The Question:

Gayle,

Would you please explain to me how these can and cannot be used in a podiatry setting.

We gave been told that 10080 is not an allowable code with Medicare. Any other one we could use?

Thanks for your help!

Jenny Wood
Executive Vice President
Wood Medical Billing Medical Professional Resources

The Answer: 

10080 is incision and drainage of a Pilonidal cyst.  I would recommend using 10060- incision and drainage of abscess.  In the CPT book you will see that this includes essentially everything we see in Podiatry that needs to be I&D'd.

Scott Schroeder, DPM
Wenatchee, WA


Coding Bilateral Procedures and Bilateral Orthotics
(Volume 108)

The Question: 

 Hi Gayle,

As per your advice, I visit FZ site often.  It has
helped me learn a lot.  But I need more help in
understanding the appropriate use of modifiers:

1. For Bilateral procedures, ins. either denies or pays
half on the second procedure.  Certain procedures like 20550, 11750 do not qualify for modifier -50 so we billed them with RT/LT modifier or T modifier but still got rejected. 11750 was done on both lateral and medial borders so we added modifier -51 for multiple procedures (with unit of service 2) but that caused confusion too.

2. Similarly for bunion surgery(28113 rt/lt) do we need
to use any modifier?

3. For orthosis (L codes), do we need a modifier to get
paid since that is always bilateral?

Please advice.

Regards,
SG

The Answer: 

Bilateral procedures typically pay half for the second procedure.  Different insurance companies may handle these differently on how they want you to bill them to get paid.  I would recommend calling your provider representative from the particular insurance company you are having problems with and ask them directly how to get paid for work your doctor has done.  If you want to play darts and just keep taking stabs at it to see if you get paid you can try the following:  If the right and left, and T modifiers are not working try the -59 modifier which means different site.  We use this on our multiple surgical procedures and have had very few problems.  This holds true for injection codes too.  L codes such as L3030 or L3000 are per "each" foot.  They should be billed with a right and left modifier and never be billed as a "pair".  Example- if your price for a pair of orthotic devices is $250 you would bill L3000-RT for $125 and L3000-LT for $125.

Scott Schroeder, DPM

Coding Corns and Calluses
(Volume 108)

The Question:

This is my first time accessing your web site. I am needing any coding information possible in regards to the trimming of corns or callosities (11055 11057) when billing Medicare Part B in the state of Tennessee.

Is it covered under any circumstances, and how to bill?

Your help will be greatly appreciated.

Caryl McCartt

The Answer:

For the Fine State of Tennessee I would recommend you contact your Medicare provider representative (yes- they are supposed to have them everywhere but many offices do not know they exist)  Contact your regional Medicare carrier and ask for a provider representative for Podiatry.  If they don't have one specifically for Podiatry they should be able to get you to someone who can help.  Ask for the routine foot care policies relating to 11055, 11056 and 11057.  They should be able to get you to the information whether it be on-line or they can send you something.  Most likely on-line these days. 
 
In the state of Washington these are covered services and we bill the codes the following way: For one callous on a patient who is "at risk" [DP and PT pulses non-palpable- or DP or PT pulse non-palpable and three other findings indicating trophic changes (thin skin, decreased hair, thickened nails, etc)we would bill 11055- Q8  with a Dx of 700 (callous) and 443.9 (unspecified peripheral vascular disease).  If two-four callouses you would use the 11056 and five or greater 11057.  There are other ways of billing it in our state with different secondary diagnosis depending on various "at risk" conditions and the policy is quite lengthy but that is the gist of it.  I do not know if the same policies hold true for Tennessee but your local rep should be able to help you with that.
 
Scott Schroeder, DPM


Coding Casting Materials
(Volume 108)

The Question:

Hi Gayle,

I was wondering if you can offer any help on how we can get Medicare to reimburse us for Code A4590, special casting material.  We have used it with these diagnoses and have been denied - primary, 729.5,  secondary, 825.25, tertiary, 707.14.  Any help would be appreciated.

Thanks,

Mary Triolo
Alvarado Podiatry Center

The  Answers:

The appropriate code for cast supplies for Medicare are as follows: 
Q4037- cast supplies-short leg cast-plaster-adult(11+ years)
Q4038-cast supplies-short leg cast-fiberglass-adult
Q4039-cast supplies-short leg-plaster-pediatric
Q4040-cast supplies-short leg cast-fiberglass-pediatric 

This includes all rolls of plaster or fiberglass and padding per cast.
 
Scott Schroeder, DPM


A few years ago, Medicare (in their wisdom?) developed a series of 52 cast supply codes, to replace the 2 that had been used (including A4590).  For Medicare, each of these Q codes was specific for a type of cast and age of the patient.  Scott is quite correct
 
I think Medicare thought everyone else would think this was a great idea.... but no one else has followed.  A recent Federal Register would seem to imply that Medicare will be moving away from their stance (and going back to A4590, etc.?  I doubt it).
 
Rick Horsman, DPM
Olympia, WA

Coding for Complications versus Staged Procedures
(Volume 108)

The Question:

If we do a partial debridement of a wound in the office and code a 11040 and then send out for a wound culture, isn't there something else we are supposed to be billing for other then the 11040 and the 99213-25?  Maybe specimen handling?
 
We are simply sending out the culture to a laboratory and awaiting results, but I thought perhaps we were supposed to be able to charge for the specimen handling here?
 
The other question I have is that if this is during his global post-operative period, I can still bill that, but I need the modifier 79 right, or is it considered related because of the diagnosis 998.32 wound dehiscence?
 
Really curious,

Kelly
South Portland, ME

The Answers:

There are several components to the question, but the very first important parameter is whether this is a Medicare patient.
 
If so, any management of complications that does not require a return to the OR is included in the global allowance.  So, evaluation and management of a wound dehiscence, culture, debridement, antibiotics, etc is all included in the global allowance-- for a Medicare patient.  If these services are performed in the hospital OR or OSC, they can be billed with a modifier, reflecting a staged and related procedure.  Otherwise, they're free.
 
P.S.:  Medically necessary and documented x-rays are billable.
 
For a non-Medicare patient, you can bill for both the E/M and debridement.  You really should not bill for the specimen handling (it pays about $3 anyway).  If the problem is wound dehiscence, you may have problems billing for these services after a prior surgery.  A diagnosis of cellulitis may be more favorably considered.
 
Not every payer will reimburse for these services, so you might be wise to contact the payer in question, advise them of the problems the patient is having, and what you intend to do (and charge for....), and get some guidance from them
 
What you DON'T want is to provide a surgical procedure to a patient, have a wound complication (which may or may not be considered "the doctor's fault"), and then hammer the patient with charges for non-covered post op services.
 
Rick Horsman, DPM


A follow up on this question-
 
If this is a diabetic or other type wound that required debridement in the O.R. (I&D, or debridement) and the doctor knew at that time that this wound would likely require further debridement or wound closure then this can be documented at the time of surgery and further debridement codes and wound closure codes should be covered with  -58 modifiers (staged procedure during post-operative period).  This holds true even if all the procedure codes have global periods.  If the physician performs a debridement in the operating room of a wound into subcutaneous tissue (11042) which has no global period and the patient is treated as an in-patient or out-patient, these visits should be charged for.  If the procedure was an I&D (10060-10061) or a 11043/11044 then a 10 day global applies and an office visit or hospital visit would not be able to be billed.  However, if further debridement was performed at bedside or in the office then the appropriate debridement code (11040-11044) with a -58 modifier should apply and be paid.  Please make sure your physician documents at the time of original debridement or I&D that further would care will most likely be needed.
 
Scott Schroeder, DPM