The Free Online Podiatry Coding Class - Student Doctor Network

[Feli]

No

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

78 on that one and 58 for DPC, yeah.

24 is mostly for the unrelated E&Ms in global.

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[PODIATRYCRAZE]

HPI: 82M long time patient with type 2 diabetes, no previous vascular history, quit smoking 10 years ago, started feeling his right foot and toes falling asleep more often. No associated pain or history of wounds. Physical exam shows non palpable pulses and very faint monophasic sounds on doppler.

Treatment: In office ABIPVR, shows adequate perfusion to left leg, and 0.6 to right ankle. Educated patient on diabetic foot wound precautions and peripheral vascular disease. Follow up in 3 months, referral to vascular surgery.

 

[PODIATRYCRAZE]

ICD10: I73.9 Peripheral vascular disease
E13.59 Diabetes with circulatory problems

CPT: 99213 Office Visit
93923 Ankle Brachial Index

Reimbursement: $150? I do not believe a modifier is necessary

 

[HardRoadPaved]

ICD10: I73.9 Peripheral vascular disease

i70.221

E13.59

11.51

CPT: 99213 Office Visit

99214

93923 Ankle Brachial Index

Reimbursement: $150? I do not believe a modifier is necessary

Clinicians would use CPT code 93922 when performing a “limited” arterial study involving bilateral assessments on one to two levels on the lower extremity. One would employ CPT code 93923 when performing “complete” arterial study involving bilateral assessments on three or more levels on the lower extremity. The CPT code 93923 is also appropriate for a single level study with provocative functional maneuvers (i.e. reactive hyperemia).

 

[dtrack22]

99214

Nothing in the prompt itself gets you to a level 4 visit

 

[HardRoadPaved]

Nothing in the prompt itself gets you to a level 4 visit

Yea i think this is one of those visits where there is more meat on the bone. For the hospital/msk doc who can review notes and labs and coordinate care they are gonna get the first and second columns down pat.

 

[ExperiencedDPM]

This is how you bill:

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Park Avenue Podiatrist Under Investigation After Bill For Simple Foot Procedure Costs More Than Heart Surgery​

Written by
Abraham Jaros
|
Updated on Tuesday, Oct 24, 2023
A case involving a high-profile Park Avenue Podiatrist is garnering media attention and considerable local scrutiny for what many in the medical and legal communities believe are outrageous charges. The case - which is profiled in a recent New York Post article - involves a questionable bill for two simple foot procedures. Jaroslawicz & Jaros is representing the woman who underwent the procedure and her husband in this matter. A Questionable Bill The podiatrist - Suzanne Levine - is a well-known specialist who caters to celebrity patients and has been featured on a number of television shows, including Dr. Oz. She has gained notoriety for offering procedures such as foot facelifts, Botox injections to smooth out imperfections in the feet, and Juvéderm injections to cushion pads of the feet when wearing high heels. Although there are no laws regulating prices for podiatrist procedures in New York, the prices Levine’s office billed this particular patient were concerning. Levine performed two procedures to straighten two of the patient’s toes. Both procedures were performed in-office and took less than 30 minutes each. Other Podiatrists in the area, including the Upper East Side, charge less than $3,000 for such a procedure. Levine’s office, however, charged nearly $200,000. Although the patient was assured that the procedures would be covered by her insurance, Levine’s office billed the patient $6,000 and then attempted to recover more from her insurance provider, United Healthcare. The patient’ insurance company agreed to pay $170,940 and an additional $4,158 in interest - more than the cost for major heart surgery.Levine’s office attempted several times to recover the insurance check that was mailed to the patient and her husband for endorsement. Skeptical and concerned by the monstrous charge, the patient’s husband asked for a statement, which revealed two “surgical operating room charges" at $86,450 apiece. Protecting Clients’ Rights When contacted by the New York Post, Levine’s office claimed that the check had been issued in error, that a corrected claim had been submitted, and that Levine herself was not aware of the mistake or her office manager’s attempts to obtain the check. United Healthcare has launched an investigation into the questionable charges and has suspended payment while the investigation in pending. The patient and her husband intend to hold onto the uncashed check until a resolution is reached. Although the billing issue is still being investigated, many believe that the egregious charges are a case of professional malpractice and potential insurance fraud. At Jaroslawicz & Jaros, our legal team is passionate about protecting the rights and interests of our clients, as well as recovering their losses. You can read more about this case on this New York Post article.


