My experience buying out a retiring podiatrist straight out of residency

[heybrother]

Look up an “Akin”. It’s CPT code 28310 (CPT 28298 is a bunionectomy with an Akin). If you look up 28310 you will see it’s designated as a “separate” procedure which denotes it should not be billed with another procedure for the same pathology at the same anatomical location.

The "separate procedure" text if fascinating. That I believe is what put an end to billing a 28285 with an MPJ capsulotomy or a flexor tenotomy and a IPJ capsulotomy etc.

I don't really believe in Akins though I did see someone the other day who needs one. The cynical negative side of me feels a lot of people just saw them as a way to pick up an extra $400 while doing an Austin. What pays better than one procedure - two procedures!

I know you're seeing lots of unbundling - but I'm now being challenged on every case by Novitas where I do more than 1 hammertoe. I somewhat agree with recent posts about jokingly the future being here's a lump sum of money for whatever you do. I find this somewhat fascinating since what I feel like I see when I watch ACFAS stuff is the number of procedures getting bigger and bigger. Extend the fusion even further and repair and transfer more things. And that may be appropriate and great and what not but I don't think the future is to be paid for your combination Achilles lengthening+ osteotomy + rearfoot and midfoot fusion + PT debridemeent + FDL transfer + spring ligament repair.

---

Members don't see this ad.

 

[Creflo]

For experienced dpm and others, existing medicare patient comes in with new problem of ingrown nail. You do a partial avulsion. Do you bill an e&m for this along with the cpt 11730, or just the 11730?

 

[PeaJay]

I discuss and document tx options including abx, slant back, temporary, and matrixectomy. My billers claim that this justifies e&m coding. Procedure is billed in addition. If there is no discussion and just ingrown with knee jerk avulsion then no e&m.

 

[Feli]

...I don't really believe in Akins...

Akins don't believe in you either.

For experienced dpm and others, existing medicare patient comes in with new problem of ingrown nail. You do a partial avulsion. Do you bill an e&m for this along with the cpt 11730, or just the 11730?

The former... you just link the E&M to ICD cellulitis or something else appropriate. 92203-25 and 11730-59-TA (or whatever fits)
If you can't find something besides the ingrown, open the eyeballs ...cellulitis, xerosis, bunion, PF, etc etc? If there isn't pain anywhere, just palpate harder!

 

[Feli]

I discuss and document tx options including abx, slant back, temporary, and matrixectomy. My billers claim that this justifies e&m coding. Procedure is billed in addition. If there is no discussion and just ingrown with knee jerk avulsion then no e&m.

I would actually say this is wrong... or at least subpar.
You don't want to link the E&M and procedures to same diagnosis (or similar). Read the -25 and -59 modifier definitions... "unique," "separate," etc. It will work with a few payers to do same dx, but it will fail on more of them than it will go through ok. So, the billers are wrong on this... you can have a 45min discuss with a patient about arch pain, but if you do the visit and the inject to fasciitis, the inject often bounces (or even the visit on some payers if that was going to be worth more).

So, you don't want E&M for ingrown and procedure for same... visit and inject both for PF... visit and procedure both linked to dx of verruca, etc. It is easy if you just think about it... visit for PTTD but inject for PF, visit for metatarsalgia or xerosis but procedure for verruca, visit for cellulitis but procedure for ingrown, visit for tinea but nail care for onycho and pain, etc. The only exception is with Xrays... those codes can go to same dx as the E&M (since XR aren't procedures... they code more like labs, other imaging, etc).

 

[dtrack22]

So, you don't want E&M for ingrown and procedure for same... visit and inject both for PF

All of my payers still cover this for new patient e/m codes. L60.0 for the e/m and for the 11750. But I do try and have multiple dx codes so my coders can split em up for visits with a procedure

 

[Feli]

All of my payers still cover this for new patient e/m codes. L60.0 for the e/m and for the 11750. But I do try and have multiple dx codes so my coders can split em up for visits with a procedure

That's cool... I'm surprised it's 100% of payers, though. They would cover E&M for wound and wound debride for same ICD, E&M for neuroma and neuroma inject same ICD, etc? Does it work for f/u pts or just new 9920x? Good stuff

I have def never worked in a locality like that... even most MCR carriers would probably bounce my avulsions/matrix if I did that. I agree with multiple dx on E&M (I almost always do 4+ since claim supports 4) for that reasoning, and primary code my E&M never the same as code for any procedure (if at all reasonably possible).

 

[dtrack22]

They would cover E&M for wound and wound debride for same ICD, E&M for neuroma and neuroma inject same ICD, etc? Does it work for f/u pts or just new 9920x?

I really only use it for new patients who don’t have another dx. Which ends up being ingrowns without cellulitis and that’s about it. Oh and warts too.

I’m now convinced at least new patient e/m with CPT on same day using same ICD 10 is a lot less likely to get denied than podiatrists will tell you. One of my previous jobs the in-house biller would say that even a cellulitis code for an igtn e/m and the ingrown code for the procedure wasn’t good enough, because the cellulitis and the ingrown are on the same toe and part of the same pathology (which is true). She said it will get rejected and she would only bill out the matrixectomy CPT. But, a) this was in a state where BCBS auto-denied all claims with a 25 modifier so I can understand why they thought this way and b) its the same biller that would tell me I didn’t write enough words in my plan to justify a level 4. I had to show her the e/m guidelines and spell out how I hit them. They were unreasonably cautious and I’m pretty sure the fact that her experience was entirely with this one office and it gave her billing/coding tunnel vision. So to speak.

 

[heybrother]

If you experience what dtrack experienced - ie. complete 25 modifier denial - you really have no choice but to change your behavior. The heart of that issue is that its total bullcrap.

