The Free Online Podiatry Coding Class - Student Doctor Network

[PODIATRYCRAZE]

HPI: You operated on this 40F 2 months ago and performed an Austin. Prior to the surgery she had right foot medial eminence pain and right foot 5th toe callus pain. She was afraid to get surgery on both in case it went wrong and did not want 2 botched toes. The bunion hurt more so she decided to go ahead with treating that first. She called to make an appointment today about her 5th hammertoe.

Treatment: Removed callus and are now preparing for surgery

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[PODIATRYCRAZE]

ICD: M20.41 Hammertoe
L85.1 Callus

CPT: 99213 Office visit 79 modifier
11055 Callus debridement

Reimbursement: $100. Important thing to note for this situation is that it is an appointment in the postoperative global period of 90 days, but it is not a postoperative appointment. The 79 modifier tells the insurance company that today's visit is not related to the original bunion surgery (which they already paid you for and they expect that larger payment to cover the postoperative visits). Without the modifier the software they use will automatically flag your visit and assume it is postoperative and deny payment. So in this case you would not use the 99024 postoperative visit code.

 

[heybrother]

ICD: M20.41 Hammertoe
L85.1 Callus

CPT: 99213 Office visit 79 modifier
11055 Callus debridement

Reimbursement: $100. Important thing to note for this situation is that it is an appointment in the postoperative global period of 90 days, but it is not a postoperative appointment. The 79 modifier tells the insurance company that today's visit is not related to the original bunion surgery (which they already paid you for and they expect that larger payment to cover the postoperative visits). Without the modifier the software they use will automatically flag your visit and assume it is postoperative and deny payment. So in this case you would not use the 99024 postoperative visit code.

You are going to continue to get all of these wrong until you figure out that certain modifiers go on CPT codes and certain modifiers go on E&M codes. Happy to share more, but you should literally make a column for each and write them down.

 

[PMG03470]

ICD: M20.41 Hammertoe
L85.1 Callus

CPT: 99213 Office visit 79 modifier
11055 Callus debridement

Reimbursement: $100. Important thing to note for this situation is that it is an appointment in the postoperative global period of 90 days, but it is not a postoperative appointment. The 79 modifier tells the insurance company that today's visit is not related to the original bunion surgery (which they already paid you for and they expect that larger payment to cover the postoperative visits). Without the modifier the software they use will automatically flag your visit and assume it is postoperative and deny payment. So in this case you would not use the 99024 postoperative visit code.

The -79 modifier is for a procedure done in the global period. The -24 modifier is for an office visit (E&M) in the global period.

 

[air bud]

Also do both same time tell her she is an idiot if that is what she is afraid of.

 

[Carbon13]

68 y/o male with PVD and dialysis. Non diabetic.
Chronic callus with recurrent ulceration and periodic infections. Sub 1st MTH. Peroneal over drive present. Non responsive to routine care and offloading modalities.
Planning P. Longus release with possible transfer to Brevis.

Appropriate CPT coding for tendon surgery?

Bonus question: If decision is made to apply short series of outpatient grafting. Is this possible during post op global period since grafts are considered DME ? Modifiers?

 

[PODIATRYCRAZE]

ICD: M21.6x9 Foot deformity for the plantarflexed metatarsal
I73.9 Peripheral vascular disease
L97.509 Non pressure foot ulcer

CPT: 27675 Repair of peroneal tendons
15275 Skin graft application
99024 Postoperative visit

Reimbursement: $600 for the surgery
$200 for the skin graft application + profits from patient?
$0 for the postoperative visit

I would use a 99024 and still match it to the foot deformity, because that is what the surgery was for. For the skin graft application I would use 79 modifier.

When they come back to the office, I would not use a 99213. Although I wonder what would happen if we pair that to the peripheral vascular disease code and a 24 modifier. Is this allowed?

Very good example to get me thinking, love the participation. Thank you.

 

[Hybrocure]

68 y/o male with PVD and dialysis. Non diabetic.
Chronic callus with recurrent ulceration and periodic infections. Sub 1st MTH. Peroneal over drive present. Non responsive to routine care and offloading modalities.
Planning P. Longus release with possible transfer to Brevis.

Appropriate CPT coding for tendon surgery?

Bonus question: If decision is made to apply short series of outpatient grafting. Is this possible during post op global period since grafts are considered DME ? Modifiers?

Don’t cut.

Revasc before doing any tendon work. Any elective work. Even an ingrown.

Also maybe I’m missing something here but messing with the peroneals usually isn’t my first go to in a 1st MH ulcer on an unhealthy patient

 

[PODIATRYCRAZE]

HPI: Yesterday you operated in a patient for a right triple arthrodesis. Everything intraoperatively went well but in PACU her O2 was low and ended up being admitted for observation. No events overnight.

