Sep 7, 2019
6
5
Status
Podiatrist
I've been out for a few years now and have noticed everyone has their own way of billing / coding to maximize their reimbursements. Why isn't there one standard way of doing things? Why does it always feel like you have to beat the insurance companies with billing to make a buck. For example, some docs don't see their partial nail avulsions at all, some see them within the 10 day global, some see these patients after 2 weeks so they can bill a 212/213, and last I've heard of several docs seeing them after 2 weeks to bill a 97597 after making one swipe on the nail border with a currette ?! I've only used this code for ulcer debridements but it seems like there are pods that use this code (you guys may even be on here reading this). APMA coding lecturers state you need to have a good reason as to why you see them after 2 weeks vs 10 days. It just blows my mind. Do other specialties have this same problem or are we in a category of lower paid providers that we need to do this? I've heard of some docs giving vit b12 PT blocks routinely to their diabetics with neuropathy to bill an injection w their RFC. I couldn't find articles to support this treatment. I've always tried to do everything by the book but the things I've heard of in the past few years makes me raise an eyebrow.

What resources do some of you guys use to make sure you are coding/billing correctly while maximizing your reimbursements?
Does anyone on here recommend the APMA coding resource subscription service?
Has anyone referenced 2020 Coding Companion® for Podiatry | Optum360Coding
 

CutsWithFury

I like to cut
Feb 2, 2019
361
420
Podiatry Hell
Status
Podiatrist
I've been out for a few years now and have noticed everyone has their own way of billing / coding to maximize their reimbursements. Why isn't there one standard way of doing things? Why does it always feel like you have to beat the insurance companies with billing to make a buck. For example, some docs don't see their partial nail avulsions at all, some see them within the 10 day global, some see these patients after 2 weeks so they can bill a 212/213, and last I've heard of several docs seeing them after 2 weeks to bill a 97597 after making one swipe on the nail border with a currette ?! I've only used this code for ulcer debridements but it seems like there are pods that use this code (you guys may even be on here reading this). APMA coding lecturers state you need to have a good reason as to why you see them after 2 weeks vs 10 days. It just blows my mind. Do other specialties have this same problem or are we in a category of lower paid providers that we need to do this? I've heard of some docs giving vit b12 PT blocks routinely to their diabetics with neuropathy to bill an injection w their RFC. I couldn't find articles to support this treatment. I've always tried to do everything by the book but the things I've heard of in the past few years makes me raise an eyebrow.

What resources do some of you guys use to make sure you are coding/billing correctly while maximizing your reimbursements?
Does anyone on here recommend the APMA coding resource subscription service?
Has anyone referenced 2020 Coding Companion® for Podiatry | Optum360Coding
I do see my partial nail avusions two weeks after procedure to ensure complete healing. But I don't do any of the other above stuff that you mentioned.

Sounds like jail time or a heavy fine in the future
 

Scrantonicity

10+ Year Member
Jul 15, 2007
107
91
Status
Attending Physician, Podiatrist
I've been out for a few years now and have noticed everyone has their own way of billing / coding to maximize their reimbursements. Why isn't there one standard way of doing things? Why does it always feel like you have to beat the insurance companies with billing to make a buck. For example, some docs don't see their partial nail avulsions at all, some see them within the 10 day global, some see these patients after 2 weeks so they can bill a 212/213, and last I've heard of several docs seeing them after 2 weeks to bill a 97597 after making one swipe on the nail border with a currette ?! I've only used this code for ulcer debridements but it seems like there are pods that use this code (you guys may even be on here reading this). APMA coding lecturers state you need to have a good reason as to why you see them after 2 weeks vs 10 days. It just blows my mind. Do other specialties have this same problem or are we in a category of lower paid providers that we need to do this? I've heard of some docs giving vit b12 PT blocks routinely to their diabetics with neuropathy to bill an injection w their RFC. I couldn't find articles to support this treatment. I've always tried to do everything by the book but the things I've heard of in the past few years makes me raise an eyebrow.

