The Question:

Thanks for your service.
I have a provider who wants to use L3020 code, what would be the appropriate fee to charge an insurance company for this code?
 
What about L4210?

Dayna Coats

The Answers: 

For L3020, the provider's fees for orthotics would apply as long as casts were taken and the orthotics fabricated off of the casts.  For repair of an orthotic L4210 this is all going to depend on what was done and what the provider feels it is worth.  These are difficult fees to come up with for all of us.  Usually we end up under-billing for the time spent on repairs for us and our staff.  We typically do this as a partial courtesy to our patients.
 

Scott Schroeder, DPM
Wenatchee, WA


When I first started in practice almost 30 years ago, there were no "fee schedules". You had no guidance on what to charge for nail care, or a neuroma excision, or a bunionectomy, or anything else. When you're first starting out, you REALLY have no idea.
 
The California RVS ("CRVS") was the first publication I ever saw which listed a numerical weighted value of all services and procedures.  It was considered "price fixing" (and therefore illegal) in most parts of the country.
 
With RBRVS, the relative weighted value of all listed services is there as public record. You may feel some are overvalued, and some undervalued, but at least there is some published agreed-upon standard.
 
The problem comes in with the codes you describe, as they do not have an RBRS value. They are essentially "by report".  You must look at your own expenses (both fixed and variable; tangible and intangible), to the best you can calculate them, and come up with a fee which you feel is reasonable.  There will be no guidance from the carrier.  They are hoping that you will "low-ball" the fee, and charge less than what their internal computer files have calculated as an industry average.  Similarly, you don't to go way over the mark, as you come across as a money-grubbing scoundrel.
 
That's how it's supposed to work- the system is not perfect, by any means
 
FYI    L3020 is per orthosis- NOT per pair.  Presumably, the fee for repair of an orthosis would also be per orthosis, not per pair.
 
Rick Horsman, DPM
Olympia, WA

Coding Punch Biopsies
(Volume 107)

The Question:

Gayle,
 
We have started doing punch biopsies here in the office.  I am not sure how to bill for them.  Can you help me?

Thanks,
Cindy Bryce, PMA
for Dr. Roy Corbin
Bangor, Me

The  Answer:

CPT 11100 (Biopsy, one lesion) is the correct code. It includes any anesthesia and closure, if necessary.
 
Use CPT 11101 for each additional lesion biopsied. CPT 11101 is an "add-on" code, and must not be used without also billing CPT 11100.

Rick Horsman, DPM

 
Coding with -58 Modifier
(Volume 107)

The Question:

With wart destruction or incision and drainage there is a 10-day global period (17110). Is it appropriate to use a 58 modifier if the doctor wishes to treat the patient within the 10 days global?

-58 modifier reads: "staged or related surgical procedure"
                         
 "Use this modifier if there is a need to indicate that the performance of a procedure or therapy in the post op period was pre-planned. Use the modifier on the staged or related procedure. Do not use this modifier for the return to the operating room.  -78 should be used in that situation."
 
Gail Bennett
Office of Ronald J. Douglas, DPM

The Answer:

"Global" means "global".
 
For Medicare, these codes have a 10-day global period.  If you are seeing the patient for follow-up regarding the same problem and its management, you do not charge separately.
 
I have trouble perceiving any indication for a true staged procedure with these codes.  I certainly cannot think of any pre-planned reason for follow-up other than a quick "look over" to ensure everything is ok.
 
If the global period were 0 days, the allowance for the code would be less; not the same.
 
But remember, other payers may not have a 10 day global.... you won't know if you don't ask.
 
Rick Horsman, DPM

Coding Multiple Lesions
(Volume 107)

The Question:

Gayle,
 
Hope all is going well.  Have an example questions!
 
Example:  5 lesions to be removed.  Would you bill 17000 and 17003 OR 17000 and 17003 x 4.  There seems to be ongoing confusion and would like to get this straight in our minds once and for all.
 
Jenny Wood for
Associates in Podiatry

The Answer:

17003 is an "add-on" code. It  should not be used without 17000.
 
17000 is billed once for the first lesion.
 
17003 is billed as many times/units as you treat additional lesions..up to 14
 
So, for treating 4 lesions:
17000
17003 (three units)
 
If treating 15 or more, you ONLY bill 17004. 17000 and 17003 are no longer applicable.
 
Rick Horsman, DPM

 

The Answer :

This code is to be used if there is a suspicious lesion associated with the nail unit and the doctor wants to take a biopsy. This includes the nail plate, bed, matrix, hyponychium (skin at/under the end of the nail), as well as proximal and lateral nail folds.

Scott Schroeder, DPM
Wenatchee, WA

Coding for Night Splints
(Volume 106)

The Question :

Hi,
 
Could you please give me the correct code to use for a night splint, we are a little confused, were told to use L1930 or L4396

Thank you,

Renee

The Answer:

 L4396 is the more appropriate code for a night splint.

