice like that btw targeted google ADs , targeted facebook ads and zoc doc galore and your office will fill up with "non medicare" young " MSK" patients btw... but you seem to always point out the how negative RFC is or how its fraudulent, etc... when it is the essence and roots of podiatry ....its what comes to mind in the average american's head when they hear the word foot doctor or podiatrist and there is nothing wrong with it... as a matter of fact 11721 is the most billed code in ALL of medicine LOL


LOL at "attack"... just calling you out on what i noticed as a common pattern in your posts

Your comments are very rambled. Feeling OK tonight? You're going off the unsolicited deep end here.

I said in the original post with the correct class findings I do nail care. I dont turn it away. Look above. Its there and I 100% agree its a needed service.

I find that many if not most of my patients that want me to be their pedicurist dont have the correct class findings. I turn them away. "My primary care says I am diabetic so I have to have my nails cut only by a DPM" "....NO you dont". Maybe its my patient population, who are extremely healthy, or maybe its because I follow the laws set before me. Following the laws set before me has increased my bottom line dramatically (see my statements above and if you're a regular comments in other threads about how much more profitable running a MSK practice is than a nail farm).

I also said 90% of my practice is medicare. . What the hell are you blabbling about finding "non medicare" patients by targeting google ads, facebook ads, etc? Im really curious how you got to this statement? Can you elaborate more? The hell you talking about?

Seriously sit back and ask yourself and please dont lie. How many times did you bill "pain" and toenail debridement today in a non diabetic patient with zero risk factors who showed up for their routine scheduled 9 week nail debridement? How many times did you fib on loss of protective sensation or arterial disease "to get it covered"? I know deep in your heart you did some (if not a ****load) of that today alone. You wont admit it but you did. And all DPMs know it because most of us do it. Nursing home DPMs who "line em up" are the biggest offenders.

Podiatrists - the diabetic foot experts- can not Rx diabetic shoes for medicare patients and most insurances without the PCP sign off. Why? You guessed it. Years of fraud.

Regarding non qualifying nail care you will probably get away with it. Medicare does look the other way most of the time. We all know that and thats why we let things "slide". But laws are the laws and I am going to follow them. Every now and then they pluck one of us out of the crowd and put us on a pedestal for all to see. Again see my above comments about googling "DPM nail care fraud". Anyone reading this who is trying to learn more about this subject I strongly recommend you click the link.

DPMs have found a way to become pedicurists for profit because they can't fill their schedule with anything else. Its true. And it fills this thread perfectly with the discussion of fraud.

 

[NobodyDPM]

DPMs have found a way to become pedicurists for profit because they can't fill their schedule with anything else. Its true. And it fills this thread perfectly with the discussion of fraud.

Actually, Podiatry evolved from being "pedicurists" into where we are today. If anything, Podiatry as a whole is trying to evolve away from being "pedicurists" into being "Foot and Ankle Surgeons" only. Which is a tragedy. I can't say there is anything I do that is more rewarding than taking care of the elderly, learning from them, and enjoying sharing my family life with them. And seeing them often enough where they feel I am a part of their lives. And performing a service for them that they truly appreciate.

Not only that, but as I get older, I feel that trying to save the world in the OR takes too much effort, time and ultimately costs me money, based on what I can make in the office versus waiting for a 2 hour turn around at a hospital. Which is why, at this point in my career, I'm very happy doing the bread and butter stuff, and leaving the complex stuff to the young hotshots looking to make a name for themselves in our profession.

 

[DYK343]

Actually, Podiatry evolved from being "pedicurists" into where we are today. If anything, Podiatry as a whole is trying to evolve away from being "pedicurists" into being "Foot and Ankle Surgeons" only. Which is a tragedy. I can't say there is anything I do that is more rewarding than taking care of the elderly, learning from them, and enjoying sharing my family life with them. And seeing them often enough where they feel I am a part of their lives. And performing a service for them that they truly appreciate.

Not only that, but as I get older, I feel that trying to save the world in the OR takes too much effort, time and ultimately costs me money, based on what I can make in the office versus waiting for a 2 hour turn around at a hospital. Which is why, at this point in my career, I'm very happy doing the bread and butter stuff, and leaving the complex stuff to the young hotshots looking to make a name for themselves in our profession.

I agree with all you said.

I also do nail care. I just follow class findings to justify it. Laws are laws. I dont make them but I do follow them.

I agree OR and surgery is almost not worth it. I make way more money in clinic than the operating room.