You either
(a) push all the procedures out a day/week which comes with both its own problems like technically its still wrong and also its bad for business/PR.
(b) bill only the procedure even though about 1/2 the patients do legitimately have something else to talk about.
(c) Contest and fight every single case and hope that in the "between" they pay the higher of the 2 codes and not the lower or neither.

I like to ask people how/why they do what they do.

-A new hire at my office was an office manager in another state. Quite a few of the things she's said to me don't seem kosher. For example she said when patients show up for uncovered care (ie. established patient, no-systemic diagnosis, "routine care") they charge them for an office visit and for the "self pay" nail/calluses. I don't see how that flies. What is the basis for the 99212? She told me they "always" wrote an abx and pushed them to another day. She had no explanation why except "that's how its done".

-My office's 30+ year secretary/former office manager told me "you can't bill E&M and CPT on the same visit because you'll be paid less for the CPT". There is no evidence to support that at all in any of our billings/collections. I've seen in some of the Medicare documentation discussions about future potential policy leading to reductions in reimbursement when E&M and CPT are billed together but nothing has come of it yet. We aren't the only people who would be affected by that.

-Another podiatrist in town told me that he regularly pushes nail surgery to Saturday morning because he's too busy to do it same day. Ugh. But he also believes a new patient nail is totally fine with an E&M and CPT because when the patient presents you don't actually know its a nail yet. Until then its just "pain" and therefore both are right because you had to get to the procedure with your examination. This is an overly convoluted logic to me that wouldn't be the shield I'd choose to use. Jokingly it takes a real "JPS" of a patient to not write "ingrown toenail" on their sheet though I have seen a fair amount of toe pains that were ultimately nails. My problem with this "I didn't know" strategy is
(a) if ever we move forward to a computer denies all 25s or a computer denies all E&M if its with a CPT using the same diagnosis codes - then it doens't matter what your logic was - the computer will just deny it and you'll have to appeal
(b) secondly - the CPT contains an inherent quantity of pre-E&M/procedure/post-op value and even if this is all a rip-off to us - there's enough E&M built into the CPT to at least account for the amount of physical exam it takes to figure out a toenail hurts, right?

-The APMA people would tell you to write out your full explanation and thought process to justify why the E&M and CPT are a "significant, separately identifiable evaluation and management service by the same physician". This is I believe what peajay's coders above are referring to. The flipside of this coin is what dtrack has somewhat argued in the past - ultimately in a reductionist sense a toe is a toe. You can build a mountain out of it but the patient came to you and received toenail surgery whether you walked in with a needle in your hand or you talked for awhile about outcomes. Additionally, if a computer reviews this and the E&M and CPT use identical diagnoses it would be very easy to deny this either through automatically disqualifying 25s or demanding paperwork to prove its something more if the codes are the same.

-Another regular topic is that adding another diagnosis code will make this kosher. An old school PP doc who used to post on here regularly once wrote that the vast majority things podiatrists ultimately do started with a patient who was there to discuss a nail problem. I do see plenty of ingrown toenails where I also counsel on diabetes or pursue bunion surgery or hell - Charcot or whatever. We should do a quality examination and discuss real issues some of which the patient may bring up and some of which we may bring up. If you bring more care to bear that is justified at these visits you should be able to bill for it. But I've seen too many "Oh - also, you have a hammertoe. Its not causing you any pain. Its very mild. There's no indication for surgery for it." That's not real, not justified, not medically indicated. A coder at a medical event once said to me that "well, you made the determination that surgery isn't indicated therefore its a surgical determination". By that logic every patient you see that you don't operate on you made the determination not to operate. That can't be how it works. Where I'm also going with this is that most people are looking for at least a 99203 and if the patients not a problem is really not a problem then its like a 99202.

I'm currently using the APMA or whatever papershield. I try to spell out my thought process and I do discuss all options with the patient from antibiotics to procedures, history of the condition, potential future outcomes/future surgery, should they also be treated for fungus, how can their diabetes affect this etc. I will discuss other conditions as relevant during the visit and provide treatment for them along with the CPT.

In my area - I'm getting paid by essentially all payors for first visit E&M and procedure. The real question though is - will we be audited in the future and will we be able to defend it.

 

[NobodyDPM]

We are sometimes challenged on E/M codes for L60.0 if/when we do an avulsjon or P&A on the same visit. When we are, we send a letter to the insurance company asking them how they expect us to do a minor surgery on someone without evaluating them in the office before hand. They pay us every time.

 

[heybrother]

We are sometimes challenged on E/M codes for L60.0 if/when we do an avulsjon or P&A on the same visit. When we are, we send a letter to the insurance company asking them how they expect us to do a minor surgery on someone without evaluating them in the office before hand. They pay us every time.

Do you view Medicare/private insurance as "the same" for coding decision making?

 

[air bud]

For experienced dpm and others, existing medicare patient comes in with new problem of ingrown nail. You do a partial avulsion. Do you bill an e&m for this along with the cpt 11730, or just the 11730?

Both. New problem. Who says we have previously taken into account immunocompromised status, blood thinners etc when I previously saw then for a callus sub 5th met head. That's not even a question, I hope you are joking.
Now if you want to question a E&M on a patient with a new ulcer sub 1st mph of the left foot and you have previously seen them for a ulcer on the distal tip of their 3rd toe of the right foot then legit question. But if you are talking about (AND DOCUMENTING) the fact that they have a cavus foot type and due to pull of PL and equnius blah blah blah contributing etc etc then that is still an EM. Sure have taken into account DM, Neuropathy in the past. Anyways....

 

[air bud]

I would actually say this is wrong... or at least subpar.
You don't want to link the E&M and procedures to same diagnosis (or similar). Read the -25 and -59 modifier definitions... "unique," "separate," etc. It will work with a few payers to do same dx, but it will fail on more of them than it will go through ok. So, the billers are wrong on this... you can have a 45min discuss with a patient about arch pain, but if you do the visit and the inject to fasciitis, the inject often bounces (or even the visit on some payers if that was going to be worth more).