Treatment: Kept dressings and splint intact. Just stopped in to check their overall health

 

[PODIATRYCRAZE]

ICD: M19.07 Foot osteoarthritis
M79.671 Right foot pain
R07.02 Shortness of breath (If you are admitting team)

CPT: 28730 Triple arthrodesis (For the surgery)
99024 Postoperative visit (For today's scenario)

Reimbursement: Let's hope for $1000 for the surgery. For the next day rounding is $0. The patient is still in the postoperative global period. Does not matter the setting, inpatient or outpatient. No point in billing for your service.

However, if you were the primary admitting team, I wonder how that would go because then the diagnosis code for your admission would not be arthritis. It would be shortness of breath. In this scenario you probably could get paid for your medical services.

Another thing to note is for a triple arthrodesis the code is classified as fusion of multiple foot joints. You would not use a single fusion (28725) code 3 times.

 

[heybrother]

28730 is not the CPT code for a triple.

28725 is not the code for a single joint midfoot fusion.

Its not that there's "no point billing" - there is an available public document that describes what services can be charged for during a global if the patient has Medicare. Commercial insurance is different. The distinctions of when and when you cannot charge things is the difference between getting paid and that feeling that you are constantly doing little things for free.

And set your mind at ease, the hospitalist rounding on your patient gets paid for it.

M19.07 is not "foot arthritis". If you look it up its listed a variety of ways but it essentially always says Primary Osteoarthritis. I bring this up because there's an ICD-10 for secondary and for post-traumatic. I have yet to see insurance make a distinction, but diagnosis codes are how we tell a story of complexity.

 

[PODIATRYCRAZE]

HPI: 2cmx3cm full thickness wound to right submetatarsal 2 noted on a new 48M patient with diabetes, and neuropathy. He has had it for 6+ months and went to a podiatrist for 2 of those early months. With no improvement he decided to just do wound care on his own. Today he comes to you with no pain, but he noticed extra drainage on it today. To his knowledge there was no change in size. Upon inspection, there is no clinical signs of infection, but is very fibrotic, no exposed bone or tendons. No sensation but he does have good pulses. Drainage you saw was thankfully not purulence, just serous.

Treatment: In office debridement down to granular tissue. Foot evaluation and management. Cultures taken, XR to check pressure points of feet. Surgical planning for possible weil osteotomy vs metatarsal head resection for offloading. PegAssist insoles in surgical shoe until everything is finalized.

 

[PODIATRYCRAZE]

ICD: M01.x71 Right foot infection
M77.41 Right foot metatarsalgia
L97.512 Right foot ulcer

CPT: 99204 Office visit
11042 Wound debridement 25 modifier
73630 Foot Xray


Reimbursement: $300? $100 for evaluation, $120 for debridement, $30 for XR. $50 for the shoe insert. Lots to unpack here. Wound care is probably one of the most difficult areas to code for both for ICD and CPT.

Documentation is key to finding your appropriate ICD10. I know we didn't document very great in this scenario but most foot ulcers can be separated into pressure (L89 series) vs nonpressure ulcers (L97 series). Others include venous ulcers (I83 series), arterial ulcers (I70 series) and diabetic ulcers (E13 and E11)

After that, nonpressure ulcers can be further separated by layer. In the following codes, replace the 0 with 1 for right foot or 2 for left foot.
L97.501 - skin
L97.502 - fat
L97.503 - muscle
L97.504 - bone
L97.505 - muscle without necrosis
L97.506 - bone without necrosis
L97.508 + L97.509 - unspecified

Pressure ulcers of the heel are as follows. In the following codes, replace the 0 with 1 for right foot or 2 for left foot.
L89.600 - unstageable
L89.601 - stage 1 to skin
L89.602 - stage 2 to fat
L89.603 - stage 3 to muscle
L89.604 - stage 4 to bone
L89.606 - deep tissue
L89.609 - unspecified

Next for the CPT codes, some simple math is involved. 3x2 = 6sq cm. All of these have a 0 day global period. Size is calculated in square centimeters for our patient it is only 6sq cm. These are 2 separate series and cannot be used at the same time. Add on codes can be applied within the same series for larger wounds. For the basic codes we have:
97597 - superficial debridement under 20 sq cm
11042 - subcutaneous debridement and removal of dead tissue under 20 sq cm
11043 - debridement through muscle and fascia under 20 sq cm
11044 - debridement through bone under 20 sq cm

97598 (add on) - superficial debridement over 20 sq cm
11045 (add on) - subcutaneous debridement and removal of dead tissue over 20 sq cm.
11046 (add on) - debridement through muscle over 20 sq cm
11047 (add on) - debridement through bone over 20 sq cm

To clarify, in a larger wound you would put both 97597 + 97598 down, or 11042 + 11045 no modifier necessary. But you would not mix and match a 97597 with 97598.

I have definitely staged wounds incorrectly in the past and as far as I can tell it was still paid by insurances. However I never actually double checked. Maybe my biller fixed it, maybe my attendings did not get paid. Any experience with incorrect wound CPT/ICD consequeneces? Another follow up. Does a 40 sq cm wound debridement pay the same as a 100 sq cm debridement? 1cm vs 19cm does pay the same.

 

[HardRoadPaved]

drainage you saw was thankfully not purulence, just serous.