She charged over 86,000 for a “facility” fee and did one toe and the other a week later. So she billed $86,000 twice and for some reason it was paid.

 

[wakaflocka88]

This is how you bill:

• Articles
• >
• Firm Expertise
• >
• Medical Malpractice

Park Avenue Podiatrist Under Investigation After Bill For Simple Foot Procedure Costs More Than Heart Surgery​

Written by
Abraham Jaros
|
Updated on Tuesday, Oct 24, 2023
A case involving a high-profile Park Avenue Podiatrist is garnering media attention and considerable local scrutiny for what many in the medical and legal communities believe are outrageous charges. The case - which is profiled in a recent New York Post article - involves a questionable bill for two simple foot procedures. Jaroslawicz & Jaros is representing the woman who underwent the procedure and her husband in this matter. A Questionable Bill The podiatrist - Suzanne Levine - is a well-known specialist who caters to celebrity patients and has been featured on a number of television shows, including Dr. Oz. She has gained notoriety for offering procedures such as foot facelifts, Botox injections to smooth out imperfections in the feet, and Juvéderm injections to cushion pads of the feet when wearing high heels. Although there are no laws regulating prices for podiatrist procedures in New York, the prices Levine’s office billed this particular patient were concerning. Levine performed two procedures to straighten two of the patient’s toes. Both procedures were performed in-office and took less than 30 minutes each. Other Podiatrists in the area, including the Upper East Side, charge less than $3,000 for such a procedure. Levine’s office, however, charged nearly $200,000. Although the patient was assured that the procedures would be covered by her insurance, Levine’s office billed the patient $6,000 and then attempted to recover more from her insurance provider, United Healthcare. The patient’ insurance company agreed to pay $170,940 and an additional $4,158 in interest - more than the cost for major heart surgery.Levine’s office attempted several times to recover the insurance check that was mailed to the patient and her husband for endorsement. Skeptical and concerned by the monstrous charge, the patient’s husband asked for a statement, which revealed two “surgical operating room charges" at $86,450 apiece. Protecting Clients’ Rights When contacted by the New York Post, Levine’s office claimed that the check had been issued in error, that a corrected claim had been submitted, and that Levine herself was not aware of the mistake or her office manager’s attempts to obtain the check. United Healthcare has launched an investigation into the questionable charges and has suspended payment while the investigation in pending. The patient and her husband intend to hold onto the uncashed check until a resolution is reached. Although the billing issue is still being investigated, many believe that the egregious charges are a case of professional malpractice and potential insurance fraud. At Jaroslawicz & Jaros, our legal team is passionate about protecting the rights and interests of our clients, as well as recovering their losses. You can read more about this case on this New York Post article.


She charged over 86,000 for a “facility” fee and did one toe and the other a week later. So she billed $86,000 twice and for some reason it was paid.

Pillows for your feet
The loub job
Fabulous foot facial
Toetox

 

[heybrother]

That story is from 2014 - what new information is there?

 

[ExperiencedDPM]

That story is from 2014 - what new information is there?

None

 

[Feli]

That story is from 2014 - what new information is there?

That she is still licensed and in practice 10 years later.

Shoot for the moon with your CPT selections, gentlemen.

 

[PODIATRYCRAZE]

Throwing in a little bit of an ethics for today's lesson. Remember there are no right or wrong answers, readers are here to learn valuable tips on how to value their time, patients time, and hospital resources.

Just as you finish your last office patient of the day the ED calls you for help

HPI: 61M homeless uninsured consult from ED PMH of Diabetes, Left AKA, Right foot severe clubfoot, he now has a wound to his lateral ankle which he uses to push himself on his wheelchair. The wound looks healthy, dirty but noninfected, granular, looks like if it were offloaded it would heal. No pain, he just came in to see how the wound was doing since he cannot bend over to see it for himself.

Treatment: Light cleaning of the wound, dressed it up. Instructed to stop putting pressure on ankle. Tell patient to find insurance and a wound care doctor. Give him handful of hospital supplies.

