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I would even wager to say level 4 to be honest. I would bill a level 4 for emergent major surgery and let the chips fall where they may
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Tell me you don't do inpatient work without telling you dont do inpatient work ....
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Hardware rep taking you out for that steak dinner!
HPI: Same case as yesterday but fast forwarded a little bit to 2 days later. The 61M had his surgery yesterday. You submitted for a foot debridement through muscle layer 11046.
Treatment: Simple check on surgical site to make sure there are no infections. It looked fine, rewrap the foot.
Treatment: Simple check on surgical site to make sure there are no infections. It looked fine, rewrap the foot.
ICD: L03.119 Foot cellulitis
L02.61 Foot Abscess
CPT: 99232 Inpatient rounding again
Reimbursement: $50? $100 for the surgery. Some of you might wonder "What about the global period?" Good question. 11046 has a 0 day global period. Some surgeries are 10 days, some are 90 days, some are random days, luckily for us some are 0. We will get more practice on bigger surgeries later.
L02.61 Foot Abscess
CPT: 99232 Inpatient rounding again
Reimbursement: $50? $100 for the surgery. Some of you might wonder "What about the global period?" Good question. 11046 has a 0 day global period. Some surgeries are 10 days, some are 90 days, some are random days, luckily for us some are 0. We will get more practice on bigger surgeries later.
I am starting to feel like this is a very meticulous, hilarious troll putting a masterful mockery on the billing process.
For example - 11046 is the add on code, not the primary code. I am skeptical I would have used 11043 to begin with but whatever.
Meanwhile, over on IPED people are desperately trying to come up with ways to use biopsy codes to shave calluses instead of just charging the patient cash.
For example - 11046 is the add on code, not the primary code. I am skeptical I would have used 11043 to begin with but whatever.
Meanwhile, over on IPED people are desperately trying to come up with ways to use biopsy codes to shave calluses instead of just charging the patient cash.
I was just coming here for that. Also 28003 is the correct code with no global.
Let's just ignore this going forward please.
43M complaining of a painful soft tissue mass. However, during surgery you find it to be hard and calcified. Due to the hardness, you bill it as removal of hardware 20680
60M with thickened toenails presents for debridement. He has no hx of diabetes or PAD. However, on exam, you notice faint scarring along the lateral aspect of both 5th met heads. It turns out in childhood, he was born with polydactyly. The supernumerary toes were surgically removed when he was age 6.
You bill the 11721 with a Q7 modifier.
You bill the 11721 with a Q7 modifier.
85M with DM sitting on his stoop wants a light a light for a cigarette as you're walking by his home. You counsel him on smoking cessation but bc you feel bad and because he asked nicely you fetch him a light.
As a courtesy you trim his toenails for him because he didnt see his pcp within 6 months.
As a courtesy you trim his toenails for him because he didnt see his pcp within 6 months.
This is exactly what we needed to know. I did not realize that 11046 was the add on code. Had a different lesson planned about similar ones for another day.
For the readers, add on codes operate like this, wound care is a great example. There are multiple debridement codes based on area in square centimeters of the wound. One code is for small wounds, another code is for big wounds. If you debride a large wound, it makes logical sense to just write down the large code. This is incorrect and you will notice the significantly smaller payment once they reimburse you. To bill properly you put down the small wound code AND the large wound code. It is essentially saying you performed the small debridement in addition to a larger amount. That will yield the full reimbursement you deserve.
Yes add on code. You add it on to the base code. To be fair, wound care coding is very complicated. You can be billing debridements and stuff like that for an open ulcer while having other procedures in a global performed at the same time. You can't bill debridement and skin sub application or debridement TCC same time...lots of stuff like that. Do the toe amp no global leave open (bad hospital infections always 2 surgery even if DPC didn't pay well) then resect bone from 1st met to close and DPC....lots to learn.
There are some very good webinars out there for wound care coding by Lerhman.
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For real. I’m just an associate but I cannot for the life of me imagine spending that level of effort and typing just to try and cheese something that’s going to pay me $100 and could possibly land me in jail.
On a side note, I like how “itchy” is a justification for a procedure.
Can we add this “op” note to the SDN hall of fame?
This needs to be explained. Remember we are trying to teach young residents like me what to do and what not to do. The inexperienced, myself included, might not realize what this is.
For the reader’s who do not understand what is going on, let me explain.
