Billing and coding

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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

Because they don't see you as a "doctor", they see you as someone that's offering them free pedicures...

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Because they don't see you as a "doctor", they see you as someone that's offering them free pedicures...


"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."

This is the question that started the whole internet tough guy argument. I have patients everyday ask me to be their free pedicurist. Every single day. Class findings I do the care. No class findings I dont.

Not sure why that bothered Godfather so much but we should just move on here.
 
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"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."

This is the question that started the whole internet tough guy argument. I have patients everyday ask me to be their free pedicurist. Every single day. Class findings I do the care. No class findings I dont.

Not sure why that bothered Godfather so much but we should just move on here.

Meh, I'll still take care of them even if they don't have class findings. However, they must pay a cash amount equivalent to the highest reimbursing insurance amount that I receive. If they don't want to pay then bye Felicia.
 
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Meh, I'll still take care of them even if they don't have class findings. However, they must pay a cash amount equivalent to the highest reimbursing insurance amount that I receive. If they don't want to pay then bye Felicia.
How do you (or anyone) nicely go about the "Dr X used to do it and it was always covered" scenario? Someone non diabetic with fungal nails.

I have not been able to master this discussion to date. I've had a lot of these patients over the last several years.
 
How do you (or anyone) nicely go about the "Dr X used to do it and it was always covered" scenario? Someone non diabetic with fungal nails.

I have not been able to master this discussion to date. I've had a lot of these patients over the last several years.
I just explain the rules. I tell them podiatrists literally go to jail every year for illegally billing Medicare. I say my interpretation of the rules is different that theirs implying that the other person was committing fraud.. Patient usually says omg I don't want you to commit fraud and end of story.

I also use this example to explain the absurdity of the rules. You could be perfectly healthy no diabetes no fungal nails no medication no nothing. But you were In a terrible farming accident and lost both of your hands. You literally cannot grab these nail nippers and cut your own nails. THAT is not covered according to Medicare guidelines.
 
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How do you (or anyone) nicely go about the "Dr X used to do it and it was always covered" scenario? Someone non diabetic with fungal nails.

I have not been able to master this discussion to date. I've had a lot of these patients over the last several years.

You have to stop the problem at the main source. A majority of the PCPs within my group do not send nail care unless they have the beetus with numb feet or a history of PAD. The ones that continue to refuse to pay attention to that, I’ll cc them back on my progress note (I’ll also mark the note as important so they don’t insta-delete it) with “patient left upset and refused to pay per the ABN a non-covered nail service as they do not have neuropathy nor PAD.”

Also what AirBuds Pro said
 
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How do you (or anyone) nicely go about the "Dr X used to do it and it was always covered" scenario? Someone non diabetic with fungal nails.

I tell them that Dr. X was committing fraud and I’m not willing to pay the government money or go to jail over their toenails. I spend zero time worrying about what a patient whos in my office to have their toenails cut thinks about the care I provided.
 
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I tell them that Dr. X was committing fraud and I’m not willing to pay the government money or go to jail over their toenails. I spend zero time worrying about what a patient whos in my office to have their toenails cut thinks about the care I provided.
Yeah I had a lady yesterday who used to see a pod in some big city. She was asking if I was going to "burnish" them and I said no I don't so that. I could tell she was getting upset. I gave zero Fs as I left the room and went to my next patient. I am very fortunate to live in rural St. Nowhere where nobody has ever seen a podiatrist before so doesn't expect that.

Speaking of coding....I think I billed my first g code yesterday. Non dystrophic nail that was minimally avulsed traumatically. I just trimmed it back so wouldn't catch on something, didn't feel need to remove completely. Did I do the codey thing good?
 
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Yeah I had a lady yesterday who used to see a pod in some big city. She was asking if I was going to "burnish" them and I said no I don't so that. I could tell she was getting upset. I gave zero Fs as I left the room and went to my next patient. I am very fortunate to live in rural St. Nowhere where nobody has ever seen a podiatrist before so doesn't expect that.

