The Free Online Podiatry Coding Class - Student Doctor Network

[air bud]

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Exactly. Perfect approach.

You will lose patients if you prn too many (and I'm saying this as someone on a waitlist... so I prn as many as I reasonably can).
They will typically be lost to the competition, which is a bad look if that gets back to the PCP that Dr. Feli gave them an inject and an insole and prn... but Dr Attack took his time, Rx for PT, and they got better.

It is always much better to make a f/u appointment and tell them they can cancel if they are doing fine ("but please give us as much notice as you can so that we can give that spot to someone else"). This is as much about reading the patient as it is just the foot issue/progress. You have to put yourself into the mind of the person whose foot (or their kid's or spouse's or parent's or etc foot) was just injected, procedure was done, and they are leaving with wound instruction and a numb swollen toe.

Basically, in PP (or any office you want to grow), let them prn you.
I frequently put "3mo or PRN" or stuff like that on my f/u note to my desk, and they know to see what the pt would prefer or use their intuition when they mention "as needed." Some prefer that; many do not.

For ingrowns, I would say 90% of matrix 2wk f/u show for that visit... maybe 60% of avulsions (but again, I barely do those). Most who do not show cancelled when they got the reminder, and for the very few no-shows, it was a double book anyways.

You make some valid points here. I do the numbing, the procedure. I give them a handout which I personally review with them. I spent plenty of time with them, shut off my brain, talked to them, developed rapport. They leave happy knowing they received the care they need and if they have concerns they can follow up and be seen immediately. I can't remember one time in my career where someone complained about feeling rushed after an ingrown or they were dumped without appropriate care.

 

[AttackNME]

You make some valid points here. I do the numbing, the procedure. I give them a handout which I personally review with them. I spent plenty of time with them, shut off my brain, talked to them, developed rapport. They leave happy knowing they received the care they need and if they have concerns they can follow up and be seen immediately. I can't remember one time in my career where someone complained about feeling rushed after an ingrown or they were dumped without appropriate care.

Do you have a service that solicits feedback? We use patientpop and it does a great job getting feedback. It filters out the bad ones and gets the good ones published to google reviews. The only way I even found out that I made people feel rushed is through the filtered reviews. Otherwise I would never have found out. For people that don’t use a review soliciting service, usually you get only highly emotional responses cus otherwise why would someone think to seek out and go to write a review after a doctor visit?

 

[air bud]

Do you have a service that solicits feedback? We use patientpop and it does a great job getting feedback. It filters out the bad ones and gets the good ones published to google reviews. The only way I even found out that I made people feel rushed is through the filtered reviews. Otherwise I would never have found out. For people that don’t use a review soliciting service, usually you get only highly emotional responses cus otherwise why would someone think to seek out and go to write a review after a doctor visit?

yes, but not public reviews. I wish they did, I am basically anonymous with a public search. Like 4 reviews, one from a crazy lady 5 years ago, 1 from dtrack that he made up about me treating his nail fungus, and 2 others. the ortho group I was with didn't do public reviews. My current employer doesnt either.

This is actually a good point to bring up for employed people - your employer owns them and will likely delete them when you leave. My first rural job I had like 4.9 stars across 70 reviews....deleted from the google machine when I left. I did do a screenshot of them but that has basically been for me to show future employers.

 

[HardRoadPaved]

READ YOUR LCDs PEOPLE! 10060/1 is not acceptable for billing under medicare for ingrown toenails. It totally suck I know to get paid $75....

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID

www.cms.gov

Paronychia, when sufficiently treated with avulsion of the nail only, should be billed with CPT code 11730 and not as an incision and drainage. Permanent correction of recurring ingrown toenail by nail resection or wedge excision of the nail lip should be billed with CPT code 11750 or 11765 and not as an incision and drainage.

Partial or complete avulsion of the toenail is a common treatment for paronychia in association with an ingrown nail. In fact, incision and drainage is not commonly performed for treatment of paronychia in the foot without avulsion of the toenail. This procedure usually effectively drains any associated infection. Therefore, the provider who performs this procedure to address a localized infection should bill the appropriate code 11730, and not one for an incision and drainage service.

