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[MicroPod]

Another billing question. For bilateral matrixectomy procedures which modifier(s) is appropriate to use. 50 modifier denotes bilateral procedure, but then there are the TA-T9 modifiers denoting the toes on which the procedure was performed. Then if you are billing for the visit there would be the 25 modifier as well. Any help/explanation of how to properly bill this would be helpful.

Also, do you need to put the toe modifier if you are only doing one toe, or is it only if you are doing multiple?

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[heybrother]

-The office visit, 99203 or whatever, gets a 25.
-Each toe receives a TA, T1, etc
-I always put a 59 on the second procedure but this might be where there are other appropriate modifiers. A true coding legend would look for column edits.
-If you were in a location where you get direct feedback from payors and they weren't paying then you'd adjust your modifiers accordingly.

Your note will need to justify the 25 modifier. This is a subject of much skirmishing on the forum, but I will tell you I don't have any payor denying E&M and CPT on the first visit with a 25. I've slightly increased my aggressiveness of adding 25s for follow-ups as I think I was giving away money on follow-up visits for services I was actually providing.

A lot of what you will read on the 25 is just people's opinions that have no basis in the actual coding documentation
ie. "I performed a physical exam to locate a new callus therefore I get an E&M" or "I'll just create another diagnosis code"
*I don't believe there's any real discussion of new or established in the current E&M tables - new/established was the old system.

You should read the actual CMS 25 modifier text - it doesn't give you a lot to work with, but it gives you enough to see through most people's arguments.

My last listen to a coding discussion from the "experts" included the recommendation that you provide specific text justifying your decision making process ie. potentially call out PROBLEM #1: Injection PROBLEM #2: Your E&M and decision making and prescription etc.

I'm of the opinion the word that should stand our in your mind is "MANAGEMENT". What did you do, what did you discuss, what did you consider, what did you worry about.

Just because you get paid up front doesn't meant you'll survive an audit in the back.

 

[mandrew]

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.

Jack Nelson?

 

[Feli]

Jack Nelson?

No, female.

Nelson was awesome. He was not A+ on academic/research/book things, but he was a good communicator and entertained and motivated patients (and students) real well. That stuff is about 70% of success in most podiatry situations.

 

[Carbon13]

Another billing question. For bilateral matrixectomy procedures which modifier(s) is appropriate to use. 50 modifier denotes bilateral procedure, but then there are the TA-T9 modifiers denoting the toes on which the procedure was performed. Then if you are billing for the visit there would be the 25 modifier as well. Any help/explanation of how to properly bill this would be helpful.

Also, do you need to put the toe modifier if you are only doing one toe, or is it only if you are doing multiple?

Not sure I'm kosher on this but my IGTN has always looked like this:

99203, -25 Cellulitis
11750, -59, T(x)
11750, -59, T(x)

Until the last year this has never been rejected from any payor.
Now, a few of the Medicare replacement plans in my area are not covering same day procedures of any sort.
So with them it's either eat the 99203 on initial visit or have them come back for a scheduled 11750 at later time.
I typically never do more than 1 IGTN toe on same visit. Usually perform the other toe at the follow up visit and just charge 11750 & no EM.

 

[heybrother]

Not sure I'm kosher on this but my IGTN has always looked like this:

99203, -25 Cellulitis
11750, -59, T(x)
11750, -59, T(x)

Until the last year this has never been rejected from any payor.
Now, a few of the Medicare replacement plans in my area are not covering same day procedures of any sort.
So with them it's either eat the 99203 on initial visit or have them come back for a scheduled 11750 at later time.
I typically never do more than 1 IGTN toe on same visit. Usually perform the other toe at the follow up visit and just charge 11750 & no EM.

One of my attendings was convinced that the hospital was paying him 1/2 value on the 1st procedure when they added a 59 modifier to all procedures after the fact. He ultimately got a big check from them. I've seen EOBs for my practice submitted as you described that were still paid appropriately. The big take home is that you have to use local payor behavior as a guide and stay on top of EOBs.

It goes without saying - f&* Medicare Advantage plans. That said, I'm not experiencing what you are experiencing and being OON with them has actually been working great for me. People have previously described BCBS denying 25 modifiers a few years ago in Dallas. Not currently happening where I am. Aetna in my area is an aggressive 25 modifier denier at follow-up visits and Scott and White is now denying nails with calluses as inclusive just like Aetna and Humana do. Cigna sends something out every year claiming they are going to start fighting all the 25 modifiers but they haven't yet.

I will do 2 toenails at a time, but I'm somewhat growing weary of doing 2 big toe bilateral border matrixectomies. Its hilarious to get paid a Medicare 28296 for an office procedure, but its still somewhat plays havok on clinic flow if the day is busy or there's 2 patients wanting nail surgery in a row.