Speaking of coding....I think I billed my first g code yesterday. Non dystrophic nail that was minimally avulsed traumatically. I just trimmed it back so wouldn't catch on something, didn't feel need to remove completely. Did I do the codey thing good?
If they were diabetic and if it's Medicare did you add the proper e code and get the last day of pcp service and also get an ABN just in case it's still rejected?

And for bonus did you sell formula 3 or laser sessions.... Now you did the podiametry thing good
 
I just explain the rules. I tell them podiatrists literally go to jail every year for illegally billing Medicare. I say my interpretation of the rules is different that theirs implying that the other person was committing fraud.. Patient usually says omg I don't want you to commit fraud and end of story.

I also use this example to explain the absurdity of the rules. You could be perfectly healthy no diabetes no fungal nails no medication no nothing. But you were In a terrible farming accident and lost both of your hands. You literally cannot grab these nail nippers and cut your own nails. THAT is not covered according to Medicare guidelines.

I avoid discussing other doctors. I tell patients that I follow the Medicare guidelines. If they ask about "the other guy", I just shrug my shoulders and tell them I follow the rules. They can come to their own conclusions, and they are free to seek care elsewhere if they don't like how i bill.
 
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Let’s face it, our profession does not have a shortage of thieves and slime balls.

But as long as they keep up their antics, the insurers will keep consulting with me to review suspected fraud cases, and pay me big bucks for my analysis.

As far as unbundling bunions, it IS considered fraud. The comment below is directly from NCCI 2021 policy, chapter IV.

17. CPT codes 28288, 28306, 28307, 28310, and 28315 shall not be reported with bunionectomy CPT codes 28291-28299 for procedures performed on the ipsilateral first toe or metatarsal. CPT codes 28306, 28307, and 28310 (Osteotomy procedures) shall not be reported with a bunionectomy code because there are bunionectomy codes that include osteotomy of the first metatarsal or proximal phalanx of the first toe. CPT code 28288 (Ostectomy ...) shall not be reported with a bunionectomy code because it is a misuse of this code to report ostectomy of the median eminence of the metatarsal bone which is integral to the bunionectomy procedure. Additionally, some bunionectomy procedures include excision of the head of the first metatarsal. CPT code 28315 (Sesamoidectomy, first toe (separate procedure)) includes the “separate procedure” designation in its code descriptor. CMS payment policy does not allow separate payment
Revision Date (Medicare): 1/1/2021 IV-22

for a procedure designated as a “separate procedure” when
performed along with another procedure in the same anatomic
area.


So it is crystal clear and in black and white.

A Lapidus, no matter how it’s performed is a 28297 and not a 28292/28740. NCCI also has a policy that you must bill to the highest specificity and if there is one code that describes the procedure, that’s the one code to use.

Billing 11765 requires anesthesia in a sensate patient and requires a true WEDGE of tissue be excised.

Don’t cross the line or your name will pass my desk. And I know my stuff and if I say you’re guilty, they are coming for you.
 
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Thanks for the replies everyone!

- as far as the hardware removals, we have a guy that uses the screws (safety fix medical) that are made to be removed to prevent any retained hardware after bone healing. The patients are worked up for this. Although I do not agree with it and would never do this, does it make it legal to do this if the patient is on board? I completely understand why it is being done, but am more curious of the legality at this point.
- I was pretty sure I had a good understanding of “unbundling,” but it still blows my mind that it can be done so often with no recourse. For example, we did a random bread and butter forefoot case and the CPT codes were billed as follows:
1)28645 - repair toe dislocation
2) 27691 - revision of Lower leg tendon
3) 28270 - release of contracture
4) 28313 - repair of toe deformity
5) 28313 - metatarsal incision
6) 28285 - arthrodesis
7) 76000 - flouroscan
8) 64450 - nerve block
9) 20600 steroid injection
10) L4360 - CAM Walker
Also noticed that every patient signs a waiver for most groups here that they will be responsible for any amount not covered by insurance which also seems highly questionable.