Billing for incision and drainage procedures (CPT codes 10060, 10061, 10160) for treatment of paronychia of the foot when avulsion or resection of the toenail has been performed to treat the same condition, is not appropriate.

Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request. Then only CPT codes 10060, 10061, 10160 should be used and not combined with CPT codes 11750 or 11765.

 

[air bud]

READ YOUR LCDs PEOPLE! 10060/1 is not acceptable for billing under medicare for ingrown toenails. It totally suck I know to get paid $75....

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID

www.cms.gov

Paronychia, when sufficiently treated with avulsion of the nail only, should be billed with CPT code 11730 and not as an incision and drainage. Permanent correction of recurring ingrown toenail by nail resection or wedge excision of the nail lip should be billed with CPT code 11750 or 11765 and not as an incision and drainage.

Partial or complete avulsion of the toenail is a common treatment for paronychia in association with an ingrown nail. In fact, incision and drainage is not commonly performed for treatment of paronychia in the foot without avulsion of the toenail. This procedure usually effectively drains any associated infection. Therefore, the provider who performs this procedure to address a localized infection should bill the appropriate code 11730, and not one for an incision and drainage service.

Billing for incision and drainage procedures (CPT codes 10060, 10061, 10160) for treatment of paronychia of the foot when avulsion or resection of the toenail has been performed to treat the same condition, is not appropriate.

Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request. Then only CPT codes 10060, 10061, 10160 should be used and not combined with CPT codes 11750 or 11765.

Don't think I have ever billed an I&D for an ingrown nail. Podiatrists are the worst.

 

[Feli]

READ YOUR LCDs PEOPLE! 10060/1 is not acceptable for billing under medicare for ingrown toenails....
..."Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request. Then only CPT codes 10060, 10061, 10160 should be used and not combined with CPT codes 11750 or 11765."

It says right there in the MCR link you quoted that pus-producing paronychia can, and "should," be billed as I&D when an I&D is done and appropriate.
It tells you to use the I&D codes when appropriate (it just states don't use both ingrown and I&D codes).
That is exactly what I said... I&D for certain paronychia situations. I did not say nail removal is 11060/1.

It's up to you how you code and document.
Playing coding police and creating always/never situations only limits your own toolbox and code variety.
It's not like anyone is saying to bill 11730 for every RFC patient at the memory care center or something.

We have to realize that things which are "relatively uncommon" are actually fairly common when you see hundreds per year. We are specialists. Pus-producing paronychia occur at proximal nail fold, lateral nail folds. All of us have seen and treated such. I find this uncommon in MCR population as they are not as active (abscess nail margin is much more common in peds and working age pts who do their own nail care and wear shoes and perspire more or get pedicures that trim nails very short or disturb cuticle). They are pretty common on fingers from nail-biting and maincures. Still, paronychia around toenails definitely occur in older folks... and "relatively uncommon" in the CMS guide info is accurate. When you think about it, ingrowns of any type should be fairly uncommon in MCR population, since most of them who see a podiatrist don't cut their own nails... they get RFC done by the podiatrist (or their office), who should hopefully do better than patient or pedicure shop.

It's like the discussion Lapidus vs single TMT fusion codes... both surgery procedures exist and can be accurate, when indicated and performed. Is one much more common? Yeah, but the other is not zero percent or forbidden if appropriate to the case at hand.

Everything when indicated.

Don't think I have ever billed an I&D for an ingrown nail. Podiatrists are the worst.

Fellowship trained foot and ankle surgeons are who you want to seek care with.
3 year trained podiatrist is the new PPMR.

 

[GreenHousePub]

Fellowship trained foot and ankle surgeons are who you want to seek care with.

lol

 

[HardRoadPaved]

I think that most pus producing ingrown toenails are the exception to the rule. Many just need a wedge excision from the granuloma. More likely to use a #67 blade.