 

[PODIATRYCRAZE]

Now that I am finally in practice I can finally post about some results that I was trying to find the answers to.

Always wanted to know what a usual office visit code pays and got the same answer. It depends on the insurance. While this is true, I wanted a more solid answer.

After only 2 months in practice, here is an idea. Not very accurate because I don't use level 5 as often so the sample size is pretty small.

Most common codes are progress visits
99213- $106.62
99214- $68.65
99215- $158.12

New patients
99203- $108.88
99204- $107.25
99205- Have not billed this yet

Hospital visits
99223- $69.01
99233- $113.91

Remember this is insurance payment + patient payment. This also does not include other codes I used during the office visit, like debridements, compression, manipulations, imaging.

Clearly 99214 and 99223 are outliers. Normally we would think that these patients have the poor insurances. However, 99214 happens to be my most billed code of the ones listed above, and by a pretty large margin. With the other codes having a higher average payment, even with fewer codes being billed, safe to say I got lucky and these were all good insurances.

So in the end of it expect your office visit codes to pay around $70-$100. then whatever extra procedures you perform or products you sell are icing on top.

There is a chance that I miscalculated the averages base off of how my office counts units. Will talk to my boss about that later.

Something on the financial side for the younger doctors to look forward to. Will post my 6 month income update in the other thread about 1st year out salaries in January. Then hopefully I can kick my sdn addiction and never return.

 

[dtrack22]

Now that I am finally in practice I can finally post about some results that I was trying to find the answers to.

Always wanted to know what a usual office visit code pays and got the same answer. It depends on the insurance. While this is true, I wanted a more solid answer.

After only 2 months in practice, here is an idea. Not very accurate because I don't use level 5 as often so the sample size is pretty small.

Most common codes are progress visits
99213- $106.62
99214- $68.65
99215- $158.12

New patients
99203- $108.88
99204- $107.25
99205- Have not billed this yet

Hospital visits
99223- $69.01
99233- $113.91

Remember this is insurance payment + patient payment. This also does not include other codes I used during the office visit, like debridements, compression, manipulations, imaging.

Clearly 99214 and 99223 are outliers. Normally we would think that these patients have the poor insurances. However, 99214 happens to be my most billed code of the ones listed above, and by a pretty large margin. With the other codes having a higher average payment, even with fewer codes being billed, safe to say I got lucky and these were all good insurances.

So in the end of it expect your office visit codes to pay around $70-$100. then whatever extra procedures you perform or products you sell are icing on top.

There is a chance that I miscalculated the averages base off of how my office counts units. Will talk to my boss about that later.

Something on the financial side for the younger doctors to look forward to. Will post my 6 month income update in the other thread about 1st year out salaries in January. Then hopefully I can kick my sdn addiction and never return.

Apparently you should stop billing level 4 visits since you make more on your level 3’s…

 

[Weirdy]

Can someone give an example of when you are billing for Level 4s? Am mostly doing Level 3s. Either that or havn't gotten volume/experience up enough to see level 4 patients.

 

[PODIATRYCRAZE]

Word for word from the AMA since 2021:

1 or more chronic illnesses with exacerbation, progression, or side effects of treatment

or

2 or more stable chronic illnesses

or

1 undiagnosed new problem with uncertain prognosis

or

1 acute illness with systemic symptoms

or

1 acute complicated injury

Breaking this down into 1,2,3,4 and 5


1st example - Diabetes is a chronic illness. exacerbation is neuopathy, peripheral arterial disease, ulcer

2nd example - Diabetes is chronic, peripheral vascular disease is chronic

3rd example - New wound pops up. Prognosis is not certain. You do not know if it will heal, or if it will lead to amputation

4th example - Diabetes is an acute illness and can lead to multiple aforementioned symptoms

5th example - Any traumatic foot fracture, or achilles tear, maybe not toe fractures but the rest of the foot should be considered complicated. Once again, this changes the patient lifestyle significantly. Maybe the cannot drive, shower, grocery shop, work.

Bad examples - onychomycosis, warts, plantar fasciitis, normal diabetic foot exam,

 

[PODIATRYCRAZE]

Can someone give an example of when you are billing for Level 4s? Am mostly doing Level 3s. Either that or havn't gotten volume/experience up enough to see level 4 patients.