- If the grafts are not covered in office, can you then take a patient who honestly needs a graft to the OR and apply it there?

- my current understanding for nail and callus care is: The patient must be being treated for DM, neuropathy, PVD, or be on a long term anti-coagulant (with a few less common dx’s available as well), have certain class findings to qualify the Q codes and then you can bill 11720/11721 and/or 11055/11056 but no E&M unless you truly treat another condition that they are there for as well. If they have a painful thick nail then you can use the mycotoc nail for coverage of 11720/11721. A random painful callus on a healthy patient is not ever covered. Only ingrown P&A or the avulsion code can be used for a painful ingrown. Is this correct?
 
Thanks for the replies everyone!

- as far as the hardware removals, we have a guy that uses the screws (safety fix medical) that are made to be removed to prevent any retained hardware after bone healing. The patients are worked up for this. Although I do not agree with it and would never do this, does it make it legal to do this if the patient is on board? I completely understand why it is being done, but am more curious of the legality at this point.
- I was pretty sure I had a good understanding of “unbundling,” but it still blows my mind that it can be done so often with no recourse. For example, we did a random bread and butter forefoot case and the CPT codes were billed as follows:
1)28645 - repair toe dislocation
2) 27691 - revision of Lower leg tendon
3) 28270 - release of contracture
4) 28313 - repair of toe deformity
5) 28313 - metatarsal incision
6) 28285 - arthrodesis
7) 76000 - flouroscan
8) 64450 - nerve block
9) 20600 steroid injection
10) L4360 - CAM Walker
Also noticed that every patient signs a waiver for most groups here that they will be responsible for any amount not covered by insurance which also seems highly questionable.

- If the grafts are not covered in office, can you then take a patient who honestly needs a graft to the OR and apply it there?

- my current understanding for nail and callus care is: The patient must be being treated for DM, neuropathy, PVD, or be on a long term anti-coagulant (with a few less common dx’s available as well), have certain class findings to qualify the Q codes and then you can bill 11720/11721 and/or 11055/11056 but no E&M unless you truly treat another condition that they are there for as well. If they have a painful thick nail then you can use the mycotoc nail for coverage of 11720/11721. A random painful callus on a healthy patient is not ever covered. Only ingrown P&A or the avulsion code can be used for a painful ingrown. Is this correct?

LOL, wow...that list of CPT codes is absurd. What was the actual procedure done? And no. It makes no difference whether the patient is "on board" with it or not. That type of coding is 100% fraud.

Yes, you can take the patient to the OR to apply the graft, but you can't bill for the graft in that situation. You are only billing for the application of the graft.

Your estimation of nail care is accurate.
 
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- my current understanding for nail and callus care is: The patient must be being treated for DM, neuropathy, PVD, or be on a long term anti-coagulant (with a few less common dx’s available as well), have certain class findings to qualify the Q codes and then you can bill 11720/11721 and/or 11055/11056 but no E&M unless you truly treat another condition that they are there for as well. If they have a painful thick nail then you can use the mycotoc nail for coverage of 11720/11721. A random painful callus on a healthy patient is not ever covered. Only ingrown P&A or the avulsion code can be used for a painful ingrown. Is this correct?

I don’t know if it is regional, but being treated for DM does not fly by me. Also being on an anticoagulant does not qualify by me. Most dx (hcc/starred in EPIC EHR) require patient being seen in 6 months prior by qualifying provider with the diagnosis not only listed as active dx but actively managed (in assessment with plan). This is per coding team and the herd of lawyers.

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Basically
1. Painful ingrown nail (only painful nail treated
2. Neuropathy (pick your cause) only idiopathic neuropathy does not need active management
3. Staged CKD actively managed as above with class findings
4. Atherosclerosis with finding and active management (exact diagnosis)
5. Less common dx like MS or paraplegia

This last PCP thing does not fly for my msg. The require active management with proof not just hoping the pcp managed the appropriate things at a random appointment.
 