Follow up questions: For the hospital employed, they are essentially obligated to take care of this patient. A majority of private podiatrists who are taking call at hospitals do not get paid to take call. If you are one of the few who do get paid to take call, I would assume that you are also obligated to come in. But assuming you are an unpaid consulting doctor are you even coming in?

I personally do not look at the insurance status of the patient prior to treating them. Is this a mistake?

 

[PODIATRYCRAZE]

As mentioned before the patient has no insurance, or money to pay. So to save my time, and my office biller's time I would simply write a quick simple note to let the medical teams know my recommendations and not even mention that I did this. That way my time was wasted, but nobody elses was. In summary, no code would be used. But for the sake of practice here I have

ICD10: E11.42 Diabetes with neuropathy
L97.318 Right ankle wound

CPT: 99281 Emergency consult

Reimbursement: $0 but if there was insurance $50?

 

[Adam Smasher]

I would see him. As long as it doesn't become a recurring request on the part of the ED. But you have to be the change you want to see in the world, and you have to lead by example.

Question: given that he is homeless, can't the case managers enroll him in medicaid? Also if he is uninsured, how is he obtaining his insulin/diabetes medications?

 

[PODIATRYCRAZE]

I would see him. As long as it doesn't become a recurring request on the part of the ED. But you have to be the change you want to see in the world, and you have to lead by example.

Question: given that he is homeless, can't the case managers enroll him in medicaid? Also if he is uninsured, how is he obtaining his insulin/diabetes medications?

In this scenarios he is not taking any

 

[HardRoadPaved]

For the PP doc.... Honestly you had me at "without insurance." So I would say to hospital, pay me for call for this reason. Otherwise adios!

For the hospital employed.... if you're on call and this rolled in, I'd yell at ED attending and say "whats the emergency if its non infected? Give him the number to make appt at wound care center I'm working at." Not sure why this warrants a middle of the night call for us to look at a non-infected ulcer.

Treatment: Light cleaning of the wound, dressed it up. Instructed to stop putting pressure on ankle. Tell patient to find insurance and a wound care doctor.

Nurses do this..... not doctors

Give him handful of hospital supplies.

Dont get caught by a clipboard nurse....

 

[dtrack22]

But assuming you are an unpaid consulting doctor are you even coming in?

No

I personally do not look at the insurance status of the patient prior to treating them. Is this a mistake?

Yes

I’m employed so depending on what I was doing and who the ED doc was, I’d see it because I’m getting paid. But even the hospital employed doc should do what @HardRoadPaved suggested and ask why they need to see a chronic wound with no concern for infection/abscess.

 

[PODIATRYCRAZE]

HPI: 50M long time patient, loyal, had ankle surgery on you in the past and really trusts you. You know that he has a solid support system at home and will be compliant. He can only get this one chance off to address all of his foot problems. Bilateral hammertoes x8 and bunions x2

Treatment: Bilateral forefoot slam. Thankfully they can all be done quickly and minimally invasively. Each bunion was a distal head cut with 2 screws. Each hammertoe was an arthroplasty, no implants.

 

[PODIATRYCRAZE]

ICD: M20.12 Left hallux valgus
M20.11 Right hallux valgus
M20.40 Hammertoes


CPT: 28296 x2 Distal metatarsal head cut
28295 x8 Toe reconstruction

Reimbursement: $1210? 25 Modifier
$600 each foot

To my knowledge, the modifier will help with getting paid 1 foot separate from the other foot. $400 for each bunion, ~$100 for 1 toe, ~$50 for another toe, the remaining 2 toes are free. First surgery is full price, second is half price, third is quarter price, everything after is free. Modifier helps to reset prices for the second foot.

 

[heybrother]

ICD: M20.12 Left hallux valgus
M20.11 Right hallux valgus
M20.40 Hammertoes


CPT: 28296 x2 Distal metatarsal head cut
28295 x8 Toe reconstruction

Reimbursement: $1210? 25 Modifier
$600 each foot

To my knowledge, the modifier will help with getting paid 1 foot separate from the other foot. $400 for each bunion, ~$100 for 1 toe, ~$50 for another toe, the remaining 2 toes are free. First surgery is full price, second is half price, third is quarter price, everything after is free. Modifier helps to reset prices for the second foot.

For certain insurances - ie. Medicare - you have to be careful on a case like this.