 

[HardRoadPaved]

I also do the 90d fracture global codes occasionally when I think I won't see the patient again or when they have high copay per visit (so putting them in global helps them), but in the vast majority, it's best to do E&M each time. Can try to add more later or PM me if you don't get enough good replies here.

Can't technically do that... if you treat a fracture you are expected to code appropriately and not scan around for RVUs or reimbursement. remember undercoding is also a reportable offense

The more you learn about billing and coding overtime the more you will notice that you need to keep downcoding your billing ....

The more of an outlier you are then more of a target is on your back.

 

[NobodyDPM]

Can't technically do that... if you treat a fracture you are expected to code appropriately and not scan around for RVUs or reimbursement. remember undercoding is also a reportable offense

The more of an outlier you are then more of a target is on your back.

Bolded mine.

The problem with that sentiment is that if you are doing everything properly, you shouldn't submit lower coding just to not be an outlier. If you are confident in your medical record keeping, and how you code, then code what you think you should be paid.

That being said, you have to be prepared to fight for it if audited. Or denied payment. And not everyone is.

 

[air bud]

appreciate the discussion around fracture care. Ok, so my (kind of) understanding is that if patient comes to you for a fracture and has NOT seen anyone else they just say hey doc my ankle hurts, I xray it and shows fibula fracture, that I can bill E&M and fracture code? But if sent from ER where someone has already diagnosed it then just one or the other?

 

[NobodyDPM]

appreciate the discussion around fracture care. Ok, so my (kind of) understanding is that if patient comes to you for a fracture and has NOT seen anyone else they just say hey doc my ankle hurts, I xray it and shows fibula fracture, that I can bill E&M and fracture code? But if sent from ER where someone has already diagnosed it then just one or the other?

My understanding is that you can still bill an E&M in your office as long as it wasn't you who saw the patient on a consult in the ED. You are new to the problem and just because someone else already diagnosed the problem doesn't mean you don't qualify for an E&M. As long as your medical record justifies it, of course.

 

[dtrack22]

My understanding is that you can still bill an E&M in your office as long as it wasn't you who saw the patient on a consult in the ED

This is my understanding

You are new to the problem and just because someone else already diagnosed the problem doesn't mean you don't qualify for an E&M.

Yup, just like a person who has been diagnosed by PCP with plantar fasciitis and sent to you, or someone coming in for a second opinion after being diagnosed or treated by another Podiatrist. You bill a new patient e/m for those, fracture care is no different.

However, the fracture care codes require that you actually provide fracture care. I've been told by billers (so who knows how black & white this is) that fracture care requires a treatment (immobilization, splinting, taping, activity restrictions, manipulation, etc.) for it to be billed. You have to buddy tape a toe fracture or put them in a surgical shoe or boot. You need to put a met fracture in a boot or cast or make NWB recommendations. This sort of applies to air buds last question. If a patient comes from the ED with a boot and crutches and you tell them "you're 5th met base is broken, stay in the boot and come back in 4 weeks," then you should not bill a fracture care code because you didn't actually provide any treatment for the fracture, the ED did. Luckily my ED uses these dumb aircast stirrup braces or splints and so most folks don't come in with a boot on already.

I also do the 90d fracture global codes occasionally when I think I won't see the patient again or when they have high copay per visit (so putting them in global helps them), but in the vast majority, it's best to do E&M each time.

This is an easy one to figure out. Look at your reimbursements for e/m vs fracture care codes. Figure out how many level 2 visits it takes to make up the difference (it's usually 3 before e/m will come out ahead). Figure out how many times you are seeing these patients in a 3 month period. If its more than 2 f/u's you're just squeezing money out of people most of the time. A follow up 5th met fracture where you tell them, "transition out of the boot and begin wearing regular shoes," is not a level 3 visit. Some fracture f/u's might be, but most aren't. Also, warning a patient that they might need surgery if the bone doesn't heal won't turn the visit into a level 3. Unless you're pretending that you spent 20 minutes on the f/u toe fracture visit...then I guess you can bill your level 3s and you come out slightly ahead after 2 f/u e/m's. This, of course, is assuming that you bill a new patient e/m with a 57 modifier and the fracture care code on the first visit when comparing using the fracture care codes to straight e/m.

I worked for a podiatrist who claimed the fracture care codes paid way less than e/m's, but she was seeing them every 3 weeks and billing level 3's at every visit. So sure, if you upcode and schedule unnecessary appointments you'll come out ahead not billing fracture care CPTs. But it's really designed to be a wash. There is a reason that the fracture care reimbursement is essentially equivalent to 2-3 appropriately coded follow up visits...You aren't making any meaningful amount of extra money billing one way or the other unless you are purposefully ripping off the patient in most cases.