 

[Weirdy]

Word for word from the AMA since 2021:

1 or more chronic illnesses with exacerbation, progression, or side effects of treatment

or

2 or more stable chronic illnesses

or

1 undiagnosed new problem with uncertain prognosis

or

1 acute illness with systemic symptoms

or

1 acute complicated injury

Breaking this down into 1,2,3,4 and 5


1st example - Diabetes is a chronic illness. exacerbation is neuopathy, peripheral arterial disease, ulcer

2nd example - Diabetes is chronic, peripheral vascular disease is chronic

3rd example - New wound pops up. Prognosis is not certain. You do not know if it will heal, or if it will lead to amputation

4th example - Diabetes is an acute illness and can lead to multiple aforementioned symptoms

5th example - Any traumatic foot fracture, or achilles tear, maybe not toe fractures but the rest of the foot should be considered complicated. Once again, this changes the patient lifestyle significantly. Maybe the cannot drive, shower, grocery shop, work.

Bad examples - onychomycosis, warts, plantar fasciitis, normal diabetic foot exam,

Thank you. Think I'm over thinking it and am for sure under coding some of this stuff.

 

[heybrother]

Thank you. Think I'm over thinking it and am for sure under coding some of this stuff.

You definitely need to read the accompanying guidelines document. For example -

Acute, complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity.

Rather than just making up a reason that a problem is complicated - fit your discussion of the problem to describe how you meet the metric.

 

[Weirdy]

yah no for sure I am pretty ignorant to this stuff and need to read more.

 

[mandrew]

No, female.

Nelson was awesome. He was not A+ on academic/research/book things, but he was a good communicator and entertained and motivated patients (and students) real well. That stuff is about 70% of success in most podiatry situations.

Buchman?

 

[Feli]

...After only 2 months in practice...

Thank you, Ke-mo sah-bee.

...
99215- $158.12
...

Billing 99215 as a podiatrist and seeing any normal amount of patients/day (10-15+) will mean it can't be on time and then has to be justified on complexity. That can be done (now, with e/m changes a couple years ago), but it's very substantial documentation... as well as create low-hanging audit fruit.

You are most commonly evaluated (and scrutinized) by insurances based on your coding vs state/area peers.
I can guarantee you most of those peer podiatrists do zero percent or blue moon 99215s (and no 99205).
Fyi, that 99215 audit will logically tend to go approximately this well:

 

[AttackNME]

Read an X-ray and book someone for surgery is a level 4. Send someone to the ER or hospital for a situation which could be loss to limb (acute osteomyelitis) or loss of life (infection with constitutional symptoms) is a level 5

Bunion eval, X-rays, decision for surgery - level 4
Hammertoe eval, X-rays, decision for surgery - level 4
Toe with bone exposed, decision made to go to hospital, document concern for loss of limb - level 5
Wet gangrene, decision to go to ER for vascular and sepsis workup due to concern for limb loss and to life - level 5

 

[heybrother]

Read an X-ray and book someone for surgery is a level 4. Send someone to the ER or hospital for a situation which could be loss to limb (acute osteomyelitis) or loss of life (infection with constitutional symptoms) is a level 5

There's a catch to this - you don't get credit for the x-ray if you performed it. You only get credit if it was performed elsewhere.

Category 2: Independent interpretation of tests• Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

"Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM."

"Independent interpretation: The interpretation of a test for which there is a CPT code, and aninterpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standardsof a complete report for the test."

 

[dtrack22]

There's a catch to this - you don't get credit for the x-ray if you performed it. You only get credit if it was performed elsewhere.

Category 2: Independent interpretation of tests• Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

"Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM."

"Independent interpretation: The interpretation of a test for which there is a CPT code, and aninterpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standardsof a complete report for the test."

Oh he beat me to it…

Taking an xray in office that you read/bill the professional fee for does not count as “independent interpretation” of an outside imaging study

And some of the aforementioned “chronic illnesses” are awful examples. Not to mention, you have to actually be treating the condition you are using as a diagnosis. Cutting their toenails doesn’t count as treating their diabetic PAD…

 

[Feli]

Great points above. Also notable to point out the diff between hospital FTE billing and podiatry PP billing...

Not only the XR, but also just the relative immunity to audit with the hospital employ setup (somebody will do the audits, but it is much less likely to be DPM).

It's just a lot less of a risk to throw up a bunch of codes (higher e/m averages, bone biopsy with amp, additional wound add-on codes, etc etc) and try to beef RVUs in hospital pod than PP/collections setup. The PP pods could do that stuff, but the pushback and rejects and audits it'll usually draw are not worth it... similar to doing procedures/DME without prior auths, taking ER call, taking on pts that are medical trainwreck, etc. PP is usually better served just getting better insurance (and then you don't need to max bill or see as many pts). Some things fly fairly well in one practice setup - yet the tend to crash and burn in another. A hospital pod couldn't eat on just 992x3 and DME and injects... they need to do/find surgery and to order a lot of advanced imaging.