So, you don't want E&M for ingrown and procedure for same... visit and inject both for PF... visit and procedure both linked to dx of verruca, etc. It is easy if you just think about it... visit for PTTD but inject for PF, visit for metatarsalgia or xerosis but procedure for verruca, visit for cellulitis but procedure for ingrown, visit for tinea but nail care for onycho and pain, etc. The only exception is with Xrays... those codes can go to same dx as the E&M (since XR aren't procedures... they code more like labs, other imaging, etc).

What about just pain for E&M and ingrown for the procedure. I always make sure 2 codes when doing an E& M and a procedure, but usually just the pain code and then ingrown, callus, PF, neuroma etc.

 

[Feli]

What about just pain for E&M and ingrown for the procedure. I always make sure 2 codes when doing an E& M and a procedure, but usually just the pain code and then ingrown, callus, PF, neuroma etc.

Not sure... I don't generally do pain as a first line code since it's sorta vague, but it is better than nothing and usually better than the same code you're going to use for procedure. If it is working, you probably don't need to change a thing... as long as you meet with billers often to learn anything that isn't getting paid. As far as I was taught by DPMs who do much better than me, pain is an excellent secondary code on procedures (many payers req it, for verruca esp) and I put it on all of my OR surgery as 2/3/4 code. Something like this:

99203-25: 1 cellulitis toe, 2 onychomycosis, 3 pain in toe, 4 other appropriate icd (DM, PF, deformity, etc etc)
11750-59-T5: 1 ingrown nail 2 pain in toe

I sometimes do angry purulent ingrown avulsions as I&D abscess 11061 (or 11060 when I don't do anesthesia or culture) when I think that's appropriate (prob only 5% but still a few of them... almost always teenagers). I do take out the nail edge but mainly drain/rinse the abscess and code it that way. That 10061 has twice the RVU vs 11730... and you can still do 11750 later at f/u if you want. Obviously wouldn't do both in same visit (unless contra-lateral). I still do phenol if there is a bit of cellulitis and I don't think it's necessarily contra by that (as any good TFP will attest), but I just tell the patient the phenol success rate is probably normally 90% but down to only 50/50 if inflamed. I just don't like doing it phenol at all there is any PAD signs, ESRD or other bad healing predictor, or if it is a rockin digit cellulitis with a lot of inflammation (delay til f/u). If you ever choose 1006x, you can put the E&M to ingrown in that case since the 1006x goes with cellulitis/abscess, though... and both get pain dx as secondary in my hands.

...Gotta love coding. It's a lot like sex: you hear a bit in school, from your friends... even your teachers. You peep to see what ppl with more exp than you do during residency. You learn at meetings, at holiday parties, and on the internet. A minute to learn but a lifetime to master... lots of people never spend more than that minute. There are newsletters and videos and talks on it... some good, some crap. Nobody really knows exactly what they're doing. If there were exams on it, people would challenge and complain about unfair questions and right/wrong answers. Some people pretend to be authority on it. In the end, everybody does it similar, we all get some stuff right and some wrong, and yeah... that's just how it is!

 

[NobodyDPM]

Do you view Medicare/private insurance as "the same" for coding decision making?

Yes.

 

[619]

We are sometimes challenged on E/M codes for L60.0 if/when we do an avulsjon or P&A on the same visit. When we are, we send a letter to the insurance company asking them how they expect us to do a minor surgery on someone without evaluating them in the office before hand. They pay us every time

I agree with you 100%

I believe it is illegal or even malpractice for a doctor to do a procedure on a new patient (or follow up patient) without first evaluating the patient. So I don't understand the logic of whether you bill for an E/M or not. I ALWAYS bill for an E/M on every new patient. If it gets denied, I ALWAYS appeal and get paid. I don't care what a biller or a pod or whatever anyone says. Even if a patient wrote "ingrown nail" on the intake form, we as Doctors still have to do an E/M to decide on the appropriate treatment, be it a procedure or not. Anyone not billing for an E/M on a new patient is selling him/her self way short. I must add that my note is very detailed to defend me incase of an audit but don't let an audit make you to under bill. Own up to your hard work!

 

[619]

Some people pretend to be authority on it. In the end, everybody does it similar, we all get some stuff right and some wrong, and yeah... that's just how it is!

This sums up the summary of the whole argument here. No one is 100% certain, it's all hearsay from a biller, office manager, older pod, colleagues, conference, online, sdn etc. At the end of the day, it all goes down to what each and everyone is comfortable doing. If anyone fails an audit; the biller, office manager, older pod, colleagues etc will not be there to defend you. Practicing medicine could be scary at times, but y'all can't let fear rule you.

 

[NobodyDPM]

This sums up the summary of the whole argument here. No one is 100% certain, it's all hearsay from a biller, office manager, older pod, colleagues, conference, online, sdn etc. At the end of the day, it all goes down to what each and everyone is comfortable doing. If anyone fails an audit; the biller, office manager, older pod, colleagues etc will not be there to defend you. Practicing medicine could be scary at times, but y'all can't let fear rule you.

Not really, no. If you should get paid for something, and you don't, fight it. If you are audited and fail because of something you disagree with, fight it. Coding is not that difficult, AND if your medical record justifies the reason for the level of coding you submit, and you don't get paid, fight it. It's not rocket science, but don't think that insurances are in the business of paying you, either. They are in the business of paying you as little as they can get away with. It's up to you to fight for what you think you should get paid. According to the fee schedule of course. And as long as you know the ropes. If you fight for unbundling, good luck with that. Fight for what you believe to be fair and yours. As I've said, I've been audited, and if you are just going to lie down for them, you deserve what you get.