-Medicare rigorously enforces a MUE of 1 for bunionectomies.
-They don't just block the 2nd bunion - they freeze the claim till its resolved.
-In general, commercial insurance will pay for 2 bunions (presumably they recognize the stupidity of paying twice).
-The MUE for hammertoes as you allude to above is not 8 - you will be doing some of these toes for free. If you submit over the MUE you are likely to not be paid until the claim is resolved.
-I've had an issue in the past with Medicare where I did bilateral 2/3 which is technically below the MUE and they still refused to pay the claim. It was weird.
-I'm not being reimbursed like you are on the reductions. For my cases I receive full for the first procedure and then half for every thing after. So the second bunion is half off - not full value.
-The exception to this rule is Aetna. Aetna reimburses full for first, half for second, and then like 1/4 for anything else.

That said - if this is what you are getting for a case like this - jokingly add a WHC or a nursing home or something because your reimbursement is bad. Medicare pays like $500 for 28296 where I am so $400 is 80% of Medicare. Had those stains at Tricare not cut my reimbursement I would have finally gotten everything to Medicare or above.

 

[Feli]

... Bilateral forefoot slam. ...

1984 is on line 1 for you.

Bilateral osseous elective foot surgery is basically malpractice present day, man... not to mention it won't be paid.

Have you ever done - and seen the office f/u for - bilateral bunion surgery? (serious question)

 

[HardRoadPaved]

Reimbursement: $1210? 25 Modifier

25 is affixed to e/m on the same day as a minor procedure for unrelated item to the procedure.

Based off this scenario you'd be an idiot on so many fronts to do a bilateral slam.... which most of which is unpaid an exposes you to significant liability. And what's with these scenarios insinuating we should do or give anything away for "free?"

 

[PODIATRYCRAZE]

1984 is on line 1 for you.

Bilateral osseous elective foot surgery is basically malpractice present day, man... not to mention it won't be paid.

Have you ever done - and seen the office f/u for - bilateral bunion surgery? (serious question)

Assisted in bilateral lapidus, similar story to the case I presented. Unfortunately never saw the follow up since I am a resident and this was at an outside surgery center. Attending said he healed fine. Long time patient friendly, healthy guy, not the type to sue, could only get this one block of time off for work.

Yes these stories are outrageous. The way I am outlining these posts is more for diversity of scenarios, not so much medical knowledge. In this case, how to bill for and get reimbursed for bilateral procedures and multiple procedures.

 

[HardRoadPaved]

In this case, how to bill for and get reimbursed for bilateral procedures and multiple procedures.

Honestly your time is worth money. You have me completely lost in any scenario that involves free work. There is no way to extract money from a patient where the insurance denies you from balance billing. To any bilateral eager patients, I tell them adios. The risk is just to great to pray and wait for the "type that wont sue."

 

[Adam Smasher]

If you use the 50 modifier for the 28296, it works around the MUE of 1, I believe.

8 hammertoes in a row seems like a lot of work. Even if there's a MUE workaround, it's still at 25%. Maybe you get in your groove and do them 4x faster?

Of course, consider what hardroad and feli are also saying. If you want to do charity care, matrixectomies for the uninsured are not demanding of your time with negligible liability.

 

[PODIATRYCRAZE]

HPI: 35M athletic male who you previously saw for plantar fasciitis and arch pains returns for follow up. He attempted the stretches but was too painful to continue on a routinely basis.

Treatment: Arch pain fully resolved from the supports you gave him. Injection given to patient's heel at plantar fascia insertion, but instructed that this will help him get through the stretches and he needs to continue. If he still struggles with stretches, you also gave him a physical therapy script.