 

[NobodyDPM]

However, the fracture care codes require that you actually provide fracture care. I've been told by billers (so who knows how black & white this is) that fracture care requires a treatment (immobilization, splinting, taping, activity restrictions, manipulation, etc.) for it to be billed. You have to buddy tape a toe fracture or put them in a surgical shoe or boot. You need to put a met fracture in a boot or cast or make NWB recommendations. This sort of applies to air buds last question. If a patient comes from the ED with a boot and crutches and you tell them "you're 5th met base is broken, stay in the boot and come back in 4 weeks," then you should not bill a fracture care code because you didn't actually provide any treatment for the fracture, the ED did. Luckily my ED uses these dumb aircast stirrup braces or splints and so most folks don't come in with a boot on already.

Totally agree with you here.

 

[G0dFather]

Your comments are very rambled. Feeling OK tonight? You're going off the unsolicited deep end here.

Not at all actually and i was feeling OK sleeping in my bed, were you feeling OK? i only ask because you must have been pounding on that keyboard at 1:12 AM ... oh did your pager go off? LOL

Seriously sit back and ask yourself and please dont lie. How many times did you bill "pain" and toenail debridement today in a non diabetic patient with zero risk factors who showed up for their routine scheduled 9 week nail debridement? How many times did you fib on loss of protective sensation or arterial disease "to get it covered"? I know deep in your heart you did some (if not a ****load) of that today alone. You wont admit it but you did.

Here is yet another example where you bring up fraud again trying and to entangle me in it to boot ( maybe you have some deep rooted issues there taking you off the deep end) .... the toenail pain scenario you describe is not what i refer to when i bring up RFC... i dont see pts like that, its a waste of time... when i refer to RFC i mean at risk RFC... true DM and PVD patients with class findings ( even if they have some palpable pluses they can still qualify through a Q9 scenario) that require nails AND calluses debrided to keep them out of the OR... that is a VERY profitable visit, you need the calluses... i agree with you on wasting time doing painful mycotic nail care, one should just attempt to cure the fungal nail if possible

DPMs have found a way to become pedicurists for profit because they can't fill their schedule with anything else. Its true.

WTH !? Again with the generalization, how can you actually prove that its true ? SAD when it comes from a dpm

Actually, Podiatry evolved from being "pedicurists" into where we are today. If anything, Podiatry as a whole is trying to evolve away from being "pedicurists" into being "Foot and Ankle Surgeons" only. Which is a tragedy.

Indeed a tragedy ... evolving their way to poverty

I can't say there is anything I do that is more rewarding than taking care of the elderly, learning from them, and enjoying sharing my family life with them. And seeing them often enough where they feel I am a part of their lives. And performing a service for them that they truly appreciate.

This was very touching ... thank you for this, puts things into perspective for the young pods out there

This is an easy one to figure out. Look at your reimbursements for e/m vs fracture care codes. Figure out how many level 2 visits it takes to make up the difference (it's usually 3 before e/m will come out ahead). Figure out how many times you are seeing these patients in a 3 month period. If its more than 2 f/u's you're just squeezing money out of people most of the time. A follow up 5th met fracture where you tell them, "transition out of the boot and begin wearing regular shoes," is not a level 3 visit. Some fracture f/u's might be, but most aren't. Also, warning a patient that they might need surgery if the bone doesn't heal won't turn the visit into a level 3. Unless you're pretending that you spent 20 minutes on the f/u toe fracture visit...then I guess you can bill your level 3s and you come out slightly ahead after 2 f/u e/m's. This, of course, is assuming that you bill a new patient e/m with a 57 modifier and the fracture care code on the first visit when comparing using the fracture care codes to straight e/m.

Im with you on this ... but have you factored in the money from xrays taken/billed on each visit as well? Wouldnt the EM scenario come out on top then?

 

[G0dFather]

The more of an outlier you are then more of a target is on your back.

The bigger the target on your back .... the faster they will knock

 

[G0dFather]

Podiatrists - the diabetic foot experts- can not Rx diabetic shoes for medicare patients and most insurances without the PCP sign off. Why? You guessed it. Years of fraud.

oh... it doesnt have to do with being limited in our degree ?

 

[air bud]

JFC godfather we get it. @DYK343 is a MSK god who only treats healthy attractive wealthy people and you are NYC TFP with unknown confirmation of mustache presence. We have a good thread going. Also @NobodyDPM is a boomer.