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- my current understanding for nail and callus care is: The patient must be being treated for DM, neuropathy, PVD, or be on a long term anti-coagulant (with a few less common dx’s available as well), have certain class findings to qualify the Q codes and then you can bill 11720/11721 and/or 11055/11056 but no E&M unless you truly treat another condition that they are there for as well. If they have a painful thick nail then you can use the mycotoc nail for coverage of 11720/11721. A random painful callus on a healthy patient is not ever covered. Only ingrown P&A or the avulsion code can be used for a painful ingrown. Is this correct?


Yes that all looks good, a couple of points you should NOT bill RFC as an EM code ( this i have seen rampant with providers in multiple states, the excuse is that RFC gets audited alot and this is how i will avoid this since the thinking is that a 99213 wont get audited ) ... for DM RFC its not enough for the patient to just be a diabetic, they also MUST have class findings as well, if they are diabetic only with no other complications then RFC wont be a covered service.
 
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I don’t know if it is regional, but being treated for DM does not fly by me. Also being on an anticoagulant does not qualify by me. Most dx (hcc/starred in EPIC EHR) require patient being seen in 6 months prior by qualifying provider with the diagnosis not only listed as active dx but actively managed (in assessment with plan). This is per coding team and the herd of lawyers.

Edit:

Basically
1. Painful ingrown nail (only painful nail treated
2. Neuropathy (pick your cause) only idiopathic neuropathy does not need active management
3. Staged CKD actively managed as above with class findings
4. Atherosclerosis with finding and active management (exact diagnosis)
5. Less common dx like MS or paraplegia

This last PCP thing does not fly for my msg. The require active management with proof not just hoping the pcp managed the appropriate things at a random appointment.
Bolded mine. It depends on what stage they are at. They can qualify for Q9 if they have severe edema due to inactivity and neuropathy.

Btw, you should be billing an EMR for all RFC patients once a year. Full eval, full medical record, and MIPS. Medicare allows that.
 
you should be billing an EMR for all RFC patients once a year. Full eval, full medical record, and MIPS. Medicare allows that.
Where is that in the LCD? For NJ its L35138
  1. Evaluation and management (E/M) services for any of the conditions defined as ROUTINE FOOT care will be considered ineligible for reimbursement, with the exception of the initial E/M service performed to diagnose the patient’s condition.
  2. Evaluation and management (E/M) services provided on the same day as ROUTINE FOOT care by the same doctor for the same condition are not eligible for payment except if it is the initial E/M service performed to diagnose the patient's condition or if the E/M service is a significant separately identifiable service indicated by the use of modifier 25, and documented by medical records.
 
Where is that in the LCD? For NJ its L35138
  1. Evaluation and management (E/M) services for any of the conditions defined as ROUTINE FOOT care will be considered ineligible for reimbursement, with the exception of the initial E/M service performed to diagnose the patient’s condition.
  2. Evaluation and management (E/M) services provided on the same day as ROUTINE FOOT care by the same doctor for the same condition are not eligible for payment except if it is the initial E/M service performed to diagnose the patient's condition or if the E/M service is a significant separately identifiable service indicated by the use of modifier 25, and documented by medical records.

I'll be honest, I do this on the basis of what CMS taught us at a billing seminar I attended by them. Especially now, with MIPS and having to document so much once a year, I can't see how they would deny that E/M. I mean, when I go to see my PCP with no new problems, they get paid for that annual visit. I guess I push the envelope a little.
 
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@Pronation

Based on your "dislike" of my comment, you see patients for years and years and never do a full and complete podiatric H&P, to update their height, weight, BP, ask them about new meds or allergies, new surgeries, etc, and don't document that?

If you do, you don't think you deserve an E/M code for that? Do you do MIPS in your practice?

Again, just because it's not expressly written down, as I've said, if you do it, and think you deserve to get paid for it, fight if audited. Based on my experience, you will win this particular fight.
 