 

[PODIATRYCRAZE]

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

CPT: 99213 Office visit
20551 Ligament insertion injection

Reimbursement: $200? ~$100 for visit, ~100 for injection 25 modifier

Couple things to note for the students who made it this far. Even though the pes planus was resolved from last visit, I kept it on the list to keep it attached to the office visit. That way I can also get fully reimbursed for the injection using a 25 modifier and attaching the plantar fasciitis to the injection. Without the modifier, and without the second diagnosis, insurances would think you used 2 codes (the office visit and the injection) to solve 1 problem, and probably toss 1 of them out. Once again, this is my understanding and interpretation

Physical therapy script and any other scripts you write do not get any reimbursement. Some offices charge a fee to fill out disability paperwork. The thinking behind this is that (of course it is a lot of writing and work) they need you to write this paper so that they can get their disability pay, so they will do anything for this

 

[Adam Smasher]

This is straightforward and I largely agree with what you're going for. Some notes:

1. Q66.51 is congenital pes planus as opposed to acquired pes planus M21.41 so choose whichever is most apt.
2. I use 20550 for my heel pain injections which reimburses practically the same, lots of articles discussing which is most appropriate
3. 25 mod goes on the 99213
4. Yes I charge a fee for disability forms, but I refuse to put anyone on disability for heel pain, because who knows when they'll get better or how much time off they'll need.

 

[Feli]

Pes planus is a really weak code... avoid it. A lot of payers reject it.
Use PT tendonitis instead... M76.82x

99213-25 is fine
20550 in my hands (needs RT or LT)
use appropriate Jxxxx code for steroid you use (those don't need any mods).
...the J codes don't pay much, but the vials are costly, you should at least get your money back (usually roughly double, payer dependent).

Why is any podiatrist doing disability? Work note, sure. Temp disability for procedure/surgery, sure. Temp handicap parking? Sure.
Permanent disability? No way. Send them to PCP, PM&R, neuro, etc... just let them take their note to support.

 

[HardRoadPaved]

20551 Ligament insertion injection

Injections for plantar fasciitis are addressed by 20550 and ICD-10-CM M72.2. Injections for other tendon origin/insertions by 20551. Injections to include both the plantar fascia and the area around a calcaneal spur are to be reported using a single 20551.

Article - Billing and Coding: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma (A57079)

Use this page to view details for the Local Coverage Article for Billing and Coding: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma.

www.cms.gov

 

[heybrother]

January 2024 J code values

Steroid is a straight money loser.

 

[air bud]

I don't understand what's going on here. What is arch pain? PT tendonitis? You injected the plantar fascia again? Is this all related to plantar fascitis? If so then you injected and it's a normal PF injection again. But then again it's fully resolved he has no pain so why an injection? Or the more distal pain resolved and now just insertional? Regardless I don't see how you are billing an office visit with this. They are related and nothing new performed other than an injection. Bfd about the PT referral still not an office visit.

 

[Feli]

January 2024 J code values
View attachment 379912
Steroid is a straight money loser.

Yeah, J codes are no big winner, but would we rather get $7 beta or $4 triam... or $0 from not knowing or not submitting the J code?

Also, the table above is govt plan values (majority of most pod office pts)... but private plans will vary for whatever is contracted.

Beta and kena (40mg/ml... aka 4 units per inj) should absolutely be break-even or slight gains, depending where one buys their vials. I would have to look, but I think my vials are around $40 for 5ml beta or 10ml kena... so $8 per inj beta and $4 kena. Methylprednisone is also good (effect and J code), but I don't know very many DPMs who use that.

Dexameth is nothing... I agree, not worth billing (but also costs almost nothing... under a dollar per inj unit). I have it for nerve injects, but I use it so little that it often expires and gets thrown out.

It's very easy to just have MAs photo the vials when they draw them up and send to biller. I wouldn't skip it. It's quite significant over months and years.

PF inject = 992xx-25, 20550-RT and/or 20550-LT and J0702 or J3301 x4 or J1040 or whatever

Personally, I want a codes for lidocaine and for syringe and for needle, and I phoned APMA. They were unavailable... probably working on new podiatry schools in Seattle and Boston?

 

[PODIATRYCRAZE]

HPI: New consult pops up on your list, 82F from the psychiatry ward, unkempt, toenails are thick, mycotic, and 5+ cm long. No open wound caused from it yet, but there is a sore of raw skin rubbing from the 5th to the 4th toes, and 2nd to the hallux. Complete sensation, good pulses, otherwise healthy feet. It is well known across the hospital that inpatient is not the setting for toenails, but in certain dangerous scenarios like this, you are the only one who can handle this problem.

Treatment: Debridement with nail nippers, outpatient follow up with whoever her most convenient podiatrist is.