Love you guys and appreciate everyone's POV.

Ok so the whole putting in boot or splinting makes total sense. Although just because a PCP says PF doesn't mean it is...whereas an xray, a radiologist and an ED doc all say that bimal ankle fx is broken. But I like your interpretation.

Related to this how important is it to code localized edema if you are trying to bill/dispense and pneumatic walking boot? Doesn't anyone use non pneumatic?

 

[G0dFather]

you are NYC TFP with unknown confirmation of mustache presence

why slam JC ? LMAO ...Im that NYC TFP that will drastically slow down in seeing pts/FIRE in next 5 to 7 years thanks to my business and TFP associates, i cant imagine seeing pts daily like this past 40 ... i dont have a mustcache should i grow one ? ...love you to "bud" lol

 

[G0dFather]

Related to this how important is it to code localized edema if you are trying to bill/dispense and pneumatic walking boot? Doesn't anyone use non pneumatic?

i dont find that as important as biiling the actual trauma or inflammatory dx to get a L4361 covered... we never had issues

 

[Feli]

0...have you factored in the money from xrays taken/billed on each visit as well? Wouldnt the EM scenario come out on top then?

It is just like if you did ORIF: You still get the XRs during a fracture global (just like in post-op globals) and should code for casts and cast supplies and DME too. You will need mods just like in a post-op global. You will get the occasional patient reading EOB who says "I never had surgery" since the fx global will probably say the fx code was a surgery. I would have to check (since I don't use the fx globals much), but I don't think you get the cast/wrap/splint/strap code on the day you start the global (but you do have to put one on or say why you didn't... I often give a free post-op shoe as my immobilize for digit and met fx). Simply think of it as a surgery code. You are basically killing related E&Ms for 90d following (but not he E&M on the fx global date) and losing that first cast/splint/strap from that same date... and you gain the fx global code in exchange. That's all... and figure out if that makes sense for the pt and for you.

Basically, like dtrack said, you just have to weigh the NF RVU of the fx code vs E&Ms for the visit(s) you'd anticipate they'll need during that global span. In most areas, you are usually going to just avoid the fx code and best to bill E&M for most patients. When I ran the numbers maybe 5 years ago, it's heavily in favor of E&Ms on digit and met, slightly in their favor in mid/hindfoot fx codes (although those would prob need a cast at first fx dx visit... which wouldn't pay). And fwiw, I use non-manip fx codes in the office when I do use them... most don't need manip or it's too late by then. Some DPMs use the manip ones in office (I only do that in ER if I local and reduce... and it's a non-op fx).

So, by my own conclusion, the only ones I usually do the 90d fx global on are the high copay patients (save them the $40+ copay on next few visits and discuss that with them) and the fx patients who are tourists, etc to my area where I'm highly unlikely to see them again... seems dumb to not get the fx code when you do that work of wrap, teach, explain DME, explain recover timeline, etc. I might also do it for a dinky digit fx in a pt I can tell is a workaholic and probably won't even show for their f/u XR visit.

If it's a fx that is peds or going to go to surgery or likely to be non-compliant with immobilize (delay heal, bust through casts, pain, other foot conditions, etc) it is very bad to use the fx code and will probably only cause reject/delay/modifier headaches. For the large large majority of any fx type, the E&Ms in the span will outweigh the fx global code. It's a personal choice how to code and how to chart, though.

...back when I was in pod school, there was a F&A ortho who advertised himself as 'orthopedic heel specialist' and would see new pts for E&M new pt, order t99 scans (at a center he owned) on all of those plantar fasciitis, have it read (by a buddy radiologist) as heel fx since it lights up (obviosly). Then, f/u visit was a fx code, boot, and 3mo follow up. Genius average per visit. Ethical? Meh.

 

[Pronation]

see new pts for E&M new pt, order t99 scans (at a center he owned) on all of those plantar fasciitis, have it read (by a buddy radiologist) as heel fx since it lights up (obviosly). Then, f/u visit was a fx code, boot, and 3mo follow up. Genius average per visit. Ethical? Meh.

Nice, thanks for the new business model

 

[heybrother]

Feli - are you sure there isn't anything in the CPT book that would get you in trouble for doing a fracture care code on a patient that you won't follow-up?

My question/issue (and honestly I don't know) is - imagine you did an ORIF and then sent them back down the road and said - follow this up with your DPM/ortho whatever. You would theoretically have to use the modifier code for surgery only and lose the follow-up/after care reimbursement. Is there not some component built into this indicating their expectations that you follow it through?