Also always felt funny that's it's incision and drainage. Incising with a nail elevator and then using an anvil nipper seems odd to call it an I&D from a coders perspective.

 

[PODIATRYCRAZE]

HPI: New patient 28M healthy playing basketball in winter with friends and he slipped on black ice. Comes to emergency department immediately for right ankle pain after hearing a crack. XR was taken showing bimalleolar fracture mildly displaced.

Treatment: You come in to reduce him, no anesthetics given, then apply a fiberglass splint. Next XR shows satisfactory reduction and alignment. Discharged for outpatient surgery.

 

[PODIATRYCRAZE]

ICD: S82.841A Right displaced bimalleolar fracture
M25.71 Right ankle pain

CPT: 27808 Closed reduction of bimalleolar fracture and application of cast
99283 Emergency room visit

Reimbursement: $100 hoping for $200?

 

[Feli]

27808 ... Discharged for outpatient surgery.

Why would you create a 90d global in ER when planning an office pre op visit and then OR surgery shortly after?
What a nightmare for the biller... and your bottom line.

Don't ever do that... it'll guarantee at least the office visit pre-op being no charge, possibly makes the OR surgery 50% or no pay also - depending on payers and biller skill with mods.

Bill the ER consult and splint,
then pre-op E&M and boot,
then OR day surgery codes (that starts the 90day).

 

[dtrack22]

You come in to reduce him

No I won’t…that’s the ED docs job. In fact, since being in practice, I don’t know that I’ve ever been asked to even chat about a closed ankle fracture in the ED.

 

[619]

No I won’t…that’s the ED docs job. In fact, since being in practice, I don’t know that I’ve ever been asked to even chat about a closed ankle fracture in the ED.

Unfortunately a lot of attendings here still practice like they are 1st year residents. These are most likely (always) associates of a PP (the owner takes no call) where they take calls at 2-4 different hospitals and have to "go in" for every consult even in the ED.

 

[HardRoadPaved]

99283 Emergency room visit

You are a consultant not the ER doc.... Coding for hospital admission, consultations, and emergency department visits | The Bulletin

 

[GreenHousePub]

No I won’t…that’s the ED docs job. In fact, since being in practice, I don’t know that I’ve ever been asked to even chat about a closed ankle fracture in the ED.

That's because they are calling orthopedics.

 

[PODIATRYCRAZE]

@HardRoadPaved Very good point, thank you for catching that mistake. I am definitely not the only one who will benefit from your guidance.

HPI: Same 28M from last case coming in for surgery. Right ankle bimalleolar fracture.

Treatment: Open reduction with internal fixation. Medial malleolus fixated with 1 screw, lateral malleolus with plate and screws

 

[PODIATRYCRAZE]

ICD: S82.841A Right displaced bimalleolar fracture
M25.71 Right ankle pain

CPT: 27814 Open treatment of bimalleolar fracture

Reimbursement: $1000? Including 2-3 postoperative visits.

If anyone runs their own DME business, please insert billing tips for that.

 

[PODIATRYCRAZE]

HPI: 35M athletic male comes in for sudden onset of heel pain in right foot after a wedding 2 weeks ago. Says it is a sharp pain that starts when he walks and first step of the day is the worst. Pain is reproducible with palpation to medial tuberosity. Flat feet noted. When asked about it he says he gets aching arches after long activity since he was a kid but never bothered him enough to get it looked at.

Treatment: Right foot XR - flat feet confirmed, calcaneus normal. Orthotics with arch support dispensed. Stretching instructions gone over with patient, explained course of treatment for plantar fasciitis. If it does not improve by follow up in 1 month, will try injections. Will keep an eye on arch pain after plantar fasciitis resolves.