Also, btw, if you use a billing service and the billers there are "certified", they actually are partially responsible, if you fail an audit. You are paying them to find these things and alert you to them. If they have not, they are financially responsible. Believe it or not, they should be the coding experts. Not you. Also, if you have a good relationship with some of your local colleagues, they can help you. I have. And it's worked out quite well for the friends I've helped.

 

[heybrother]

Part of the reason I bring up these secretaries and office managers and old pods is that they aren't actually in any way trying to find out what the answer is. Someone told them something and they are just parroting but none of them have actually tried to parse the paragraph below. What I want to hear is the opinion of other pods who have read CMS/NCCI and then tried to put it into practice. To some degree there's going to be a spectrum of practicing.

In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses.

 

[NobodyDPM]

Part of the reason I bring up these secretaries and office managers and old pods is that they aren't actually in any way trying to find out what the answer is. Someone told them something and they are just parroting but none of them have actually tried to parse the paragraph below. What I want to hear is the opinion of other pods who have read CMS/NCCI and then tried to put it into practice. To some degree there's going to be a spectrum of practicing.

In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses.

The italicized part is for outpatient procedures at a separate facility for the most part. And, as it says, "in general".

When you do your pre-op evaluation at the hospital/surgery center, you should not be billing for an E/M for that evaluation.

When I have fought this and won, it's because I explained that I had no idea the patient needed "minor surgery" until the patient presented for their initial visit for the problem. Either as a new or established patient. I have fought this as well with ED visits that lead to the OR on the same day. Some insurances would not pay me to evaluate the patient in the ED, because the surgery was for the same diagnosis on the same day. I once again explained that there was no way to know they would need surgery until they were properly evaluated. Which I should be paid for. When I fight them, I get paid for that E/M every time. Fight for what you believe you deserve.

 

[dtrack22]

In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service.

I don’t understand how CMS can justify this when the “minor surgery” has a lower wRVU component than the e/m. How can the procedure include e/m services when the physician work component is less? Now, the reimbursement from CMS for 11750 is higher than a 99203 (by maybe $40?) but it’s because of the practice expense and liability components. Not the “work” component. Which makes sense. More staff/supplies are likely being used for a minor surgery and your malpractice liability is increased. But you can’t tell me the e/m component is built in to the surgical CPT when it is worth less wRVU than the e/m all by itself.

All that aside, CMS and NCCI manuals give examples of billing e/m and minor procedures on the same day and sort of explain how to justify it even when the dx code might be the same.

“If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.”

Notice what components of the encounter are part of the CPT code, “that lac needs sutures, you have no allergies, your tetanus is up to date, here’s the consent form.” Admittedly there are many ingrown visits that are that simple. But just like the head lac needs neuro status evaluated and NCCI considers that separate from the decision to suture/staple the lac, the matrixectomy patient needs a history taken and vascular, Derm, possibly neuro exams done. Either pay me more for matrixectomies or all of those things will continue to be used to justify my e/m and 25 modifier. For new patients at least. In theory the established patient has already has those workups and any treatments done, so if there is no change to the status of any of those other systems then I only bill the CPT code when they come in 6 months later with an ingrown on the other side and no other complaints and no infection.

 

[619]

In theory the established patient has already has those workups and any treatments done, so if there is no change to the status of any of those other systems then I only bill the CPT code when they come in 6 months later with an ingrown on the other side and no other complaints and no infection.

Follow-up patient presents 6 months later for ingrown nail on the other side, I always add an E/M to the visit when doing a procedure because I have to evaluate them for this NEW COMPLAIN. I can't base my exam based on what I did 6 months ago, I do a new exam to make sure those status from the last visit have not changed. I discuss the treatment options again, alternatives and what not. I can't just tell the patient to recall what I told them 6 months ago and carry on with the procedure.

Maybe I can train my MA to perform the ingrown nail procedure so I can just pop my head in to do consent and say hello. Then I won't bill an e/m and I will only bill for the procedure. Same goes for follow-up injections etc. Let my MA run the clinic while I'm kicking it in clinic replying to comments on sdn.

 

[dtrack22]

Follow-up patient presents 6 months later for ingrown nail on the other side, I always add an E/M to the visit when doing a procedure because I have to evaluate them for this NEW COMPLAIN. I can't base my exam based on what I did 6 months ago, I do a new exam to make sure those status from the last visit have not changed.

what makes the above scenario different than a mycotic nail patient with class findings who comes back 3 months later with a new mycotic toenail? Are you doing a new exam to make sure the status hasn’t changed from last visit? Are you billing an e/m for this new complaint? I mean, it’s the same dx as last visit but it’s a new toe just like the hypothetical ingrown patient, right?

 

[G0dFather]

99203-25: 1 cellulitis toe, 2 onychomycosis, 3 pain in toe, 4 other appropriate icd (DM, PF, deformity, etc etc)
11750-59-T5: 1 ingrown nail 2 pain in toe

You dont need the -59 here ... there is only one procedure youll flag yourself this way for improper usage of the 59 mod for no reason

Gotta love coding. It's a lot like sex: you hear a bit in school, from your friends... even your teachers. You peep to see what ppl with more exp than you do during residency. You learn at meetings, at holiday parties, and on the internet. A minute to learn but a lifetime to master... lots of people never spend more than that minute.

