Medicare Fee Schedules Values 2000 through 2022 for common codes

[heybrother]

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Something different - just worth a look / consideration of evolution of payment through time.

Locality is Texas Rest of State.
28296 is facility
If (a/b) year data were identical I merged them

Codes were selected at random.

 

[msuDPM]

Something different - just worth a look / consideration of evolution of payment through time.

Locality is Texas Rest of State.
28296 is facility
If (a/b) year data were identical I merged them

Codes were selected at random.

View attachment 363524

Is 28296 a distal osteotomy bunion? I don't do enough of those to memorize the code.

Otherwise, interesting and while not great against recent inflation, not as bad as what I would have imagined.

 

[PlainsPod]

Is 28296 a distal osteotomy bunion? I don't do enough of those to memorize the code.

Otherwise, interesting and while not great against recent inflation, not as bad as what I would have imagined.

Sure is, but @ExperiencedDPM would recommend you use about 4-5 different codes when you do a distal osteotomy just to be on the safe side

 

[ExperiencedDPM]

Sure is, but @ExperiencedDPM would recommend you use about 4-5 different codes when you do a distal osteotomy just to be on the safe side

What are you taking about? Don’t put words in my mouth that are bullish-t.

I never recommend multiple codes or unbundling. Leave my name out of your posts.

 

[NatCh]

What are you taking about? Don’t put words in my mouth that are bullish-t.

I never recommend multiple codes or unbundling. Leave my name out of your posts.

I get the feeling he was joking...

Speaking of Medicare, apparently they now allow only one 11750 (matricectomy) per toe per lifetime unless you appeal. That's like a forever-global. They also won't pay for another 11730 for 32 weeks on any particular toe without an appeal.

 

[deleted285117]

What are you taking about? Don’t put words in my mouth that are bullish-t.

I never recommend multiple codes or unbundling. Leave my name out of your posts.

I think he was joking 😁

 

[heybrother]

I get the feeling he was joking...

Speaking of Medicare, apparently they now allow only one 11750 (matricectomy) per toe per lifetime unless you appeal. That's like a forever-global. They also won't pay for another 11730 for 32 weeks on any particular toe without an appeal.

What's your source for this?

The reason I ask is - this whole thing is weird. They put out new guidance but the values weren't really lifetime. They required a substantial time period between procedures, proof of which toe, specific modifiers if you did it, and a different modifier if another doctor did it which is garbage because you'd never know.

The second it went in Medicare in my area denied 2 11750's done at the same time on every patient. The code text was bizarre. We appealed using the new Medicare modifier and they didn't pay.

I stupidly had my office drop some of the second procedures. My partner did not. He ultimately got paid for them from what I can tell.

I brought it up with an APMA rep at a conference. He told me he wanted to see it. Said the guidance was rescinded the second it was put in place and he didn't know why they'd be doing that. I sent it. He never responded.

I keep waiting for new info. So what have you seen?

 

[PatchAdamsFan]

What's your source for this?

Article - Billing and Coding: Surgical Treatment of Nails (A52998)

Use this page to view details for the Local Coverage Article for Billing and Coding: Surgical Treatment of Nails.

www.cms.gov

Searched 'Medicare 11750' and got the link above. Confirms that's been in place since 6/2022.

Per the article:
CPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.
CPT code 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision. This part's vague, but read as "lifetime"
A medically reasonable and necessary repeat avulsion or excision of the same nail within 32 weeks of a previous avulsion, or excision, of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.

 

[PTPuser]

I know this is a dumb question but does fee price changes if the procedure e.g. that 28296 was done by pod v. ortho?

 

[NatCh]

Yes, CMS.gov is our source. I haven’t had any denials yet according to my biller.

Article - Billing and Coding: Surgical Treatment of Nails (A52998)

Use this page to view details for the Local Coverage Article for Billing and Coding: Surgical Treatment of Nails.

www.cms.gov

Searched 'Medicare 11750' and got the link above. Confirms that's been in place since 6/2022.

Per the article:
CPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.
CPT code 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision. This part's vague, but read as "lifetime"
A medically reasonable and necessary repeat avulsion or excision of the same nail within 32 weeks of a previous avulsion, or excision, of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.