What resources do some of you guys use to make sure you are coding/billing correctly while maximizing your reimbursements?
Does anyone on here recommend the APMA coding resource subscription service?
Has anyone referenced 2020 Coding Companion® for Podiatry | Optum360Coding
I would say 2 weeks is pretty standard timing, and why not be able to bill an office visit for a patient that fills a time slot? Most times, they have all kinds of questions about why it's still draining--why there's still some redness, yada yada yada. As far as the other stuff, it's pretty sad that people feel the need to bill that way. I know we are nickeled and dimed to death, especially when it comes to our nail patients (gotta see a LOT of it to really make it worth the money), but trying to bill outside the box or add frivolous charges has never turned out well for anyone. Eventually someone is going to raise an eyebrow, and then that doctor is screwed. Usually best to avoid being an outlier. Outliers are why so much of this crap is so heavily regulated in the first place.
 
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king22

5+ Year Member
May 11, 2014
25
17
Status
Podiatrist
Every specialty tries to maximize their revenue and the "rules" are very "grey". No one is really an "expert" in coding; most of the times when you to go the seminars you're essentially listening to someone's opinion based primarily on their own experience. That's why you can go to 3 seminars and be told 3 separate contradictory things.


The rules aren't clear so the guidance will never be clear. At some point you in your career you will have to pay back money to an insurance company or Medicare.
 

El-Rami

5+ Year Member
Jun 6, 2015
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Do you get any training in billing and coding prior to finishing your residency, or are you just expected to pick this up on your own?
 

DYK343

2+ Year Member
Jan 7, 2018
169
245
Status
Podiatrist
No training and you can get kicked off insurance, heavy fines, and or go to jail if you get it wrong.

The people in jail typically are malicious and intensional about fraud/falsly documenting to get higher reimbursements.

There are so many questions I have every day on billing. I suspect I am underpaying myself significantly. But I sleep better at night.
 

Apolo106

Foot in the Sand
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Mar 16, 2015
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Amazon product
Both are great references. I like the second book for the clarity ease of use.
 

king22

5+ Year Member
May 11, 2014
25
17
Status
Podiatrist
No training and you can get kicked off insurance, heavy fines, and or go to jail if you get it wrong.

The people in jail typically are malicious and intensional about fraud/falsly documenting to get higher reimbursements.

There are so many questions I have every day on billing. I suspect I am underpaying myself significantly. But I sleep better at night.
Not to be a di**, but remember under-billing is technically fraud as well.

I was originally taught based on the strategy to "never be an outlier". I don't necessarily agree with that strategy since not everyone's patient population is two SDs from the median. Bill for what you do. If you're an outlier, as long as your notes justify why you did something (and it follows the payers guidelines) you'll be fine
 
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CutsWithFury

I like to cut
Feb 2, 2019
361
420
Podiatry Hell
Status
Podiatrist
what I find strange with billing, as an employee of a hospital, is that my billers typically under bill for surgery (use wrong codes or code procedure wrong completely) but then want me to overbill for clinical encounters. I get audited twice a year and my clinic billing audit is never 100% as they tell me I underbill for some clinical encounters. They want me coding 99214 visits for some patient encounters which I think is ridiculous. The only time I am billing a level 4 visit is if we are discussing surgical options/risks/benefits and we sign the patient up for surgery that day. Hospitals are worse than some podiatrists in terms of billing.
 
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air bud

10+ Year Member
Nov 11, 2008
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what I find strange with billing, as an employee of a hospital, is that my billers typically under bill for surgery (use wrong codes or code procedure wrong completely) but then want me to overbill for clinical encounters. I get audited twice a year and my clinic billing audit is never 100% as they tell me I underbill for some clinical encounters. They want me coding 99214 visits for some patient encounters which I think is ridiculous. The only time I am billing a level 4 visit is if we are discussing surgical options/risks/benefits and we sign the patient up for surgery that day. Hospitals are worse than some podiatrists in terms of billing.
I agree with this and see the same thing. However I disagree that the person needs to sign up that day. If you talk about risks benefits etc and then tell them when ready to schedule call my office, that's a level 4.

I think things will get significantly easier Jan 1 with the new changes. Only MDM matters, no more hpi, exam etc ( except what's pertinent) and then time based includes record review and prep ( although time does increase).
 