 

[air bud]

HPI: New consult pops up on your list, 82F from the psychiatry ward, unkempt, toenails are thick, mycotic, and 5+ cm long. No open wound caused from it yet, but there is a sore of raw skin rubbing from the 5th to the 4th toes, and 2nd to the hallux. Complete sensation, good pulses, otherwise healthy feet. It is well known across the hospital that inpatient is not the setting for toenails, but in certain dangerous scenarios like this, you are the only one who can handle this problem.

Treatment: Debridement with nail nippers, outpatient follow up with whoever her most convenient podiatrist is.

Wrong answer. You tell them this is not something to consult you for. No exceptions. If you want you can drop off some nail nippers for them to do it.

If for some reason you are dumb enough to do this, I probably don't even document or bill for it because I have already wasted enough of precious time on this.

 

[PODIATRYCRAZE]

ICD10: B35.1 Onychomycosis

CPT: 99242 Inpatient consult

Reimbursement: $50?

I skipped billing for the debridement (11721) for basically no reason. Just a hunch from other podiatrists saying that it would be rejected. But if I was actually in practice I would see no harm in trying. Despite the lack of class findings, I am sure it could be argued that it was a necessary service.

 

[Feli]

Wrong answer. You tell them this is not something to consult you for. No exceptions. If you want you can drop off some nail nippers for them to do it.

If for some reason you are dumb enough to do this, I probably don't even document or bill for it because I have already wasted enough of precious time on this.

Ahoy.... cases like these clearly need the expertise of the nearby associate mill's newly hired fellowship trained foot and ankle sturgeon.

 

[PODIATRYCRAZE]

Very understandable viewpoints on nails. However as a self proclaimed expert of the foot I would say why not do the nails if it is part of the foot. To my knowledge the average person is definitely not capable of taking nails that are the size of chicken nuggets down to normal length. On top of that, many health professionals also do not know the best, least painful, quickest approach. What takes me 5 minutes could take them an hour. Not that I love nail work, but in other medical circumstances I encountered while rotating through other specialties:

Cannot get the IV, call the doctor
Nasogastric tube not sliding in easy, call general surgery
Easy ear foreign body not coming out in ED, call otolaryngology
Baker’s cyst on the floor, call orthopedics
Don’t most specialties have a mycotic toenail equivalent?

Legitimately speaking these toenails are significantly more difficult than a typical cellulitis or chronic osteomyelitis consult.

 

[Sweatshirt]

Legitimately speaking these toenails are significantly more difficult than a typical cellulitis or chronic osteomyelitis consult.

HAHAHAHA

This is a late 2023 submission for meme of the year!!!

 

[air bud]

Very understandable viewpoints on nails. However as a self proclaimed expert of the foot I would say why not do the nails if it is part of the foot. To my knowledge the average person is definitely not capable of taking nails that are the size of chicken nuggets down to normal length. On top of that, many health professionals also do not know the best, least painful, quickest approach. What takes me 5 minutes could take them an hour. Not that I love nail work, but in other medical circumstances I encountered while rotating through other specialties:

Cannot get the IV, call the doctor
Nasogastric tube not sliding in easy, call general surgery
Easy ear foreign body not coming out in ED, call otolaryngology
Baker’s cyst on the floor, call orthopedics
Don’t most specialties have a mycotic toenail equivalent?

Legitimately speaking these toenails are significantly more difficult than a typical cellulitis or chronic osteomyelitis consult.

The first paragraph is ART. Thank you.

 

[HardRoadPaved]

I skipped billing for the debridement (11721) for basically no reason. Just a hunch from other podiatrists saying that it would be rejected. But if I was actually in practice I would see no harm in trying. Despite the lack of class findings, I am sure it could be argued that it was a necessary service.

Undercoding is also fraud. Get paid for your work... end of story. Too many scenarios of this free/undercoding BS

11721 does not need class findings nor systemic qualifying disease (calluses always do). You can affix the pain in toe code to this CPT. Read your Medicare LCD.

 

[air bud]

Undercoding is also fraud. Get paid for your work... end of story. Too many scenarios of this free/undercoding BS

11721 does not need class findings nor systemic qualifying disease (calluses always do). You can affix the pain in toe code to this CPT. Read your Medicare LCD.

I am just trying to give credence to the idea of hw this is beneath you and all this was a waste of my time. I feel like I am taking crazy pills.