 
Scott Schroeder, DPM

Coding for Custom Orthoses
(Volume 106)

The Question:

Gayle,

When billing for L3000 is it required that you bill for both right and left foot every time?

I know this may sound crazy but what about an amputee of one foot?
 
Thanks,
 
Jenny Wood
Executive Vice President
Wood Medical Billing Medical Professional Resources

The Answers:

You would only bill L3000 for those services actually provided.
 
First, it must be a custom made orthosis fabricated from a cast of the patient's foot/feet. The code is used once for each device so dispensed.
 
If BOTH feet are casted and supplied with an orthosis...billing is L3000 LT and L3000 RT. That it preferable over the "bilateral" modifiers.
 
If the patient is a unilateral amputee (absent right leg, for example) coding is L3000 LT.
 
Rick Horsman, DPM
Olympia, WA

L3000 is billed per foot.  So, yes it can be billed alone, just designate which foot. 
 
Scott Schroeder, DPM

Coding for Electrical Stimulation
(Volume 106)

The Question:

The Dr. I work for is frustrated that PA Medicare reimburses so little for 97032 and wants to know what the CPT code is for the leads and how to bill for it.

Holly

The Answers:

Let me preface my remarks by stating that this is not a service I provide.  Correspondingly, I might be "wrong".
 
With that stated, a few points.... all relative to Medicare; policies may well be totally different for other payers.
 
All providers are held to the same standard as a certified physical therapist: a written plan, goals, expectations, etc.
 
Medicare is rapidly (as we speak) demanding that these services must be provided by either a certified physical therapist (not a therapy assistant, office assistant, water boy, groundskeeper), or the physician him or herself.  No one else can provide any of this care and have it reimbursed by Medicare
 
This is a "hands on" service... not the same as sticking the patient in a whirlpool while you go out for a coffee and danish, and keep the meter running.
 
I am not aware of any disposable/reimbursable supplies for this modality. To my understanding, there is no reimbursement associated with this other than CPT 97032 itself
 
The bottom line; you're not going to get rich off of this code, and Medicare is tightening up the criteria for those clinical indications they will reimburse it, and who must provide it, and how and how often and how many times it is provided.
 
In my own office, this would be a loss-leader, and I would refer it out to a physical therapist, and move on to other services with other patients.
 
Just my opinion.... and don't forget my disclaimer at the beginning
 
Rick Horsman, DPM

I checked with our physical therapy friends and for electrical stim the electrical leads are included in the service and are not reimbursable separately.  They are using the code 97014 for their electrical stim.  You may want try this code to see if the reimbursement is any better.
 
Scott Schroeder, DPM

Coding with G0127
(Volume 106)

The Question : (Compiled from two separate inquiries)

Gayle,

Is it true that Medicaid and Ca Resource do not accept G0127 as a valid code?
Can we bill 11040 and G0127 together.  And if so what modifier should we use?

Also G0127 is not accepted by Medicaid.  This is a problem with Medicaid secondary especially.  Since Medicaid will not consider coinsurance this is a write off!?
 
Thanks for your help!
 
Jenny Wood

The Answer:

I do not know if Medicaid or Ca Resource accepts GO127 as a valid code.  I would not think so since this was developed by Medicare for its purposes.  Dr. Horsman will have better insight into GO127 than I would.  I have not ever used this code since there are better codes out there.

Scott Schroeder, DPM 

Can anyone tell me if there is a CPT code for a compression dressing.  Would this be the same as Unna boot?  Thanks for any info!!!!

Stacy

The Answer :

Gayle,

The CPT code 29580 is specific for an Unna boot. The compression dressing may be able to be billed with HCPCS supply codes A6448-A6455. These are listed as being under carrier discretion, so they may or may not be covered. The application of the bandage/dressing would be covered in the E&M visit code.

Scott Schroeder, DPM
Wenatchee, WA

Coding Unna Boots
(Volume 105)

The Question:

We have a patient that we applied Unna Boots bilateral.  The doctor also sent 2 Unna Boots home with patient.  Patient is a Medicare patient.  I know I can bill the two Unna Boots applied in the office to Medicare( I used code 29580). But what about the ones sent home?  What code do I use and is it billed to Medicare or DMERC?
 
Thanks,
 
 Cindy

The Answer:

Gayle,
 
CPT code 29580 is for the application of the Unna boot and many carriers include the material in this code.  If material was sent home an attempt could be made to bill the supply under HCPCS code A6456 but this is a carrier discretion code and may not be covered.  I would start out sending it to DMERC.  If that is unsuccessful then try Medicare.  It may end up being something the patient will have to pick up at the local medical supply store or drug store if available.  If it is an item that is frequently used our local medical supply store usually is quite happy to stock it.
 
Scott Schroeder, DPM

Rick Horsman, DPM
Olympia, WA