 

[Feli]

Feli - are you sure there isn't anything in the CPT book that would get you in trouble for doing a fracture care code on a patient that you won't follow-up?

I don't know what you mean. I will follow them up. I can't help it if they were visiting from Florida when they did their Danis Weber A and that they didn't want to make their 4wk f/u xray. That may or may not be related to what I might have noticed on their new patient form that they live 1000miles away. I was ready to follow them up though, man. My xray was on and ready that day they cancelled or no-showed.

 

[G0dFather]

there was a F&A ortho who advertised himself as 'orthopedic heel specialist' and would see new pts for E&M new pt, order t99 scans (at a center he owned) on all of those plantar fasciitis, have it read (by a buddy radiologist) as heel fx since it lights up (obviosly). Then, f/u visit was a fx code, boot, and 3mo follow up.

wow insane .... and they call pods fraudsters with RFC LOL this is on a whole other level

 

[G0dFather]

Feli - are you sure there isn't anything in the CPT book that would get you in trouble for doing a fracture care code on a patient that you won't follow-up?

When you bill fracture care you should have follow up visits just like when billing a 11750 ( there should be at least 1 follow up visit in the global) ... but like he said what can you do if they never come back ?

 

[DYK343]

Not at all actually and i was feeling OK sleeping in my bed, were you feeling OK? i only ask because you must have been pounding on that keyboard at 1:12 AM ... oh did your pager go off? LOL

Time zones. We learned about them in elementary school.

Here is yet another example where you bring up fraud again trying and to entangle me in it to boot ( maybe you have some deep rooted issues there taking you off the deep end) .... the toenail pain scenario you describe is not what i refer to when i bring up RFC... i dont see pts like that, its a waste of time... when i refer to RFC i mean at risk RFC... true DM and PVD patients with class findings ( even if they have some palpable pluses they can still qualify through a Q9 scenario) that require nails AND calluses debrided to keep them out of the OR... that is a VERY profitable visit, you need the calluses... i agree with you on wasting time doing painful mycotic nail care, one should just attempt to cure the fungal nail if possible

You didnt answer my question on how many times you billed pain with onychomycosis/callus to get it covered. Or found a way to diagnose PAD/neuropathy to get it covered. We all do it. Its a DPM thing.

I never said I dont do foot care.

Regardless we wont see eye to eye and I suppost thats OK. Your above attack prompted the responses here but ill stop responding after this. Ive made my point. You've made yours.

Edit: I can do a TMA but not prescribe diabetic shoes. That has nothing to do with our degree. It has to do with history...

 

[deleted285117]

Darn, I shouldn’t be billing 28285 for those handmade crest pads then... 😜

 

[dtrack22]

but have you factored in the money from xrays taken/billed on each visit as well? Wouldnt the EM scenario come out on top then?

Like Feli already said, X-rays are paid when you take them in the fracture care global just like they are in the post-op global. As are casts, DME, trips to the OR, etc.

Doesn't anyone use non pneumatic?

Why would you? They cost about the same and they reimburse less…c’mon non- employed private office doctor, think of the $

I’ve never had the pneumatic walking boot rejected for not having a swelling diagnosis. M72.2 all by itself gets pneumatic walking boots paid for in my area

 

[NobodyDPM]

This was very touching ... thank you for this, puts things into perspective for the young pods out there

Thank YOU! I find the older I get, the more I hope that the younger generation will treat me well in my golden years. So I try to emulate that as much as possible. People, in general, have lost the art of listening to others and learning from them. I have some patients that survived the Holocaust, and others that fought in WWII and The Korean War. I wish I could sit with them for hours and listen to their stories. And even more so, I wish I had the time to write their stories down. To preserve them and their memories.

 

[HardRoadPaved]

I wish I had the time to write their stories down. To preserve them and their memories.

Hell I wish I more time to write their damn notes of the visit let alone their life stories.

 

[G0dFather]

Time zones. We learned about them in elementary school.

I went to podiatry school .

You didnt answer my question

Yes I did, its literally in what you quoted ... answer is none... frankly i dont know how you can bring someone in every 9 weeks for soley painful nail debridement, who would keep coming to a "doctors" office for that ? Patients would just not end up coming back if that is what your offering so i dont know what on earth your referring to... and you wont get paid on callus care with pain not covered service .... nails and calluses for at risk patients i get

Ive made my point. You've made yours.

You didnt make your point, your trying to take me in circles. But i have made my point very clearly regarding the stuff you try to pull on here.