DYK343

2+ Year Member
Jan 7, 2018
169
245
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Podiatrist
Not to be a di**, but remember under-billing is technically fraud as well.

I was originally taught based on the strategy to "never be an outlier". I don't necessarily agree with that strategy since not everyone's patient population is two SDs from the median. Bill for what you do. If you're an outlier, as long as your notes justify why you did something (and it follows the payers guidelines) you'll be fine
Office based billing is easy. Just gotta meet the required billing points and its a 99213 vs 99214. That's very well defined and clear IMO. Most of my office visits are 99213's but I bill multiple 99214 a day.

I find medicare and nail care to be the hardest as I really dont think half the patients (or more) who want their nails cut actually have any qualifying factors. It has to be forged to get it covered and I'm not comfortable doing that so I turn them away and they send complaints to my company. The other DPMs in our group bill a lot of nail care and I do not. This was brought up in my last review as I have gotten complaints. I pointed the staff to medicare guidelines and told them I wasnt comfortable bending the laws. Got an eye brow raise but I never heard back about it. I still turn them away...

It's surgical billing which gets confusing for me. We (Maybe just me?) often do cases that are not necessarily in the CPT book and have to find something that is close enough.

What do you bill when you have a bimal equivalent ankle fx w deltoid tear. Slap a fibular plate on, dont touch the deltoid operatively other than stressing under fluoro, and bill it as ORIF fibula or ORIF bimal? I think people would bill this differently based on how they interpret it or how aggressive their billing is. This is one example I had recently where I really didnt know how to bill it and was never taught. I billed ORIF fibula (because thats what I did). This is one recent example where I may have lost out on cash.

Then there is scenarios where one podiatrist is billing an achilles repair with haglunds resection for a speed bridge takedown and one is just billing a haglunds. Or unbundling the lapidus vs not. Or billing an I&D plus debridement vs just an I&D. Multiple examples of this where different providers in the same community billing differently.
 
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CutsWithFury

I like to cut
Feb 2, 2019
361
420
Podiatry Hell
Status
Podiatrist
Office based billing is easy. Just gotta meet the required billing points and its a 99213 vs 99214. That's very well defined and clear IMO. Most of my office visits are 99213's but I bill multiple 99214 a day.

I find medicare and nail care to be the hardest as I really dont think half the patients (or more) who want their nails cut actually have any qualifying factors. It has to be forged to get it covered and I'm not comfortable doing that so I turn them away and they send complaints to my company. The other DPMs in our group bill a lot of nail care and I do not. This was brought up in my last review as I have gotten complaints. I pointed the staff to medicare guidelines and told them I wasnt comfortable bending the laws. Got an eye brow raise but I never heard back about it. I still turn them away...

It's surgical billing which gets confusing for me. We (Maybe just me?) often do cases that are not necessarily in the CPT book and have to find something that is close enough.

What do you bill when you have a bimal equivalent ankle fx w deltoid tear. Slap a fibular plate on, dont touch the deltoid operatively other than stressing under fluoro, and bill it as ORIF fibula or ORIF bimal? I think people would bill this differently based on how they interpret it or how aggressive their billing is. This is one example I had recently where I really didnt know how to bill it and was never taught. I billed ORIF fibula (because thats what I did). This is one recent example where I may have lost out on cash.

Then there is scenarios where one podiatrist is billing an achilles repair with haglunds resection for a speed bridge takedown and one is just billing a haglunds. Or unbundling the lapidus vs not. Or billing an I&D plus debridement vs just an I&D. Multiple examples of this where different providers in the same community billing differently.
You def should only be billing ORIF fibula for a bimalleolar equivalent.

Bimalleolar ORIF code is for fixation of defined fractures at fibula and medial malleolus.
 