No its not, like it was said here before billing is OBJECTIVE the rules are out there ... they are not in our favor and are changed not in our favor but thats another issue .. you sign the many page contract with these bloodsucking ins companies



Also the 11061 and 11750 coding on a TOE you spoke about is insane, i get it but i can easily see money being paid back for that as you would be an outlier using a billing pattern like that

 

[Feli]

You dont need the -59 here ... there is only one procedure youll flag yourself this way for improper usage of the 59 mod for no reason



No its not, like it was said here before billing is OBJECTIVE the rules are out there ... they are not in our favor and are changed not in our favor but thats another issue .. you sign the many page contract with these bloodsucking ins companies

Also the 11061 and 11750 coding on a TOE you spoke about is insane, i get it but i can easily see money being paid back for that as you would be an outlier using a billing pattern like that

You're right that -59 is not needed on the first procedure, but I often do multiple proc, so it helps to teach the billers to just put it on everything. I don't want them screwing it up if I do bilateral ingrown, nails+calluses+ingrown, nails+ingrown, ingrown+inject+J code, etc. I'm a "bird in the hand" type for sure... I think that staging office stuff and is not wise for any busy DPM since you waste patients' time and may never see the patient again. But I suppose that's a whole other coding topic.

...and no, I don't think 10061 (or 10060 if no anesth or culture or multiple pustules) on a toe is insane at all if the chart backs it up. I probably do it for <5% of ingrowns I see, but I do it more typically for diabetic hammertoe tuft infections, purulent blister/callus hallux, etc. You can do the wound care, tendonotomy, amp, etc later as appropriate. Pus = abscess (or foreign body, depending on the better code that better fits the situation). Again, different strokes...

 

[heybrother]

(1) One of my former attendings found his hospital putting 59s on every single procedure ie. 1st through 3rd. When it was investigated they'd cut his 1st procedure reimbursement in half because the 59 was on it.

(2) I had some attendings who were using the I&D code for like every avulsion. Of the many dangers here - they weren't making an incision and some of these codes require an incision ie. some of the "anywhere" foreign body codes specifically require an incision.

(3) Before I understood how reimbursement was calculated/what the Medicare fee schedule was I had the choice on a case between I&D and 11042. One of those codes has a global and one doesn't.

EDIT: This is more a talking outloud of things I've had trouble or seen issues with and not an implication.

 

[HardRoadPaved]

What about 11765 in your coding arsenal? Wedge excision seems to be great when you have that granuloma on an ingrown nail fold. Most red swollen toes out there for three weeks are more inflamed granulomas to me than "cellulitis"

 

[air bud]

What about 11765 in your coding arsenal? Wedge excision seems to be great when you have that granuloma on an ingrown nail fold. Most red swollen toes out there for three weeks are more inflamed granulomas to me than "cellulitis"

Never considered it. Remove the nail and all is good in time. Curious to see others responses.

 

[NobodyDPM]

what makes the above scenario different than a mycotic nail patient with class findings who comes back 3 months later with a new mycotic toenail? Are you doing a new exam to make sure the status hasn’t changed from last visit? Are you billing an e/m for this new complaint? I mean, it’s the same dx as last visit but it’s a new toe just like the hypothetical ingrown patient, right?

It is different than the routine care patient.

Yes, you should do a new exam and ask all the pertinent questions, and document the answers for every ingrown nails you. "Any new allergies?" should be the first question you should ask.

And this argument is not applicable because we didn't make the rules as far as the routine care. Technically, as much as we are "just cutting nails", for the at risk patient, we are making sure they don't have other issues that require care. Which is the point. That's why it's "medically necessary" for them to come in for nail care.

I know I might get heat on this, but taking care of an ingrown nail is considered a surgical procedure. Same argument I made before. Yes, I'm aware that trimming a callus is also considered a surgical procedure, but again, we didn't make the rules. We just have to know how to make the most of the ones we are provided. Legally, of course.

 

[619]

It is different than the routine care patient.

Yes, you should do a new exam and ask all the pertinent questions, and document the answers for every ingrown nails you. "Any new allergies?" should be the first question you should ask.

You took the words out of my mouth.

For follow up visit, you still (always for me) do an E/M before a procedure verifying any new allergies, change in medications etc. And you document it. If I were just copying and pasting my last exam note from last visit then you don't need to bill for an E/M. That's why I said you can train an MA to do the procedure and you pop your head in to say hello/sign consent and then bill for just the procedure.

 

[HardRoadPaved]

That's why I said you can train an MA to do the procedure and you pop your head in to say hello/sign consent and then bill for just the procedure.

Why not just start an ingrown toenail fellowship and source it out to your fellow who can bill the e/m and dispense dme for a cam boot after the procedure?

 

[Feli]

What about 11765 in your coding arsenal? Wedge excision seems to be great when you have that granuloma on an ingrown nail fold. Most red swollen toes out there for three weeks are more inflamed granulomas to me than "cellulitis"

I do this occasionally, but I only do it in the OR as a revision. I don't use it in office. I have never had to do one of my own surgically with suture, but I have definitely done revision phenols and I would do full thickness if they failed a couple phenols and my office mini-surgical one I do with 6200 blade after avulsing the nail margin for any revision/difficult matrix (just bill 11750 for that since phenol afterward also)... that technique's kinda hard to explain but anyone who has worked or trained with me has probably seen that, 18ga for flexor tendonotomy, etc tricks that I've picked up at conferences over years that save time but get the job done in office.

But to the surg matrix topic, I've seen a few pyogenic granulomas or just really weird nail spicule cactus things from other DPMs' procedures (always matrixectomy attempts). I have no idea if they are using too much phenol, too long, or not rinsing it off or what (or if I've just been "lucky"?), but I have seen some that were pretty crazy looking or the granuloma was neglected by the TFP for almost a year as it grew and scarred and avulsed the whole nail ("healing fine" in his notes). I just bring them to OR asap, avulse the whole nail, send the path sample of mass or the excision, and then sew up a wedge Winograd uni or bilateral... or the whole matrix (H-shape excision aka Zadik from same article link/pic).

It only takes 15min in the OR or ASC, but think it's a little too much bleed and stitching for most ppl to have in the office, it gets you behind on pt flow in clinic, and I want to send the path and mainly to have good visualization. It's a revision, so I don't want to take any chances. You can also bill excision benign lesion and nail avulsion on the masses that aren't clearly pyo if you want (duck and cover for coding criticism).