From what I am understanding this is a 5th toe callus. Typically just needs to be shaved/debrided. This podiatrist calls it a cyst so he can get some extra money from insurance companies.
Now there is a possibility that this is a rare patient who does have a cyst on this location and he did everything right. But that happens once every 2-5 years at most.
I offer these patients without hesitation a 5th toe IPJ arthroplasty.
So does the person above almost assuredly to justify the 99203+ but they don't actually care whether it happens or if the patient follows through. In fact, they might prefer the patient never comes back or comes back in a year so they can feel justified in a new E&M. A Medicare 28285 is $370 and has free follow-up visits. A "callus biopsy" or a "callus wart removal" generates a quick, risk free $200-300 visit on something that didn't justify it and then the doctor just moves on to the next room. The patient is happy. They are none the wiser that in fact the service wasn't covered by insurance and was unnecessary and should have been self-pay. If the doctor generates a couple of $200+ encounters an hour using aggressive billing of nails and calluses their clinic looks pretty good and they tell their friends they have a dermatology focus. There are no unpleasant encounters where the doctor has to say "no, I'm sorry, that's not covered by your insurance" and the amount the insurance pays if often higher than what the doctor could have charged the patient in cash. Everyone wins. Except its fraud.
HPI: It is 4pm today, your 46M has purulence from his right foot wound. At the end of your visit you tell him to go to the emergency department. You called the ED and told them the plan. Planning for surgery the next day.
Treatment: After talking to the patient, he guaranteed you that he will go to the ED. Because of this you hold off getting cultures in the office, and wait so the hospital can take care of that. 6pm you are now home. and the hospital puts in the consult and calls you.
Treatment: After talking to the patient, he guaranteed you that he will go to the ED. Because of this you hold off getting cultures in the office, and wait so the hospital can take care of that. 6pm you are now home. and the hospital puts in the consult and calls you.
ICD: L02.61 Foot Abscess
CPT: 99213 Office visit
Reimbursement: $100? If you have not noticed, we only billed for the office visit. After the consult was put in, we do not go in to see the patient. IT can wait for the morning. You already gave instructions and they should be able to handle it. Trust your colleagues, and let yourself relax to prepare for surgery tomorrow. If you do decide to go see the patient in the hospital, the encounter will not be billable anyways because they were already seen by you in the office on the same day. So you would have wasted time, and probably provided no real extra value to the patient's care.
CPT: 99213 Office visit
Reimbursement: $100? If you have not noticed, we only billed for the office visit. After the consult was put in, we do not go in to see the patient. IT can wait for the morning. You already gave instructions and they should be able to handle it. Trust your colleagues, and let yourself relax to prepare for surgery tomorrow. If you do decide to go see the patient in the hospital, the encounter will not be billable anyways because they were already seen by you in the office on the same day. So you would have wasted time, and probably provided no real extra value to the patient's care.
How do you hide a $100 bill from a hospitalist?
Place it under a dressing.
Place it under a dressing.
That’s a level 4 office visit easily, not only for severity but likely time spent also. Especially if you think it warrants a trip to the ED. Plus debridement code if this is a new wound. If it’s an old wound, forego the E/M and just bill a debridement code. Or you can bill the E/M as cellulitis etc and do a debridement code on top of that for the ulcer itself.
You then have an X-ray code to add, and did you dispense anything to offload? CAM, etc.
This can be a very high pay visit.
For me personally, pus doesn’t automatically mean admission/surgery. I’ve had patients do well with in office debridements with washouts and oral abx. Assuming no osteo or gas. Even then I rarely admit osteo. I do those amps outpatient. All of this assuming the patient isn’t septic. I draw labs, take cultures in office. Gas is always debride what I can in office and admit.
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The real answer is to bill the office work to the max and then send them to "that amazing hospital" you dont have privileges at
HPI: Same patient from before. Remember you saw him in the clinic yesterday, sent him to the hospital that night. Now it is the morning of the next day. During his admission, he received an MRI in the morning showing a tract that extended all the way to his third toe showing complete osteomyelitis. On this same first day you round on him early in the morning before breakfast. Clinically the toe is rapidly deteriorating, potential necrotizing fasciitis. You caught it just in time.
Treatment: Straight to the operating room and perform a right third toe amputation.
Treatment: Straight to the operating room and perform a right third toe amputation.