Scrantonicity

10+ Year Member
Jul 15, 2007
107
91
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Attending Physician, Podiatrist
Yeah I especially wouldn't want to be "creative" with surgery codes. Insurance easily gets ahold of your op report, and they'll scrutinize it and whittle it down to almost nothing without batting an eye...they're good like that!
 

dtrack22

10+ Year Member
Apr 20, 2008
2,184
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Bimalleolar ORIF code is for fixation of defined fractures at fibula and medial malleolus.
nitpicky but goes back to the importance of learning the actual CPT wording/terminology. It’s “open treatment” with or without fixation on pretty much every fracture care code you would use for an ORIF procedure. If you did anything to treat the medial structures (even if it was opening up just to sweep the deltoid out of the gutter), then you could bill a bimal.

But yeah, otherwise virtually every bimal equivalent where all you fix is the fibula, should be billed as open tx of fibula fracture and NOT the bimal code.

I personally don’t think it is very difficult to understand what you are “supposed to bill” for most encounters. The differing opinions at coding courses or from one doc to another almost always boils down to maximizing reimbursement because the doc doesn’t feel like the correct code pays them enough. As long as they get away with it, they will tell other people, “this is how you should do it.” Most of them know exactly how it was intended to be billed, they just don’t care and haven’t gotten in trouble for it. Lapidus coding is a perfect example of this
 

DYK343

2+ Year Member
Jan 7, 2018
169
245
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Podiatrist
I agree. But why is there a trimalleolar code one for with and one for without fixation of the posterior mal?

If you dont fix the posterior mal the RVU/reimbursement is higher than a bimal which is essentially what you are doing.

This is why I questioned if I should bill bimal or not.
 

dtrack22

10+ Year Member
Apr 20, 2008
2,184
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I agree. But why is there a trimalleolar code one for with and one for without fixation of the posterior mal?

If you dont fix the posterior mal the RVU/reimbursement is higher than a bimal which is essentially what you are doing.
Because reimbursements and wRVU values don’t always correspond to difficulty/work. More often than not, “worse injury” or “bigger joint” pays more. I mean, I could throw a needle at someone’s knee and get it in their joint. Still pays more than an ankle injection which is technically more challenging.

But none of that changes the fact that when you actually read the 2-3 relevant ankle fracture treatment codes, it’s pretty obvious which one you would select when you orif a fibula and don’t do anything medially when the patient has a fibula fracture and deltoid injury. I think using common orthopedic terminology (ie ORIF, bimal/trimal equivalent) is what makes things messy and confuses people. The language of the CPT codes themselves makes it pretty clear what you should be billing based on injury and your treatment.
 

GreenHousePub

2+ Year Member
Apr 30, 2018
188
156
Status
Podiatrist
No training and you can get kicked off insurance, heavy fines, and or go to jail if you get it wrong.

The people in jail typically are malicious and intensional about fraud/falsly documenting to get higher reimbursements.

There are so many questions I have every day on billing. I suspect I am underpaying myself significantly. But I sleep better at night.
People in jail are most often repeat offenders. One primary care guy by me that went to jail was warned by the feds 8 times and kept doing it.
 

king22

5+ Year Member
May 11, 2014
25
17
Status
Podiatrist
Office based billing is easy. Just gotta meet the required billing points and its a 99213 vs 99214. That's very well defined and clear IMO. Most of my office visits are 99213's but I bill multiple 99214 a day.

I find medicare and nail care to be the hardest as I really dont think half the patients (or more) who want their nails cut actually have any qualifying factors. It has to be forged to get it covered and I'm not comfortable doing that so I turn them away and they send complaints to my company. The other DPMs in our group bill a lot of nail care and I do not. This was brought up in my last review as I have gotten complaints. I pointed the staff to medicare guidelines and told them I wasnt comfortable bending the laws. Got an eye brow raise but I never heard back about it. I still turn them away...
One of the practices I work for never lets me bill a 99214. I had one patient that I see for routine care who's a diabetic with sever neuropathy. They came in for their "usual" and I ended up finding an ulcer that probed deep to the first metatarsal head with strong clinical evidence of a significant infection. I took X-rays, worked them up, ordered multiple tests (patient refused to go to the hospital). all in all, I spent a good about 45 minutes with the patient. I was told that I could only bill a Level 3 visit because I billed a 11042 as well. The exact words were "Medicare will think your visit costs too much". I call this the "podiatry inferiority complex" where we don't think our services are really worth the amount that an MD/DO would charge for the same exact service.