 

[PODIATRYCRAZE]

ICD10: M72.2 Plantar fasciitis
Q66.51 Pes planus
M79.671 Pain in right foot

CPT: 99203 Office visit
73620 Right foot XR

Reimbursement: $130? From insurance
$100 office visit
$30 from XR
~$50 from patient for orthotics

 

[Sweatshirt]

ICD10: M72.2 Plantar fasciitis
Q66.51 Pes planus
M79.671 Pain in right foot

CPT: 99203 Office visit
73620 Right foot XR

Reimbursement: $130? From insurance
$100 office visit
$30 from XR
~$50 from patient for orthotics

Need to be doing more courtesy nails trims man

 

[Adam Smasher]

ICD10: M72.2 Plantar fasciitis
Q66.51 Pes planus
M79.671 Pain in right foot

CPT: 99203 Office visit
73620 Right foot XR

Reimbursement: $130? From insurance
$100 office visit
$30 from XR
~$50 from patient for orthotics

Remember, if you are the one performing and billing the xr, the radiograph order+interpretation do not count towards your data points for the purpose of calculating data complexity. Based on what you've given us, you have a decently complex DDx, but no real risk or data complexity. However, if you make a throwaway remark like "try ibuprofen," now you've got some otc drug management, which earns you your 99203. (that was a joke, you need to do slightly more than that for otc drug management, but surprisingly not much)

This brings up several strategies for heel pain that I have observed.

1. The minimalist. (My preferred approach) You know there's not a tremendously wide differential for post static plantar heel pain, so you give a perfunctory explanation of plantar fasciitis and stretching +/- prefabricated orthotics. Tell them if they don't stretch consistently, they will never get better and to follow up prn if that doesn't work. It's just a 99202, but you gift yourself some extra time to devote to more productive ends.

2. The ally-oop. Send them straight to PT. Automatic 99203.

3. The hospital employee. Access your health system EHR, review data points, and prescribe NSAID. 99204. I can't take credit for this one.

4. The Norman Rockwell. Sit with your patient, learn about their personal trials and tribulations to really figure out what's the root cause of their heel pain. Then educate them using the anatomical diagrams you have hanging on your wall as well as your skeletal foot model on the etiology of the disease, discussing the windlass mechanism and the subtalar joint axis. You've gained their trust and they feel better. You haven't actually done anything, however. (Bill for time)

5. The Nuclear Option. XR, injection, night splint, cast for cfo, then at pickup appt, push Shockwave.

 

[HardRoadPaved]

ICD10: M72.2 Plantar fasciitis
Q66.51 Pes planus
M79.671 Pain in right foot

CPT: 99203 Office visit
73620 Right foot XR

Reimbursement: $130? From insurance
$100 office visit
$30 from XR
~$50 from patient for orthotics

He is telling you pain in the AM.... L4397 $80-125. Hell even a Strassburg sock, something...

Pain - why not give NSAID Rx.

Athletic male ---- look at his shoes and make sure he isnt exercising in sketchers.

$50 for OTC orthotics? Dr. Scholls at Walmart are like $80-90.

 

[heybrother]

Outpatient Visit Current Procedural Terminology Code Level Selection Trends in Hand Surgery Following Criteria Changes by the American Medical Association - PMC

Introduction: Beginning on January 1, 2021, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions with regard to the outpatient evaluation and management (E/M) criteria ...

www.ncbi.nlm.nih.gov

I don't have E&M distribution tables for podiatry, but I've seen some distributions for other specialties and 99202s make up a tiny percent.

 

[air bud]

He is telling you pain in the AM.... L4397 $80-125. Hell even a Strassburg sock, something...

Pain - why not give NSAID Rx.

Athletic male ---- look at his shoes and make sure he isnt exercising in sketchers.

$50 for OTC orthotics? Dr. Scholls at Walmart are like $80-90.

80 bucks for dr scholls? you shop at beverly hills walmart? They are 50 bucks my brother in fungus. And its so much easier to be able to say hey,, get these powersteps, they are cheaper and better than dr. scholls at walmart.

disclaimer - I don't dispense orthotics in my office.

Bonus - custom orthotics are unnecessary for less than 1 percent of the patients you will see. Its all a scam to make money. Unless there is TRUE deformity, powersteps will provide patients relief. Fight me.