ICD: M72.6 Necrotizing Fasciitis
CPT: 28825 Toe amputation
RT Modifier
T7 Modifier
Reimbursement: $200? A couple lessons for today. If you round on a patient on the same day as a surgery, you cannot bill for rounding and the surgery. Choose 1, obviously the surgery will pay more. Second lesson which we have not been diligent with during the class is siding and toe modifiers. Whether or not you put them in, you might think you get paid for them, but the truth is your biller is probably putting them in for you behind the scenes. It is still better to try and do it yourself to prevent any confusion. In the event that you forgot and yout biller forgot, you will probably not get paid.
RT Right lower extremity
LT Left lower extremity
TA-Left hallux
T1- Left 2
T2- Left 3
T3- Left 4
T4- Left 5
T5- Right hallux
T6- Right 2
T7- Right 3
T8- Right 4
T9- Right 5
CPT: 28825 Toe amputation
RT Modifier
T7 Modifier
Reimbursement: $200? A couple lessons for today. If you round on a patient on the same day as a surgery, you cannot bill for rounding and the surgery. Choose 1, obviously the surgery will pay more. Second lesson which we have not been diligent with during the class is siding and toe modifiers. Whether or not you put them in, you might think you get paid for them, but the truth is your biller is probably putting them in for you behind the scenes. It is still better to try and do it yourself to prevent any confusion. In the event that you forgot and yout biller forgot, you will probably not get paid.
RT Right lower extremity
LT Left lower extremity
TA-Left hallux
T1- Left 2
T2- Left 3
T3- Left 4
T4- Left 5
T5- Right hallux
T6- Right 2
T7- Right 3
T8- Right 4
T9- Right 5
Isn’t putting both the laterality and the specific toe modifier redundant? I thought just the toe modifier works
Just the toe modifier matters, in this case T7 is sufficient
Specificity matters in other ways. 28825 is amp through the IPJ, 28820 is amp through MTPJ. Both are 0-day globals. If you amp a toe and resect the met head, it's a 28810, 90 day global, no matter how little of the met head you take. I've tried unsuccessfully to unbundle it as a toe amp + met head resection, just because that seems more accurate than calling a ray resection, but alas.
Ditto with I&Ds, did you incise below the fascia or into bursa or into cutaneous? How many compartments did you I&D? 28002 is one compartment and 10 day global, 28003 is multiple compartments and 90 day global. 28001 is I&D bursa (I've never done this). Cutaneous I&D (e.g. popping a zit) is 10060 or 10061, and no I don't know the difference between the two.
Specificity matters in other ways. 28825 is amp through the IPJ, 28820 is amp through MTPJ. Both are 0-day globals. If you amp a toe and resect the met head, it's a 28810, 90 day global, no matter how little of the met head you take. I've tried unsuccessfully to unbundle it as a toe amp + met head resection, just because that seems more accurate than calling a ray resection, but alas.
Ditto with I&Ds, did you incise below the fascia or into bursa or into cutaneous? How many compartments did you I&D? 28002 is one compartment and 10 day global, 28003 is multiple compartments and 90 day global. 28001 is I&D bursa (I've never done this). Cutaneous I&D (e.g. popping a zit) is 10060 or 10061, and no I don't know the difference between the two.
28002 and 28003 are zero day globals.
The difference between 10060 and 10061 is that you have to write a longer note to justify billing the complicated code. It appears 10061 is also used as the code for multiple. Global is 10 days.
The difference between 10060 and 10061 is that you have to write a longer note to justify billing the complicated code. It appears 10061 is also used as the code for multiple. Global is 10 days.
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my coding book says otherwise but it's not up to date, I just checked CMS and this is truth 👍
This is why you open amp the toe 28820, round the next day bill for that, wait for further soft tissue demarcation then come back a day or 2 later, resect met head and further debridement and then bill partial excision of met 28122 and DPC 13160 and then enter the global.
They way this is described and almost all toe amps that are going to have a CRP of 10 plus, sed rate over 100 etc these never do well with primary closure one surgery. Stage it. Again and advantage for hospital docs doing this, i walk 100 feet down the hallway to do the rounding st lunch the next day takes 5 mins. Whereas PP doc may need to drive 30 mins to do this which sucks. And they probably don't do this, instead just doing 1 surgery.
This is why hospitals should not rely on PP docs for infection, they should have their own dedicated pods. Continuity of care, better management.