If a patient has a matricectomy on a given toe from a provider, then has another ingrown toenail on the same toe years later but doesn’t recall which toe or doesn’t inform the new provider about it, then does the new provider get a denial? Sounds like it. 👎🏼

 

[Feli]

Article - Billing and Coding: Surgical Treatment of Nails (A52998)

Use this page to view details for the Local Coverage Article for Billing and Coding: Surgical Treatment of Nails.

www.cms.gov

Searched 'Medicare 11750' and got the link above. Confirms that's been in place since 6/2022.

Per the article:
CPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.
CPT code 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision. This part's vague, but read as "lifetime"
A medically reasonable and necessary repeat avulsion or excision of the same nail within 32 weeks of a previous avulsion, or excision, of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.

Yeah, anyone needs to be aware of this. For sure.

You need the medically necessary repeat -77 mod (or -76 as applicable) and decent documentation on these... this applies most in big groups, but it applies to any group. Probably smart to just get accustomed to applying it on all payers (not just MCR) and building it into EMRs.

I don't think we've had any denials or re-submits as yet. It will probably start any time now. Merry Chanukah 🙂

 

[heybrother]

Article - Billing and Coding: Surgical Treatment of Nails (A52998)

Use this page to view details for the Local Coverage Article for Billing and Coding: Surgical Treatment of Nails.

www.cms.gov

Searched 'Medicare 11750' and got the link above. Confirms that's been in place since 6/2022.

Per the article:
CPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.
CPT code 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision. This part's vague, but read as "lifetime"
A medically reasonable and necessary repeat avulsion or excision of the same nail within 32 weeks of a previous avulsion, or excision, of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.

Yep - thanks for reposting. Read it 6 months ago and read it a few times while trying to sort out our billing issue.

 

[Pronation]

Yeah, anyone needs to be aware of this. For sure.

You need the medically necessary repeat -77 mod (or -76 as applicable) and decent documentation on these... this applies most in big groups, but it applies to any group. Probably smart to just get accustomed to applying it on all payers (not just MCR) and building it into EMRs.

I don't think we've had any denials or re-submits as yet. It will probably start any time now. Merry Chanukah 🙂

Oy vey, if I do a matrixectomy they better give me my shekels!

 

[heybrother]

I know this is a dumb question but does fee price changes if the procedure e.g. that 28296 was done by pod v. ortho?

Medicare defines "facility" and "non-facility" physician fee schedules for each locality. So if you are private practice surgeon and go to your ASC - each physician will receive their technical component reimbursement. The facility however will receive ASC type reimbursement. Meanwhile, if the procedure is done at a hospital the facility will receive reimbursement on a different schedule still.

Interestingly, BCBS in my area is now reimbursing surgeries at a higher rate if they are done outpatient (I'll have to look at exact wording, might be ASC, might just require outpatient).

 

[air bud]

The above discussion I believe is only for certain MACs. Not applicable on my previous one, is on my new one.

Also this was discussed at ACFAS billing course this year....it's not all how to take a small wedge of bone when doing a weil and then place that in your lapidus site and bill a harvest of autograft.

 

[PTPuser]

Medicare defines "facility" and "non-facility" physician fee schedules for each locality. So if you are private practice surgeon and go to your ASC - each physician will receive their technical component reimbursement. The facility however will receive ASC type reimbursement. Meanwhile, if the procedure is done at a hospital the facility will receive reimbursement on a different schedule still.

Interestingly, BCBS in my area is now reimbursing surgeries at a higher rate if they are done outpatient (I'll have to look at exact wording, might be ASC, might just require outpatient).

So the pricing only changes based on what you stated above, but it doesn't matter if the procedure is done by podiatry or ortho, right?

 

[msion]

Speaking of Medicare, apparently they now allow only one 11750 (matricectomy) per toe per lifetime unless you appeal. That's like a forever-global. They also won't pay for another 11730 for 32 weeks on any particular toe without an appeal.

That's just great. First nails then callus codes, now this.
The solution may just be offering a 28825 if recurrence is noted after 11750 😆
Honestly Medicare is so much BS. Audits and denials are just not worth it. Medicare currently accounts for 7% of my patients, trying to get that number below 5%.
The worst is when a medicare patient wants custom orthotics or any kinda DME.
"What do you mean I have to pay? I have Medicare and they pay everything! Just write a prescription and it will be covered."🙄

 

[HardRoadPaved]

Interestingly, BCBS in my area is now reimbursing surgeries at a higher rate if they are done outpatient (I'll have to look at exact wording, might be ASC, might just require outpatient).

I'm seeing quite a nice hike for -24 POS with BCBS as well!