 

[Adam Smasher]

Outpatient Visit Current Procedural Terminology Code Level Selection Trends in Hand Surgery Following Criteria Changes by the American Medical Association - PMC

Introduction: Beginning on January 1, 2021, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions with regard to the outpatient evaluation and management (E/M) criteria ...

www.ncbi.nlm.nih.gov

I don't have E&M distribution tables for podiatry, but I've seen some distributions for other specialties and 99202s make up a tiny percent.

custom orthotics are a necessary for less than 1 percent of the patients you will see. Its all a scam to make money. Unless there is TRUE deformity, powersteps will provide patients relief

If we're going to contend that custom foot orthotics aren't necessary for heel pain, that it's all a cash grab, then using the EXACT same logic, high complexity MDM requiring level 3+ e/m services also isn't necessary either. Upcoding your heel pain encounter is also just a cash grab. Fight me.

 

[air bud]

If we're going to contend that custom foot orthotics aren't necessary for heel pain, that it's all a cash grab, then using the EXACT same logic, high complexity MDM requiring level 3+ e/m services also isn't necessary either. Upcoding your heel pain encounter is also just a cash grab. Fight me.

But it's insurance so it's ok bro

Also you are wrong.

 

[Adam Smasher]

Also you are wrong.

I bow before your superior discourse, I have been thwarted

 

[air bud]

I bow before your superior discourse, I have been thwarted

And there you have it folks. Like and follow for more 10x ideas.

 

[HardRoadPaved]

80 bucks for dr scholls? you shop at beverly hills walmart? They are 50 bucks my brother in fungus. And its so much easier to be able to say hey,, get these powersteps, they are cheaper and better than dr. scholls at walmart.

Nah retail theft and inflation has driven the price up + tax. You can get them direct from Dr. Scholls for 58-63 Custom Fit Orthotics Shoe Inserts | Dr. Scholl's

Most people have no idea what powerstep is. They do know Dr. Scholls so they think because of the brand awareness its better.

disclaimer - I don't dispense orthotics in my office.

to each their own. some areas pay rubbish or have a bad payer mix so I get it.

Bonus - custom orthotics are unnecessary for less than 1 percent of the patients you will see. Its all a scam to make money. Unless there is TRUE deformity, powersteps will provide patients relief. Fight me.

you mean necessary. everyone should be doing OTC first then upgrade to custom if an issue. not sure howd youd pass an audit without trying prefab first unless there was a contraindication. In fact Aetna / Cigna has it in their rules to have failed prefab

 

[air bud]

Nah retail theft and inflation has driven the price up + tax. You can get them direct from Dr. Scholls for 58-63 Custom Fit Orthotics Shoe Inserts | Dr. Scholl's

Most people have no idea what powerstep is. They do know Dr. Scholls so they think because of the brand awareness its better.

to each their own. some areas pay rubbish or have a bad payer mix so I get it.


you mean necessary. everyone should be doing OTC first then upgrade to custom if an issue. not sure howd youd pass an audit without trying prefab first unless there was a contraindication. In fact Aetna / Cigna has it in their rules to have failed prefab

No I mean unnecessary. OTC does the trick. Case closed.

 

[Feli]

I concur with dunking dog...
PowerStep type for 95% are fine.

I only do custom orthotics if it's symptomatic cavus, youth clubfoot, biggun with PTTD, limb length or asymmetric needing heel lift, intoe, severe out toe, etc... and I typically Rx those out to Hanger-type stores.

The occasional runner or cop or arch pain or flat foot pt who wants something durable can get custom ortho. Sure, I will do those in office. But they were fine (probably better) getting 7 or 8 pairs of PowerSteps for that money instead.