 

[dtrack22]

On top of that, many health professionals also do not know the best, least painful, quickest approach.

But there are a lot of ladies who speak Vietnamese or Mandarin at various strip malls all across the country who do. Of course they won’t do it for free, only a podiatrist will.

I think it’s hilarious to think that somehow I can trim toenails better than literally any other able bodied adult. Did some of you guys and gals actually receive some sort of special training or instruction on how to cut toenails? I never had any class, course, professor or attending who “taught” me how to cut toenails. I think it’s insane for me to claim that somehow I am more qualified to do it for patients than even folks who work in the hospital cafeteria. Drop a pair of nail nippers off for the floor nurse and tell him/her to have fun.

 

[PODIATRYCRAZE]

I have family in the nail salon business. They are great for slantbacks, nail trims, making nails looks good, probably better than us at foot skin care. But I promise you that they do not and probably cannot handle these chicken nugget/goat horn toenails that I am describing. Their tools are much smaller than ours.

 

[HardRoadPaved]

probably better than us at foot skin care.

 

[Shiyuan]

chicken nugget toenails

LOL Never heard them called this. I’m gonna reuse…. 👊🏻

Thank you.

 

[air bud]

Very understandable viewpoints on nails. However as a self proclaimed expert of the foot I would say why not do the nails if it is part of the foot. To my knowledge the average person is definitely not capable of taking nails that are the size of chicken nuggets down to normal length. On top of that, many health professionals also do not know the best, least painful, quickest approach. What takes me 5 minutes could take them an hour. Not that I love nail work, but in other medical circumstances I encountered while rotating through other specialties:

Cannot get the IV, call the doctor
Nasogastric tube not sliding in easy, call general surgery
Easy ear foreign body not coming out in ED, call otolaryngology
Baker’s cyst on the floor, call orthopedics
Don’t most specialties have a mycotic toenail equivalent?

Legitimately speaking these toenails are significantly more difficult than a typical cellulitis or chronic osteomyelitis consult.

HAHAHAHA

This is a late 2023 submission for meme of the year!!!

 

[Adam Smasher]

Let's be a little nice, this doctor finds meaning in attending to the overgrown toenails of our unfortunate mentally infirm hypothetical patient.

Airbud presents a good alternative: why can't the doctors/nurses on the wards do it themselves?

These are both reasonable views and I don't think either are wrong. Some people like their fries with ketchup, some with mayonaise.

Is no one going to comment on the coding aspect of this? The inpatient consult is 99222, or more likely a 99221. You don't get to bill the nail debridement at the same DOS as the consult, most insurances won't pay both at the same time. In fact, Jeffrey Lehrman has done webinars on this, that it's not an e/m at all, you only bill the 11721 unless you did some actual medical decision-making ("poor pedal pulses, consider vascular consult"). Which is why I fall in the airbud camp, just say no.

 

[PODIATRYCRAZE]

Alright you guys got me. I will refuse nails in the hospital, probably more time effective to do in office with the dremel anyways. But for real, the nails were so long they were starting to cause wounds. Maybe this residency mindset has me doing too much charity work.

HPI: 48M large painful tailor's bunion on the left foot, more from a bump not so much angle deformity, and also has a painful dorsal soft tissue mass between midshaft metatarsal 2 + 3. Today is surgery day.

Treatment: Reverse silver for the bunionette. Soft tissue mass excision for the dorsal mass through a second S-shaped incision.

Last scenario of the week, then we will take a 2 week break to enjoy the holidays, but during this break let's open up a Q&A or post about quick and easy coding tips.

My Q is What manual do you all use to learn your coding? So far from what I gather, Optum podiatry coding book is best, as well as the online Medicare Local Coverage Determinations.

My tip is for ICD10 codes, laterality is as simples as a number to differentiate left (2) and right (1). Hallux valgus right M20.11 and hallux valgus left M20.12.

 

[PODIATRYCRAZE]

ICD10: M21.622 Left bunionette
M79.9 Soft tissue mass


CPT: 28292 Left reverse silver
28039 Soft tissue mass excision foot
64702 Nerve decompression foot
14040 Skin plasty

Reimbursement: $500? 79 modifier for the silver, hopefully that lets you get paid for doing a 4th procedure