Treatment: In office debridement down to granular tissue. Foot evaluation and management. Cultures taken

......... tell me you're a resident without telling me you're a resident

 

[Weirdy]

......... tell me you're a resident without telling me you're a resident

Not all residents are taught to culture non-infected, stable wounds, with no change in size, depth, or drainage.

We'd get slapped for that.

 

[HardRoadPaved]

Not all residents are taught to culture non-infected, stable wounds, with no change in size, depth, or drainage.

We'd get slapped for that.

So youre saying we need more biocmechanical exams...

 

[heybrother]

-25 modifer still doesn't go on CPT procedures.

-Our boy Jeff would very much like for everyone to ensure the tissue that is debrided is spelled out - epidermis, dermis, subcutaneous etc.

-11042 requires that you debride necrotic tissue. Jokingly, don't go on too much about how granular that wound bed was because it has to have some necrosis in it to qualify for CMS. Rationalize this one because most wounds I see that are well tended are pink and granular...

-Documentation requirements can be substantial - below is from Jurisdiction M.

• Tool used for debridement (curette, scalpel, other instruments)
• Frequency of surgical debridement
• Measurement of total devitalized tissue (wound surface) before and after surgical debridement
• Area and depth of devitalized tissue actually removed from wound (not just depth of wound)
• Blood loss and description of tissue removed
• Progress notes or procedure notes with a detailed description of the procedure
• Evidence of the progress of the wound’s response to treatment; this documentation must include at a minimum:
  • Current wound volume (surface dimension and depth). Presence (and extent of) or absence of obvious signs of infection.
  • Presence (and extent of) or absence of necrotic, devitalized or non-viable tissue
  • Material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown

 

[air bud]

-25 modifer still doesn't go on CPT procedures.

-Our boy Jeff would very much like for everyone to ensure the tissue that is debrided is spelled out - epidermis, dermis, subcutaneous etc.

-11042 requires that you debride necrotic tissue. Jokingly, don't go on too much about how granular that wound bed was because it has to have some necrosis in it to qualify for CMS. Rationalize this one because most wounds I see that are well tended are pink and granular...

-Documentation requirements can be substantial - below is from Jurisdiction M.

• Tool used for debridement (curette, scalpel, other instruments)
• Frequency of surgical debridement
• Measurement of total devitalized tissue (wound surface) before and after surgical debridement
• Area and depth of devitalized tissue actually removed from wound (not just depth of wound)
• Blood loss and description of tissue removed
• Progress notes or procedure notes with a detailed description of the procedure
• Evidence of the progress of the wound’s response to treatment; this documentation must include at a minimum:
  • Current wound volume (surface dimension and depth). Presence (and extent of) or absence of obvious signs of infection.
  • Presence (and extent of) or absence of necrotic, devitalized or non-viable tissue
  • Material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown

Yeah, I used to get annoyed at the pre-populated epic debridement notes and now I realize that they are literally word for word what you just typed.

 

[heybrother]

Novitas has this check list above.

LCD - Wound Care (L35125)

Use this page to view details for the Local Coverage Determination for Wound Care.

www.cms.gov

This LCD is ripe with good language to put into notes. For example - hopeless wound cases that are essentially palliative with no expectation of healing would benefit from language demonstrating that the treatment plan is palliative in nature and designed to prevent hospitalization, minimize risk of severe infection, improve patient's function and quality of life. That said, these patients probably wouldn't be seen weekly.

----example text----
Wound care may be of a palliative nature. Optimally, the overall goal of care is healing, and it would be neither reasonable nor medically necessary to continue a given type of wound care if evidence of wound improvement leading to healing of the wound as outlined in this LCD cannot be shown. However, if it is determined that the goal of care is not wound healing, which would lead ultimately to wound closure, the patient should be managed following appropriate palliative care standards. Wounds of some Medicare beneficiaries residing in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs) may not close, heal, or be amenable to self-care in spite of optimal therapy. In those patients where wound closure, healing, or self-care is not a likely outcome, the goals of wound care may include prevention of hospitalization and improvement in quality of life. As such, due to severe underlying debility or other factors, the goal of wound care provided in these settings may be only to prevent progression of the wound by stabilizing the wound by:

• Minimizing the risk of infection and further progression of the wound;
• Managing the multiple issues that cause patient and family suffering; and
• Optimizing the patient’s function and quality of life.

 

[Hybrocure]

Do you guys say debridemont or debride mint.

 

[Retrograde_Nail]

Don’t cut.

Revasc before doing any tendon work. Any elective work. Even an ingrown.

Also maybe I’m missing something here but messing with the peroneals usually isn’t my first go to in a 1st MH ulcer on an unhealthy patient

If there is appropriate perfusion doing a peroneal longus tenotomy is completely appropriate here. I've done tons. They work. I usually do a tibial sesamoidectomy along with it. If there is gastroc equinus then I do a recession with it. All appropriate.

 

[Feli]

Do you guys say debridemont or debride mint.

We had a clinical professor at Barry that said "dee-breed-mont."

You almost had to sit and think the first few times you heard it.