Orthotics are just dumb in that they create multiple issues:
-turns doc into a salesman
-ruins doc/patient relationship if they don't work out
-ruins doc/patient relationship if they don't like copays at pickup or fit check or modification visits (they won't like the copays)
-makes pretty little profit after lab fees + ship fees + low/no charge visits for pickup and fit checks, time + $$ lost on refund/returns
-makes you have a bench grinder, heat gun, various arts and craft supplies, and further TFP evidence in the office

Orthotics casting/mod being done in the office as a major part of the practice is TFP stuff imo.
It's useful, but it has its major downsides, and it's not EBM. It's better to send most of it out.

The exception here is some offices where you have a ton of MCA payer patients (I do not), and you can get L3020, L3000, and even custom braces L1960 Arizona type stuff covered. In those places, it won't tend to cause the above problems (refunds, satisfaction) ... for those pt populations, it's not their $$$, so they just throw the orthotics away if they suck since they didn't pay for it (and we wonder why taxes are high?)

...to answer the coding question, most of my first visit fasciitis are 99203 + PowerStep ($50) + handout,
all get XR order (I'm in a hospital) if their PCP didn't get one already,
roughly half get inject(s) depending on pain level and their preference,
roughly a third PT Rx and/or NSAID Rx (and/or OTC stuff),
rare CAM boot for very severe cases,
rare night splint first visit (usually ppl who have seen other pods or done PT already).

 

[Adam Smasher]

Orthotics are just dumb in that they create multiple issues:
-turns doc into a salesman
-ruins doc/patient relationship if they don't work out
-ruins doc/patient relationship if they don't like copays at pickup or fit check or modification visits (they won't like the copays)
-makes pretty little profit after lab fees + ship fees + low/no charge visits for pickup and fit checks
-makes you have a grinder, heat gun, arts and craft supplies, and further TFP evidence in the office

Actually, this is a hidden benefit of orthotics. When you have an obnoxious patient who is acting crazy and emotional that you want to get rid of, I find custom foot orthotics and the associated price tag are as effective as a splash of cold water in their face and they compose themselves really quick.

 

[HardRoadPaved]

and somehow those crazies are the ones who have uhc or cigna or aetna with exclusion of benefit.

Problem is my area is bcbs heavy. They all have drank the cmo juice from pod over saturation and expect it along with a nail trim.

custom foot orthotics and the associated price tag are as effective as a splash of cold water in their face and they compose themselves really quick.

I'm next to a good feet store so I see tons of sticker shock and anything beats $1700

 

[Boba Foot]

Outpatient Visit Current Procedural Terminology Code Level Selection Trends in Hand Surgery Following Criteria Changes by the American Medical Association - PMC

Introduction: Beginning on January 1, 2021, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions with regard to the outpatient evaluation and management (E/M) criteria ...

www.ncbi.nlm.nih.gov

I don't have E&M distribution tables for podiatry, but I've seen some distributions for other specialties and 99202s make up a tiny percent.

Personally, I would rather die than bill a 2.

 

[GreenHousePub]

Actually, this is a hidden benefit of orthotics. When you have an obnoxious patient who is acting crazy and emotional that you want to get rid of, I find custom foot orthotics and the associated price tag are as effective as a splash of cold water in their face and they compose themselves really quick.

Wow! That's a great strategy.

However, when if they do decide to get a pair, they'll never be right. I had a guy come in for 5 different modifications before I finally told him I can't do anything further.

 

[Boba Foot]

Nah retail theft and inflation has driven the price up + tax. You can get them direct from Dr. Scholls for 58-63 Custom Fit Orthotics Shoe Inserts | Dr. Scholl's

Most people have no idea what powerstep is. They do know Dr. Scholls so they think because of the brand awareness its better.

I see on their website that the TV toenail débrider recommends them. They must be legit.

 

[Boba Foot]

so they just throw the orthotics away if they suck since they didn't pay for it (and we wonder why taxes are high?)

Off topic, but when people lament about the cost of Medicare and Medicaid, I really don't give half a 💩 as long as things like this (Pentagon Can't Account for $220 Billion of Gear Given to Contractors) keep going on. So much waste, kickbacks and fraud within the defense sector that could be improving the healthcare situation here in the ol' US of A.