Correct. 28003 changed a few years ago and long with toe amp codes to zero day global. This is why you pay attention to coding changes and get new books etc instead of listening to older docs. Interestingly, similar procedures in the hand still have 90 day global.
Anyways again lesson is I&D, wait 48-72 hours let stuff settle down, gave definitive cultures, come back irrigate with vanc/saline ,throw some vanc powder on the incision and close. Can also consider KCI veraflow after index procedure. Veraflow can be great, but it is picky often times clogs up pretty fast with blood. Does better going on incision 8 hours after in the floor.
An instillation vac like that is a recipe for being called 100x at 2am by the overnight nurse. Then if you get through that the macerated tissue margins awaits
Agree. Only use these if have trained nurses. And don't call me....these sound better in theory but yeah tons of problems.
If residency taught me one thing it’s that instill vacs will ruin your ****ing life if you’re the podiatrist in charge of it.
I’d wager 80% of my night calls were from nurses about clogged instill vacs.
And heavens help you if you have an attending that wants you to fix it at midnight. My attendings were great and never had me do this. But I wouldn’t put it past some places.
It’s almost always just a toy used at places where the doctor has residents to manage the headache.
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HPI: Day after the toe amputation. You round on him to check for any continued infection.
Treatment: Looks good and you are prepping him for a delayed closure tomorrow.
Treatment: Looks good and you are prepping him for a delayed closure tomorrow.
ICD: M72.6 Necrotizing Fasciitis
CPT: 99232 Inpatient rounding
For the next day 13160 Delayed skin closure
Reimbursement: $50? then $100 for the next day surgery? The crowd beat me to it already. This lesson was planned to teach you about the existence of 0 day globals for certain procedures, toe amputations being one of them. About 1 more month until we finish the class and I will post an editable master list of podiatry ICD10s, CPTs, globals, maximum reimbursements.
CPT: 99232 Inpatient rounding
For the next day 13160 Delayed skin closure
Reimbursement: $50? then $100 for the next day surgery? The crowd beat me to it already. This lesson was planned to teach you about the existence of 0 day globals for certain procedures, toe amputations being one of them. About 1 more month until we finish the class and I will post an editable master list of podiatry ICD10s, CPTs, globals, maximum reimbursements.
Can you please answer how you come up with these reimbursement numbers? I think they are absurd. I appreciate what you are doing, but they detract from what is going on.
Also you should be able to bill for further debridement (there was further tissue necrosis ....) as well as DPC
There's a ton of wound closure codes. Can we please discuss why closing a toe amputation site (5 nylon stitches for me, max) rises to the complexity of 13160? I get that you're debriding necrotic tissue and it's a contaminated wound. But you're (probably) not closing in layers. I understand this is commonly done and tennis club membeships don't pay for themselves, but it strikes me as abusive nonetheless.
Valid point. In this instance I am guessing this was further debridement, and you took what you had to work with. As opposed to some minimal osteo of a distal toe and and you did a nice clean amp at the MPJ with healthy tissue. In that case you would have done a closure at the time of surgery. If this was a terrible infection with proximal spread and multiple spaces...13160 is totally legit closure.
All of my reimbursement numbers are left with a question mark. Being honest, as a resident I do not have easy access to these numbers. Those numbers come from me getting rough numbers, not exact, from asking my biller. Sometimes I also lookup the maximum fee schedule and slash it by a margin.
Was hoping to get more accurate numbers from the crowd. Do you think my estimates are too high or too low?
I am also in the middle of a side project where I am gathering averages reimbursements for different CPTs. The office I work at takes a very wide variety of medicaid and some values are incredibly low, others more reasonable. Once this project is complete I will post it. Probably 2 more months down the road though.
I think your numbers are way too low and if this is what you're getting paid for the work you're doing you should not do it and tell them to have somebody else do it.
you realize medicare/medicaid rates are fixed and looked up online
Physician Fee Schedule Look-Up Tool | CMS
To start your search, go to the Medicare Physician Fee Schedule Look-up Tool .To read more about the MPFS search tool, go to the MLN® booklet, How to Use The Searchable Medicare Physician Fee Schedule Booklet (PDF) .
you realize medicare/medicaid rates are fixed and looked up online
Physician Fee Schedule Look-Up Tool | CMS
To start your search, go to the Medicare Physician Fee Schedule Look-up Tool .To read more about the MPFS search tool, go to the MLN® booklet, How to Use The Searchable Medicare Physician Fee Schedule Booklet (PDF) .www.cms.gov
Yes, that is the main tool I use. But for example 99213 the estimated range is between $90-$100. I guarantee the office I work at does not make that on every 99213. As I said before we take medicaid.