...had some attendings who were using the I&D code for like every avulsion...

Yeah, I think when you hammer the same codes over and over and over, it will always make you low hanging fruit for payers. The nursing home guys who do 15 nail debride and 15 avulsions every day are stupid. The many guys with an office superbill with only about 30 dx codes and 15 procedure codes on it really need to improve also. You want to mix it up. Even the DPMs doing the most L3020 or taking the most XR and coding every one XR foot (not using ankle, calc, toes occasionally) might get a call or more from payers. That happened to my first boss and I, and we just told them we see twice as many patients per day as any other DPM office around... end of story. We weren't doing anything wrong, but we were just raising our flag by being productive.

I try to spread it out what I do - esp procedures. Ingrowns are avulsion or matrix or rare I&D abscess and very rare surgical matrix as appropriate. Foreign bodies are simple or complex, blisters are I&D or just puncture, etc. I use basically all of the reasonable wound codes. I do fracture care codes occasionally for toes. Most hammertoes are hammertoes, most Weils are Weil, but a few are also MPJ cap and/or extensor tendon lengthen. I posted before that I do basic regular lapidus as the Lap bunion code 28297, and I do arthritic MC ones as 1TMT fusion plus McBride, bad MPJ ones as 1TMT fusion plus cheilectomy, etc. "But but but ExpDPM said..." Yes, I know. He is a smart guy, and he is 100% right that you never use two bunion codes (ie, Lapidus bunion and Akin bunion). Still, it is all supported in the notes and op reports and I don't have a problem with it to do 1TMC and McBride and phalanx osteotomy codes if that's what the best treatment was and what I performed. I have the resident, or me, dictate each procedure in a new separate paragraph with the CPT codes in the dictation. I do most Haglund as exostectomy and secondary Achilles repair too. Not bragging, just reading the codes, AOFAS coding guide, and what each CPT does and does not include in its descrip (eg, plantar fasciotomy includes heel spur but Achilles repair does not include posterior calc spur). Surgery is pretty underpaid, and it is not dumb to at least submit for what you did and see what happens. Again, it has a good amount of subjectivity, and there's a lot of gray area in coding. Even "expert coder" types are too rigid, too aggressive, and even in clear violations sometimes. As long as you do your best good-faith effort to reasonably describe what you do without breaking any clear rules, cest la vie.

 

[dtrack22]

And this argument is not applicable because we didn't make the rules as far as the routine care. Technically, as much as we are "just cutting nails", for the at risk patient, we are making sure they don't have other issues that require care. Which is the point.

But it is applicable. A healthy 20 yr old with an ingrown, no infection, on the right comes in and says he wants the thing you did on the left 3 months ago. Sure, you’ll ask a few questions about this toe and give the skin a once over. Honestly it’s probably less detailed of an exam than you would give an established nail care patient. So what dx are you billing the established e/m for the ingrown patient? Why aren’t you billing an e/m on the nail care patient who you provided the same level of service for

For follow up visit, you still (always for me) do an E/M before a procedure verifying any new allergies, change in medications etc. And you document it. If I were just copying and pasting my last exam note from last visit then you don't need to bill for an E/M.

But according to NCCI manuals, the things you described above are part of the 11750 CPT. Verifying allergies and new meds is a part of the procedure. And if a healthy 20 year old comes in for a left toe after having the right done with no changes in medical history why wouldn’t you copy the note and just switch right to left in your documentation? Also, let’s say there’s no infection, what are you billing for the e/m? Same dx as the procedure or do you just always code L03.XXX with your ingrowns?

That's why I said you can train an MA to do the procedure and you pop your head in to say hello/sign consent and then bill for just the procedure.

I don’t get what training an MA to do a procedure has to do with billing e/m. In most states it’s illegal, but even when it isn’t (ie Texas), even covered routine foot care is supposed to be done by the provider according to Medicare. Of course lots of podiatrists don’t abide by that rule…

 

[HardRoadPaved]

I do this occasionally, but I only do it in the OR as a revision. I don't use it in office. I have never had to do one of my own surgically with suture, but I have definitely done revision phenols and I would do full thickness if they failed a couple phenols and my office mini-surgical one I do with 6200 blade after avulsing the nail margin for any revision/difficult matrix (just bill 11750 for that since phenol afterward also)... that technique's kinda hard to explain but anyone who has worked or trained with me has probably seen that, 18ga for flexor tendonotomy, etc tricks that I've picked up at conferences over years that save time but get the job done in office.

The language for this procedure does not stipulate suture or ASC use. Just document the "wedge" and that you excised it. Seems fine to use as a primary nail surgery technique.

 

[NobodyDPM]

But it is applicable. A healthy 20 yr old with an ingrown, no infection, on the right comes in and says he wants the thing you did on the left 3 months ago. Sure, you’ll ask a few questions about this toe and give the skin a once over. Honestly it’s probably less detailed of an exam than you would give an established nail care patient. So what dx are you billing the established e/m for the ingrown patient? Why aren’t you billing an e/m on the nail care patient who you provided the same level of service for.

I'm not understanding your argument.

Medicare does not allow us to bill an E/M visit every time we see an at risk patient for nail care. I truly believe we should be allowed to, but those aren't the rules for that.

Before performing minor surgery on a patient the same day they present, I believe that we should be paid to evaluate whether they need surgery on that toe or not. The rules, the way they stand, allow me to bill that way. So I do. You don't want to? That's on you. But if we are legally allowed to, and get paid for it, what's your argument? That the Medicare rules suck? They do. I'd agree with that. Picking your battles in an important rule to live by.

 

[Feli]

The language for this procedure [11765 excis wedge matrixectomy] does not stipulate suture or ASC use. Just document the "wedge" and that you excised it. Seems fine to use as a primary nail surgery technique.