 

[PODIATRYCRAZE]

HPI: 88F PMH of DMII and neuropathy who sees another podiatrist for her wound care was admitted 3 weeks ago, for pneumonia. At the time she had a stable right heel eschar which was under the care of the wound care team. Just about ready for discharge, but today heel wound was malodorous with some extra drainage. For whatever reason, no foot XR was obtained on admission. Infectious disease is asking for a bone biopsy for culture so he can tailor his long term antibiotic treatment.

Treatment: XR ordered with clear destruction at posterior calcaneus. Did not seem like a good candidate for surgery so a bed side calcaneus biopsy was performed using a needle. No anesthesia was used and patient tolerated it well.

 

[PODIATRYCRAZE]

ICD: M86.171 Right foot osteomyelitis
L97.31 Right foot pressure ulcer

CPT: 99223 Comprehensive H&P inpatient
20240 Bone Biopsy - my understanding is that despite no use of operating room or anesthesia, it can still be billed alongside consult.

Reimbursement: $150? 25 modifier

 

[air bud]

ICD: M86.171 Right foot osteomyelitis
L97.31 Right foot pressure ulcer

CPT: 99223 Comprehensive H&P inpatient
20240 Bone Biopsy - my understanding is that despite no use of operating room or anesthesia, it can still be billed alongside consult.

Reimbursement: $150? 25 modifier

You had to have done a lot more than just biopsy an bone?

And it's not a pressure ulcer it's l97.51X

In what future payment model we will be under, your job is to make the patient as sick as possible on paper. Higher reimbursement. And medically accurate of course
But that's e11.621, l97.513, something if they have PVD, renal etc. throw in some morbidly obesity...

 

[HardRoadPaved]

Level 3?!?!? Cmon!

The rules for e/m are well established for inpatient consultation. DPM just can't get the comprehensive history and physical needed for billing. APMA even posted a video on YouTube explaining why you're just asking for an audit

 

[Adam Smasher]

A few thoughts.

Decubitous ulcers use the L89 taxonomy of codes, not L97.

Airbud is right, incorporate all pertinent HCC diagnoses into the problem list if they have bearing on your plan, which is extremely boring but important for communicating on the claim how sick this person is.

Hardroad is also right, I believe a 99223 is MDM along the lines of "decision for emergency surgery" so a 99222 is more apt.

More likely you consult (99222) on day 1 to order the xr, then follow up separate day of service for the bone bx. I have never gotten paid for inpatient consult plus CPT on same DOS, unless it was a major (90 day global) procedure and the consult was billed with a 57 mod.

Which brings me to bedside bone bx. 20240 reimburses ~$30 and poses a logistical challenge because otherwise intelligent hospital staff act really clueless when tasked with obtaining a jamshidi needle for you to use, or at least that's my experience. For your time, you're better off trimming the pt's toenails.

I know this is just a hypothetical scenario and the discussion is supposed to be about coding, but if the heel ulcer is malodorous with bone necrosis, anything short of debridement/calcanectomy is asking for a readmission. Just because ID specifically asks for a bone bx doesn't mean you're obligated to do it, you're a knowledgeable consultant and your opinion carries weight also. If the admitting team is hell bent on bone bx plus IV abx as a treatment strategy, I would say consult interventional radiology to do the bx, they're the experts on percutaneous procedures, let them hop on the pus bus for a short ride.

 

[dtrack22]

The rules for e/m are well established for inpatient consultation. DPM just can't get the comprehensive history and physical needed for billing. APMA even posted a video on YouTube explaining why you're just asking for an audit

Inpatient codes switched over to MDM only (or time), just like outpatient codes this year. You’ve been doing it wrong for all of 2023 apparently…

 

[air bud]

A few thoughts.

Decubitous ulcers use the L89 taxonomy of codes, not L97.

Airbud is right, incorporate all pertinent HCC diagnoses into the problem list if they have bearing on your plan, which is extremely boring but important for communicating on the claim how sick this person is.