I don't think I leave a lot of $ on the table in PP, but I have occasional 992x4 that I sent to ER or inpt (could've tried for level 5 with a lot more typing and coding). Similar for some visits being 992x3 when I could've maybe typed more and made a lvl 4... but I'm also doing inject or DME or OTC or u/s or all of those things or whatever. Going max E/M on all tends to invite payer rejects, payer chart requests, patients questioning EOB, wastes my time charting more, or worse (audit, clawback, etc). Those kill you on the back end. Basically, if you could have a Ford Bronco with no upkeep or have a G-Wagon but you need to change the oil every 500 miles and wash it every 3 days, what'd you choose?

 

[AttackNME]

Oh he beat me to it…

Taking an xray in office that you read/bill the professional fee for does not count as “independent interpretation” of an outside imaging study

And some of the aforementioned “chronic illnesses” are awful examples. Not to mention, you have to actually be treating the condition you are using as a diagnosis. Cutting their toenails doesn’t count as treating their diabetic PAD…

There's a catch to this - you don't get credit for the x-ray if you performed it. You only get credit if it was performed elsewhere.

Category 2: Independent interpretation of tests• Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

"Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM."

"Independent interpretation: The interpretation of a test for which there is a CPT code, and aninterpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standardsof a complete report for the test."

You guys may be right on that but as a doctor of podiatric medicine i insist that bunions that need surgery are acute exacerbations of a chronic illness. But I guess a more slam dunk level 4 is an ankle fracture that is referred from the ER, you eval X-ray from ER, and book for surgery.

 

[wakaflocka88]

You guys may be right on that but as a doctor of podiatric medicine i insist that bunions that need surgery are acute exacerbations of a chronic illness. But I guess a more slam dunk level 4 is an ankle fracture that is referred from the ER, you eval X-ray from ER, and book for surgery.

992x5 for me

 

[dtrack22]

992x5 for me

Just because your bunion surgeries are considered limb threatening to the patient…doesn’t mean it’s a level 5

 

[air bud]

I believe Medicare defines chronic illness is greater than 1 year. So someone with a bunion certainly has had for more than a year.

 

[MortonExtension]

Do you guys have patients fill out ABN forms

 

[heybrother]

-

Do you guys have patients fill out ABN forms

A practice management guru would likely recommend a diversity of ABNs to protect yourself from various forms of non-payment. Getting staff to actually understand and implement things though is very difficult and until you've eaten money in one of these situations you may not be aware of all the ways you can lose out on a claim. Additionally, some of these ABNs are essentially going to pass responsibility for payment to patients when their insurance doesn't pay and then you become responsible for collecting large balances from payments. At that point you are not just going to need an ABN - you are going to need to have a credit card on file. So then you need to have a credit card agreement.

I was going back through some Athena charges the other day where Athena has been appealing claims for greater than a year. They essentially wanted to write the charges off claiming they had been maximally pursued but the actual issue was the patient didn't have a referral. When the patient doesn't have a referral the balance passes to the patient. That's not complicated. What is complicated - is getting a patient to pay a $200-300 bill from 1.5 years ago after the fact unless you have a mechanism to implement it.

 

[Adam Smasher]

ABNs are good for demanding patients who want their nails trimmed but don't tick off all the boxes for their claims to be paid.

It's a poor use of your or your staff's time to argue with them. The easiest way to get them out of your exam room peacefully is to tell them, "ok, I can take care of your nails, and I can submit this to your insurance, you just need to sign this form and we'll see what they do." Submit the nail code with a GA modifier, and if it pays, great. If not, the pt is mad at their insurance and not the doctor but they never show up again. You lose the $30 or whatever your contracted rate is but you at least keep your schedule open for payable visits

 

[HardRoadPaved]

Submit the nail code with a GA modifier, and if it pays, great.

I ate my words last week... medicare paid.... now i have to see this crappy patient with their non-at-risk nails bc GA for some reason paid. Cant wait for that claw back

 

[MortonExtension]

ABNs are good for demanding patients who want their nails trimmed but don't tick off all the boxes for their claims to be paid.

It's a poor use of your or your staff's time to argue with them. The easiest way to get them out of your exam room peacefully is to tell them, "ok, I can take care of your nails, and I can submit this to your insurance, you just need to sign this form and we'll see what they do." Submit the nail code with a GA modifier, and if it pays, great. If not, the pt is mad at their insurance and not the doctor but they never show up again. You lose the $30 or whatever your contracted rate is but you at least keep your schedule open for payable visits

This is kind of my exact reason of wanting to implement it. Good advice thanks