It totally is fine. I bet a lot of DPMs do it. Personally, I just don't tend to do it in the office. I just know my wedges will be revisions, I'll be sending path, needing good visual, bleeding a bit more than most pt/family like to see, more risk for pt/fam anxiety problems than I want, etc. I do very few bloody or suture procedures in the office (usually just for pts I have very good rapport), do a bit more of that bloody stuff in ER and wound care out of necessity, but I steer most to OR. I don't have surgery center shares, but that's just my just my logic and my view on it.. I'm well aware I might do a bilateral bi-border wedge ingrown with sutures in the office someday for a pt with cash or high deductible or something... not opposed to that but not my top choice.

When I do my 6200 blade quasi-surgical thing for office revision (then phenol after) to try to lower chance of recurrence, I do 11750 since that's more RVU. I also don't take out a "wedge" per se.

 

[dtrack22]

Before performing minor surgery on a patient the same day they present, I believe that we should be paid to evaluate whether they need surgery on that toe or not.

The “rules” state that you are already getting paid for that in your reimbursement for 11750, for example.

The rules, the way they stand, allow me to bill that way.

No, they state that in an established patient with an ingrown toenail who has no other issues (or the infamous cellulitis dx), that you are not to be billing a separate e/m. CMS and NCCI quotes above reflect that.

 

[619]

I don’t get what training an MA to do a procedure has to do with billing e/m

Only a physician can perform and bill for an e/m. You can't train an MA to perform an e/m and bill for it.

For a procedure, an MA can assist in a procedure or even perform the procedure under the supervision of a Physician. For example, in my former practice and also very common, the MA trims the toenails for routine nail care visits. Some practices, the MA does the mayo block before the ingrown procedure. Some practices allow the MA to scan for custom inserts. I can go on an on. So by the same logic, I can train the MA to perform the whole procedure for the ingrown nail while I pop in to say hello/sign consent and just bill for the procedure. An MA is cheaper than a fellow haha

 

[NobodyDPM]

The “rules” state that you are already getting paid for that in your reimbursement for 11750, for example.


No, they state that in an established patient with an ingrown toenail who has no other issues (or the infamous cellulitis dx), that you are not to be billing a separate e/m. CMS and NCCI quotes above reflect that.

Bold mine.

Yet, I am being paid for that and have survived multiple audits with them reviewing this. Again, not sure what you're arguing about, here. Don't bill for the E/M, then. Doesn't effect me at all.

You, or they, say I shouldn't. Experience has taught me differently. And every time it's denied, I will appeal. And win. As I have every single time in the past.

 

[PeaJay]

Only a physician can perform and bill for an e/m. You can't train an MA to perform an e/m and bill for it.

For a procedure, an MA can assist in a procedure or even perform the procedure under the supervision of a Physician. For example, in my former practice and also very common, the MA trims the toenails for routine nail care visits. Some practices, the MA does the mayo block before the ingrown procedure. Some practices allow the MA to scan for custom inserts. I can go on an on. So by the same logic, I can train the MA to perform the whole procedure for the ingrown nail while I pop in to say hello/sign consent and just bill for the procedure. An MA is cheaper than a fellow haha

The lawyers at my large msg would disagree. They claim Medicare requires the DPM to physically perform all the nail care not jus some or the “critical aspects”. This was also part of some Medicare audit s around the country, per the law team, which confirmed this stance.

By this logic, we have to be present for the entire procedure with residents. Anything less is fraud per legal.

Edit: from my understanding the Mayo block by a ma is okay as it is not the billed procedure

 

[dtrack22]

The lawyers at my large msg would disagree. They claim Medicare requires the DPM to physically perform all the nail care

Correct. Some states (ie Texas) allow an MA to basically do anything a physician is comfortable teaching them to do. But that is in conflict with Medicare and their stance on billing for any procedure code, 11721 included.

Edit: from my understanding the Mayo block by a ma is okay as it is not the billed procedure

also correct

So I’m still wondering what training an MA to do a procedure has anything to do with e/m coding with a -25 modifier.

 

[dtrack22]

Yet, I am being paid for that and have survived multiple audits with them reviewing this. Again, not sure what you're arguing about, here.

Im not arguing anything. I’m trying to understand what other people are doing, what Medicare is paying, denying, what commercial carriers are doing, etc.

Just to clarify. You bill an e/m with L60.0 as a diagnosis and then slap a 25 modifier on that and bill an avulsion or matrixectomy with L60.0 as the diagnosis? And that has obviously been paid for after appeal with a commercial plan, but you’ve also had a Medicare audit or appeal where they approved it? Or are you always throwing some other dx code on the e/m so it survives first pass through the payer’s coding software?

 

[NobodyDPM]

Im not arguing anything. I’m trying to understand what other people are doing, what Medicare is paying, denying, what commercial carriers are doing, etc.

Just to clarify. You bill an e/m with L60.0 as a diagnosis and then slap a 25 modifier on that and bill an avulsion or matrixectomy with L60.0 as the diagnosis? And that has obviously been paid for after appeal with a commercial plan, but you’ve also had a Medicare audit or appeal where they approved it? Or are you always throwing some other dx code on the e/m so it survives first pass through the payer’s coding software?

There is always pain attached.

 

[619]

There is always pain attached.

I assume this is common knowledge. Patient comes in for anything, I 100% always attach the pain code (Pain in toe, Pain in Foot or Pain in Ankle).

The primary reason the patient presents is for pain and YOU the doctor makes the second or other diagnoses. If patient is diabetic, you bet I also add that too.

 

[NobodyDPM]

I assume this is common knowledge. Patient comes in for anything, I 100% always attach the pain code (Pain in toe, Pain in Foot or Pain in Ankle).

The primary reason the patient presents is for pain and YOU the doctor makes the second or other diagnoses. If patient is diabetic, you bet I also add that too.