As for nail care, I actually think the guidelines are relatively clear. You either have some qualifying diagnosis (other than vascular) such as E11.42, Class findings, or pain. In my geographic area, a medicare patient that has dystrophic nails and that complains of pain due to them is enough to get covered by medicare.
 

DYK343

2+ Year Member
Jan 7, 2018
169
245
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Podiatrist
One of the practices I work for never lets me bill a 99214. I had one patient that I see for routine care who's a diabetic with sever neuropathy. They came in for their "usual" and I ended up finding an ulcer that probed deep to the first metatarsal head with strong clinical evidence of a significant infection. I took X-rays, worked them up, ordered multiple tests (patient refused to go to the hospital). all in all, I spent a good about 45 minutes with the patient. I was told that I could only bill a Level 3 visit because I billed a 11042 as well. The exact words were "Medicare will think your visit costs too much". I call this the "podiatry inferiority complex" where we don't think our services are really worth the amount that an MD/DO would charge for the same exact service.

As for nail care, I actually think the guidelines are relatively clear. You either have some qualifying diagnosis (other than vascular) such as E11.42, Class findings, or pain. In my geographic area, a medicare patient that has dystrophic nails and that complains of pain due to them is enough to get covered by medicare.
Non diabetic patient (Or diabetic patient without risk factors) walks into my clinic with elongated thickened nails.
"Does this hurt?"
No, I would like them cut by a podiatrist. Appreciate your service...

x10 a day some days.
 

DYK343

2+ Year Member
Jan 7, 2018
169
245
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Podiatrist
Because reimbursements and wRVU values don’t always correspond to difficulty/work. More often than not, “worse injury” or “bigger joint” pays more. I mean, I could throw a needle at someone’s knee and get it in their joint. Still pays more than an ankle injection which is technically more challenging.

But none of that changes the fact that when you actually read the 2-3 relevant ankle fracture treatment codes, it’s pretty obvious which one you would select when you orif a fibula and don’t do anything medially when the patient has a fibula fracture and deltoid injury. I think using common orthopedic terminology (ie ORIF, bimal/trimal equivalent) is what makes things messy and confuses people. The language of the CPT codes themselves makes it pretty clear what you should be billing based on injury and your treatment.
Yeah, again though a bimal is going to be a more complex injury than a lateral mal fx alone. Just like a trimal with or without posterior mal fixation. Not fixing the posterior mal on a trimal is equivalent to a bimal but pays more than a bimal. It doesnt make sense and is why I was confused.

These are places people could make an assumption in billing and be fraudulent which is back to the point where we dont really have any training in billing.
 

dtrack22

10+ Year Member
Apr 20, 2008
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again though a bimal is going to be a more complex injury than a lateral mal fx alone. Just like a trimal with or without posterior mal fixation. Not fixing the posterior mal on a trimal is equivalent to a bimal but pays more than a bimal. It doesnt make sense and is why I was confused
but you weren’t treating a bimalleolar fracture. You were treating a fibula fracture. The only thing that complicates your scenario or makes it confusing is the use of the “bimal equivalent” terminology. ICD 10 and CPT don’t recognize the soft tissue aspect that orthopedic terminology has adopted in order to describe soft tissue components/stability of a rotational ankle injury. If you were to have said “I saw a patient with an unstable fibula fracture that needed surgery, but wasn’t sure if I should bill for open treatment of fibula fracture or bill for open treatment of a bimalleolar fracture,” people would think you were stupid.

The trimal/bimal/posterior mal issue you brought up is totally irrelevant to the initial fibula fx scenario. Not to mention the question it raises is not one of “which one should I bill?” Rather, “why do I get paid more/less for the exact same amount of work?” You aren’t questioning which one to pick, you’re questioning why reimbursements are different between two procedures in which the end product would look identical and require the same work/time/fixation.
 
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Sartorius P.O.D.