@Pronation

Based on your "dislike" of my comment, you see patients for years and years and never do a full and complete podiatric H&P, to update their height, weight, BP, ask them about new meds or allergies, new surgeries, etc, and don't document that?

If you do, you don't think you deserve an E/M code for that? Do you do MIPS in your practice?

Again, just because it's not expressly written down, as I've said, if you do it, and think you deserve to get paid for it, fight if audited. Based on my experience, you will win this particular fight.

These patients get about 2 minutes of my time and end up getting plenty of E&Ms anyway due to other complaints - hammertoes, new wounds, cellulitis, paresthesias, rectal bleeding etc. With all due respect, I feel like it’s a waste of my staff’s time (including hogging resources in an MSG setting) to be fighting insurances for some kind of yearly full “Podiatric H&P”
 
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These patients get about 2 minutes of my time and end up getting plenty of E&Ms anyway due to other complaints - hammertoes, new wounds, cellulitis, paresthesias, rectal bleeding etc. With all due respect, I feel like it’s a waste of my staff’s time (including hogging resources in an MSG setting) to be fighting insurances for some kind of yearly full “Podiatric H&P”
Too each is own, I guess. In today's environment, every dollar counts. And if you can do it ethically and legally, why not?
 
So I’m also assuming all of this nonsense gets factored (inflated) into the price of these old guys selling the practice as well haha

I also always hear talk of “buy-ins” for practices and surgery centers. How do you go about finding the right value for the buy in? I know most new grads don’t get a buy in offer up front, but it seems to make sense to lay out the specifics for any buy in ahead of time in order to not get trapped at a job. I’ve been told some figures of buy ins from other graduates for surgery centers and it’s pretty terrifying to think of taking out more loans to be a partner in a surgery center, but I also know that the surgery centers can be good income. for example, one of our graduates bought into a “surgical hospital” for $175k after 2 years of working for a group and they say it has been “well worth it.” $175k on top of student loans seems daunting. I’m assuming that the buy in was negotiated during the initial contract, but am not sure of that.

I also find it crazy that we never were taught any of this during school!
 
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So I’m also assuming all of this nonsense gets factored (inflated) into the price of these old guys selling the practice as well haha

I also always hear talk of “buy-ins” for practices and surgery centers. How do you go about finding the right value for the buy in? I know most new grads don’t get a buy in offer up front, but it seems to make sense to lay out the specifics for any buy in ahead of time in order to not get trapped at a job. I’ve been told some figures of buy ins from other graduates for surgery centers and it’s pretty terrifying to think of taking out more loans to be a partner in a surgery center, but I also know that the surgery centers can be good income. for example, one of our graduates bought into a “surgical hospital” for $175k after 2 years of working for a group and they say it has been “well worth it.” $175k on top of student loans seems daunting. I’m assuming that the buy in was negotiated during the initial contract, but am not sure of that.

I also find it crazy that we never were taught any of this during school!

First thing's first. Despite what people want or say about their practice, business wise, a medical practice is worthless. Unless the seller is also selling the property and building. Otherwise, this "sell for 50% of the average of three years gross collections" is pure BS. Patients aren't a commodity, and there is no guarantee they will stay. There's a lot more to it, if you're interested.

As far as surgery center investments, that gets a little stickier. You aren't buying based on gross collections, you are buying based on the profit generated and what the reported dividends are based over a number of years. If you are being asked for $175K as an investment into the business, that business better be making a metric ton of profit to justify having the shares so expensive. This is also entirely dependent on how many current partners there are, and how many shares are available. Also, they should be willing to finance your buy-in. Meaning, they take your share of the profit for x number of months/years, including a reasonable interest rate, until the buy-in is paid off. Still, though, $175K is a tremendous amount to get your foot in the door initially. I'd be glad to explain all the intricacies if you're interested.
 
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The faculty at the schools are the type of podiatrists who have no knowledge of buy ins/ownership/valuations/billing/coding/etc. and therefore have no business teaching it.
See above
 
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