I bring that logic to lowball my estimates on other codes. However that fact that you say I will be making higher than my expectations is very exciting to me.
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Don’t forget that these patients are often Medicaid. In many areas surgical shoes, boots, ect will not be covered by Medicaid if dispensed by a podiatrist. Must be through orthotist in my neck of the woods.
Medicaid fee schedules are available online. Here's an example from the Texas Medicaid fee schedule.
I actually spoke to a friend in another state awhile back who wondered if Medicaid volume was negatively impacting their revenue. Strangely enough their Medicaid rates were comparable to my Medicare rates.
Interestingly I was just checking out some other codes. Medicaid actually pays higher than United Commercial for my practice for a 28750.
I actually spoke to a friend in another state awhile back who wondered if Medicaid volume was negatively impacting their revenue. Strangely enough their Medicaid rates were comparable to my Medicare rates.
Interestingly I was just checking out some other codes. Medicaid actually pays higher than United Commercial for my practice for a 28750.
I agree with above that it's very easy to see what reimburse is.
For govt plans - and some privates - they publish fee schedule.
For any plan you see with regularity, your biller can just run a report by code+payer.
...I didn't know this "teaching" thread was run by a resident who has never actually coded or been paid.
Three main tips:
...as for MedicAid, it's a minor problem that the reimburse rates are avg/low typically. The HUGE problem is getting paid at all or having to re-submit or appeal many MCA claims... you will typically get many zeroes back from straight MCA and even more from the carrier plans, particularly the MCA carriers. The amount of PAs and refers needed are absurd. MedicAid is worse than most HMOs and work comp in that regard. The only saving grace, for podiatry, is that you can usually do some high ticket custom DME for MCA if you are willing to do the PAs and overall MCA headaches.
I am very fortunate MCA is under 5% of my pt mix. There is a reason most ortho and nearly any specialist MD refuses to deal with MCA and makes the hospital pay them well for call and/or pay BCBS rates for all cases on-call.
For govt plans - and some privates - they publish fee schedule.
For any plan you see with regularity, your biller can just run a report by code+payer.
...I didn't know this "teaching" thread was run by a resident who has never actually coded or been paid.
Three main tips:
- Definitely put 2-4 dx codes for each CPT (more than 4 is pointless due to the way claims are submitted) and try not to use unspecified codes and don't use same code(s) for E&M and associated procedure codes.
- Learn your modifiers very well.
- Look up reimbursements and subscribe to a website that shows RVU values, global periods, CPT > ICD-10 links (APMA CodingRC or similar).
...as for MedicAid, it's a minor problem that the reimburse rates are avg/low typically. The HUGE problem is getting paid at all or having to re-submit or appeal many MCA claims... you will typically get many zeroes back from straight MCA and even more from the carrier plans, particularly the MCA carriers. The amount of PAs and refers needed are absurd. MedicAid is worse than most HMOs and work comp in that regard. The only saving grace, for podiatry, is that you can usually do some high ticket custom DME for MCA if you are willing to do the PAs and overall MCA headaches.
I am very fortunate MCA is under 5% of my pt mix. There is a reason most ortho and nearly any specialist MD refuses to deal with MCA and makes the hospital pay them well for call and/or pay BCBS rates for all cases on-call.
D
deleted285117
EDIT: Just gonna keep doing things the way i’ve been doing them. Ethically.
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It doesn't matter where you work.
You should put this stuff in op report and superbill to help billers get it paid.
From other thread:
"No, the amp doesn't need any mod (except descriptive -LT/RT or -Tx).
The DPC (usually 13160) gets a -58 to break the global (or just show it's related if there is no global... and DPC gets LT/RT).
But we don't do DPCs on toe amp IPJ or MPJ codes... because we're not missing a chromosome. We just lavage and close those primary, as an ethical doc would. That is why that thread and the memes are funny.
DPC might be appropriate on TMA, first or 5th or 4/5 ray amps, gas, and certain abscess I&Ds or open fx.
We also don't do Chopart amps.... or 1/2 ray amps... or 3/4/5 amps... or various FrankenFoot amps... because they are for imbeciles.
And last, we also don't discuss things in the aptly named meme thread 🙂 😈 🙂 "