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May 25, 2014
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but you weren’t treating a bimalleolar fracture. You were treating a fibula fracture. The only thing that complicates your scenario or makes it confusing is the use of the “bimal equivalent” terminology. ICD 10 and CPT don’t recognize the soft tissue aspect that orthopedic terminology has adopted in order to describe soft tissue components/stability of a rotational ankle injury. If you were to have said “I saw a patient with an unstable fibula fracture that needed surgery, but wasn’t sure if I should bill for open treatment of fibula fracture or bill for open treatment of a bimalleolar fracture,” people would think you were stupid.

The trimal/bimal/posterior mal issue you brought up is totally irrelevant to the initial fibula fx scenario. Not to mention the question it raises is not one of “which one should I bill?” Rather, “why do I get paid more/less for the exact same amount of work?” You aren’t questioning which one to pick, you’re questioning why reimbursements are different between two procedures in which the end product would look identical and require the same work/time/fixation.
Pods I trained under told us to document and bill this way (only bill what you fixed)
Mix of hospital employed and private practice

I agree. But why is there a trimalleolar code one for with and one for without fixation of the posterior mal?

If you dont fix the posterior mal the RVU/reimbursement is higher than a bimal which is essentially what you are doing.

This is why I questioned if I should bill bimal or not.
Orhtopods I trained with told us to document and bill this way (bill for fractures, not what you actually fixed). specifically the tri-mal thing.
Mix of hospital employed and private practice

CPT 27822: Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip
or:
CPT
27823: Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip

+ CPT 27860: Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus
+ CPT 27829: Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed

Not sure what actually got reimbursed but I do know nobody was getting locked up.
 
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Pronation

Do the calc slide
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This seems to me like minutiae and the verbiage can be argued. This is of course in contrast to pods popping in an arthroeresis and billing 28575 (Closed treatment of talotarsal joint dislocation; requiring anesthesia)
 

DYK343

2+ Year Member
Jan 7, 2018
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How do you bill an artheroresis? I havent done one since residency. They have their place and I will use one someday but just havent had the right opportunity.

Unlisted CPT code is how I understand the legal way to bill the procedure and contact the insurer prior to placing artheroresis?
 

DYK343

2+ Year Member
Jan 7, 2018
169
245
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Podiatrist
Pods I trained under told us to document and bill this way (only bill what you fixed)
Mix of hospital employed and private practice



Orhtopods I trained with told us to document and bill this way (bill for fractures, not what you actually fixed). specifically the tri-mal thing.
Mix of hospital employed and private practice

CPT 27822: Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip
or:
CPT
27823: Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip

+ CPT 27860: Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus
+ CPT 27829: Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed

Not sure what actually got reimbursed but I do know nobody was getting locked up.
Maybe ExperiencedDPM can weight in his/her input. I'm glad i'm not the only one who is confused here.

But I do take point of what Dtrack said as its a deltoid ligament/soft tissue injury medially and not an actual bimal fx - even though its equivalent to one.
 
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dtrack22

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Apr 20, 2008
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How do you bill an artheroresis? I havent done one since residency. They have their place and I will use one someday but just havent had the right opportunity.

Unlisted CPT code is how I understand the legal way to bill the procedure and contact the insurer prior to placing artheroresis?
that’s how you are supposed to bill it. There is no CPT code for an arthroeresis. The problem is that unlisted CPT codes frequently don’t get paid, even if you jump through all the insurance company’s hoops and charge a reasonable fee. And it’s not just your fee which isn’t getting paid, but the facility fee isn’t covered either. Which means the patient would have to pay for everything out of pocket, implant included.

People don’t want to pay for the procedure and podiatrists want their patients to be happy. So the podiatrist picks a dislocation treatment code (even though we all know the subtalar joint is neither dislocated nor is it even subluxed), to get everything covered for their patient and to get themselves paid. I’ve never put one in either, and I don’t personally know anyone who has, so I’m not sure if any of the folks doing it have had to pay money back if/when their op note gets reviewed by insurance.
 
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air bud

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Not best example, but maybe if old and non surgical. Bimal equivalent non op you will code as conservative management of bimalleloar fracture. Bill what you did.

Also a code I think is underused is the the one for a pilon fracture. The code says fracture involving the tibial plafond. Vertical medial mal fracture that doesn't hit gutter but barely catches joint - that is a plafond injury.
 
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