Hardroad is also right, I believe a 99223 is MDM along the lines of "decision for emergency surgery" so a 99222 is more apt.

More likely you consult (99222) on day 1 to order the xr, then follow up separate day of service for the bone bx. I have never gotten paid for inpatient consult plus CPT on same DOS, unless it was a major (90 day global) procedure and the consult was billed with a 57 mod.

Which brings me to bedside bone bx. 20240 reimburses ~$30 and poses a logistical challenge because otherwise intelligent hospital staff act really clueless when tasked with obtaining a jamshidi needle for you to use, or at least that's my experience. For your time, you're better off trimming the pt's toenails.

I know this is just a hypothetical scenario and the discussion is supposed to be about coding, but if the heel ulcer is malodorous with bone necrosis, anything short of debridement/calcanectomy is asking for a readmission. Just because ID specifically asks for a bone bx doesn't mean you're obligated to do it, you're a knowledgeable consultant and your opinion carries weight also. If the admitting team is hell bent on bone bx plus IV abx as a treatment strategy, I would say consult interventional radiology to do the bx, they're the experts on percutaneous procedures, let them hop on the pus bus for a short ride.

My bad I was thinking about a forefoot ulcer for the l97. Agree on l89

 

[HardRoadPaved]

Inpatient codes switched over to MDM only (or time), just like outpatient codes this year. You’ve been doing it wrong for all of 2023 apparently…

Which brings me to bedside bone bx. 20240 reimburses ~$30 and poses a logistical challenge because otherwise intelligent hospital staff act really clueless when tasked with obtaining a jamshidi needle for you to use, or at least that's my experience. For your time, you're better off trimming the pt's toenails.

I am smart... dont do inpatient 🤓. I applaud all you guys that can/want to. Esp those damn clipboard nurses. If I did a bone bx on the floor it would be armageddon of every nurse trying to find a flaw like 'did you do a timeout and write that in a procedure note?' 'did you affix the correct label to blah blah blah'


However even still level 3 even with the new rules pretty hard to justify.

 

[PODIATRYCRAZE]

HPI: 44M healthy who had right Jones fracture and required open reduction and internal fixation 3 days ago with plate and screws. Calls you after hours saying there is throbbing pain and the dressing is feeling abnormally tight. He is already on the way to local ED. Calls again later to update you that the doctor said the incision looks infected. Patient will be admitted and started on antibiotics. Next morning during rounds you notice small amount of purulence.

Treatment: Decision is made to take him for incision and drainage. Hardware left in, packed with antibiotic beads. 2 days later delayed closure.

 

[PODIATRYCRAZE]

ICD10: L02.61 Foot Abscess
L03.115 Foot cellulitis

CPT: 28003 Incision and drainage
13160 Delayed closure

Reimbursement: $150? 25 Modifier. This will separate these procedures from the original ORIF.

We often hear about global periods and that once you do a surgery (in this case an ORIF), you don’t get paid for anything after.

There is a misconception. When abnormal complications arise a new problem is created and can then be billed. Don’t forget your modifiers.

Global periods apply to typical follow appointments that will be considered free by us / included by the insurance.

 

[Feli]

My bad I was thinking about a forefoot ulcer for the l97. Agree on l89

There is no "forefoot"... there is only Foot and RRA.

 

[heybrother]

ICD10: L02.61 Foot Abscess
L03.115 Foot cellulitis

CPT: 28003 Incision and drainage
13160 Delayed closure

Reimbursement: $150? 25 Modifier. This will separate these procedures from the original ORIF.

We often hear about global periods and that once you do a surgery (in this case an ORIF), you don’t get paid for anything after.

There is a misconception. When abnormal complications arise a new problem is created and can then be billed. Don’t forget your modifiers.

Global periods apply to typical follow appointments that will be considered free by us / included by the insurance.

But you didn't include the modifiers...

 

[dtrack22]

25 Modifier. This will separate these procedures from the original ORIF.

No

78 is the one you’re looking for when billing the I&D