I make no assumptions.

 

[Feli]

I make no assumptions.

Sounds like a rockin signature?

 

[dtrack22]

There is always pain attached.

so this

Or are you always throwing some other dx code on the e/m so it survives first pass through the payer’s coding software?

I worked for a podiatrist who said “pain” codes couldn’t be billed as a primary diagnosis for e/m. I’ve never read anything that actually says that. This is why everyone should be asking questions, you know how many associates have been taught fraudulent billing practices, given bad info re: coding and billing rules, learned to under code because they are podiatrists and podiatrists can’t do level 4 visits, etc?

 

[NobodyDPM]

so this


I worked for a podiatrist who said “pain” codes couldn’t be billed as a primary diagnosis for e/m. I’ve never read anything that actually says that. This is why everyone should be asking questions, you know how many associates have been taught fraudulent billing practices, given bad info re: coding and billing rules, learned to under code because they are podiatrists and podiatrists can’t do level 4 visits, etc?

I bill what I evaluate. I don't think I've ever used pain as a singular diagnosis because there is always a descriptor of why the pain has occurred. I have also heard of the don't bill pain as a primary diagnosis, and for us, I'm not sure how you would do that anyway. I am always able to add an additional code besides just pain. YMMV.

 

[dtrack22]

I bill what I evaluate. I don't think I've ever used pain as a singular diagnosis because there is always a descriptor of why the pain has occurred. I have also heard of the don't bill pain as a primary diagnosis, and for us, I'm not sure how you would do that anyway. I am always able to add an additional code besides just pain. YMMV.

You answered my question above with “there is always pain attached.” So let’s try this again.

healthy 20 yo comes in 4 months after left hallux matrixectomy. Complains of “the same problem starting on my right big toe.” Has tenderness to palpation of the right hallux later border. Some swelling but no gross erythema or drainage. He wants “the same thing you did on my other toe” and you agree. You do a matrixectomy on the lateral border of the right hallux.

That’s the scenario I described above that several folks say they will bill an e/m on. Nothing wrong with that. But how are people who are billing the e/m in a situation like that coding it?

99213 - 25 with what dx?
11750 - T5 with I’m assuming L60.0?

I see this somewhat regularly. On the new patient I will bill the e/m and the matrixectomy with the same dx when there is no infection. If that same patient comes in a few months later and I do nothing other than walk in the room, look at the toe and go “yup, let’s do the other side,” (again, absent any other dx including infection) then I personally just bill the procedure code. Like I said, this is a common scenario that I’m curious know how people are billing and how they are justifying. Might just change the way I bill. But I will say the people who refuse to answer the question are likely doing so because they know what they are doing is questionable and they don’t want to broadcast it…

 

[heybrother]

You answered my question above with “there is always pain attached.” So let’s try this again.

healthy 20 yo comes in 4 months after left hallux matrixectomy. Complains of “the same problem starting on my right big toe.” Has tenderness to palpation of the right hallux later border. Some swelling but no gross erythema or drainage. He wants “the same thing you did on my other toe” and you agree. You do a matrixectomy on the lateral border of the right hallux.

That’s the scenario I described above that several folks say they will bill an e/m on. Nothing wrong with that. But how are people who are billing the e/m in a situation like that coding it?

99213 - 25 with what dx?
11750 - T5 with I’m assuming L60.0?

I see this somewhat regularly. On the new patient I will bill the e/m and the matrixectomy with the same dx when there is no infection. If that same patient comes in a few months later and I do nothing other than walk in the room, look at the toe and go “yup, let’s do the other side,” (again, absent any other dx including infection) then I personally just bill the procedure code. Like I said, this is a common scenario that I’m curious know how people are billing and how they are justifying. Might just change the way I bill. But I will say the people who refuse to answer the question are likely doing so because they know what they are doing is questionable and they don’t want to broadcast it…

I don't bill an E&M on this unless something bizarre happened on the last procedure. I had 2 people a year ago have explosive infections after a matrixectomy - both young - and both revealed at follow-ups a history of MRSA infections/complicated treatment courses/IV antibiotics during prior procedures. They can have an E&M if they come back.

People are free to do what they want but asking this patient about allergies falls squarely within the NCCI example of things contained within the procedure. Touching this patients pulses which are fine because they are 20 and examining the nail isn't pushing this into an E&M for me. I suppose if this was a 70 year old diabetic done a year apart I might say - gosh, other foot pulses rechecked - seem poor - additional discussion about my concerns about PVD, delayed healing, potential need for wound healing center or something.

I regularly do bill a CPT and an E&M for the same code but the thing that pushes me isn't a small amount of additional examination - its the additional management I provide. If I bill a CPT and E&M my discussion note will be delineated into 2 clearly marked sections one indicating the procedure and one spelling out my thought process on progress, surgery, antibiotics, why we're failing or what we've done and will do next etc.

The other day I had a guy come in - 2nd visit and he's had 1.5 years of treatment elsewhere and still has plantar fasciitis. He asked me for an injection but wanted me to know he feels like he's done with conservative therapy. I rechecked all the important stuff - pulses, skin, tarsal tunnel, equinus, standing exam/pronation etc. In the end he's just going to be a plantar fascial release - so I discussed in detail the rehabilitation and recovery, plan, incision, complications etc and billed both the CPT and E&M to plantar fasciitis.

I review my billing pretty hard and only Aetna for me denies that routinely straight off the bat ie. CPT and E&M at an established visit. Aetna will deny frustrating things like a full blown 30+ minute visit where you talk MRI and schedule surgery and then inject at the patients request.

I will say a few months ago I saw a patient who my partner had already seen 1.5 years ago. I had never seen them. They wanted a matrixectomy. I did the procedure and ultimately wrote antibiotics after noting they had a very recent total knee. Billed the E&M to cellulitis and history of total knee - BCBS denied it.