Coding -  Refurbishment of Orthotics
(Volume 90)

The Question: 

Is there a code for the refurbishment of orthotics(L3010)?

Thank You,

Cindy

The Answer: 

It's not stated if she's looking for a diagnosis code, or a procedural code.

I typically use an E/M code, based upon time, materials, and complexity.  Many would consider this a non-covered service, and code accordingly.
 
Rick Horsman, DPM

Coding - I&D of Abscess 
(Volume 90)

The Question: 

Thanks so much for getting back to us so quickly,  I have another case I would like an opinion on.
 
Here is a portion of our dictation:

Removed dressings and Iodoform packing and flushed with sterile saline.  Applied saline soaked Iodoform into the wound, although did not fully fill up the wound as will let it try to begin to granulate in, but keep the skin incision open for drainage.  Applied dry sterile dressing after it was repacked.  Pt is to continue with non-weight-bearing, although she may put some weight on the heel.  Fit and dispensed removable cast to allow more protection and some ambulation, particularly on the heel.  Reevaluate in 4 days.
 
Patient is 12 days post-op for right foot abscess.  We are seeing her about every 3-4 days for this sterile dressing change.  How would you bill this,  some say an office visit with modifier.  I would like your opinion.  This is taking several minutes and does not qualify under an E&M code, the patient is not in the global period for an I&D.
 
Thanks,

Deb

The Answer: 

(A Compilation of two emails from Dr. Horsman)

This is a longer and more complex problem
 
If the patient is clearly out of the global period...I don't see anything here other than an E/M.  No other services are billable... at least, not based upon this documentation.
 
If it IS within the global, and the patient is Medicare, it's all free.

I will base my answer on Medicare-- other carriers may have different policies.
 
First...The primary assumption is that this patient is NOT subject to a global period. Assuming 12 days post op, and how the original services were billed, the patient is either just out of the global, or still in it. (They mention leaving skin incision open for drainage...that sounds like a 90 day global to me.)
 
Removal of dressing, packing, irrigation, and repacking.  That is NOT wound debridement as billable by a physician.  It's basically a dressing change.  Depending upon medical necessity, quality of documentation, etc., you could bill it as an E/M (CPT 9.9212 or 99213.). you would have trouble supporting billing for this- especially every 3-4 days
 
For Medicare, the removable brace would likely also be a non-covered item (fractures only).
 
I would look VERY closely at the global period, and seriously consider (if appropriate and medically necessary) sharp debridement of the wound.
 
Hope that clarifies (don't shoot the messenger).

Rick Horsman, DPM

"Coding -  Compartment Syndrome"
(Volume 89)

The Question: 

Could you please give me a ICD-9 code for Compartment Syndrome -  Dr. says pressure in the calf that pushes on the nerves and tendons which causes pain.  Could you please E-Mail an answer to us?
 
Thank you very much for your time,
 
Alice

The Answer: 

ICD-9 729.9    Compartment Syndrome, NONTRAUMATIC
 
ICD-9 958.8    Compartment Syndrome, TRAUMATIC
 
 
Rick Horsman, DPM

The Question:

We see several diabetic patients twice a year for neuropathy but with no other symptoms. What should we code this? Any suggestions. Thanks

Linda Casella
Dr. James Dolan

The Answer:

Rick Horsman, DPM:

The answer to the question is not as self-evident as it might seem...and depends upon the reason for the patient's presentation, and their underlying health insurer.
 
If the patient is non-Medicare, and presents without any symptoms (ulceration, infection, unrecognized injury, painful dyesesthesia, poor balance and stability...i.e. there's a LOT of latitude here), some payers would consider this screening care, and a non-covered service. Correspondingly, the documentation must be quite complete so as to support medical necessity.
 
In my own experience, such nebulous presentations are the exception, not the rule. I would bill it as an appropriate level E/M service.
 
If the patient is Medicare, the same issue applies... with the added complexity of the LOPS provisions. In my own opinion, the level of care provided in accordance with LOPS is a lesser standard of care than my patients are expected to receive, and I would avoid its use.
 
With an understanding regarding appropriate reasons for patient presentation, I would carefully document and support the appropriate E/M. Remember, neuropathic patients may not "hurt", but have abundant reason and medical necessity for evaluation, medical management, and education. Particularly in the presence of significant neuropathy, the patient may be in the worst position to determine when to seek medical care...But it will all fall to the quality of your medical documentation.

Hi Gayle,

I am returning to practice after a 6 year absence.  I am absolutely mystified as to get a handle on correct coding.  Can you recommend a way to get up to
speed quickly on the myriad of modifiers and codes we need to know?  Thanks for your great work!

Dr. Mike Prado

The Answer:

Scott Schroeder, DPM:

I would recommend you spend some time with a local Podiatrist's billing person.  It is going to be very important for a practitioner to understand how to code correctly (not just the office staff!).  It will eliminate much frustration for a practice and speed up payments.  McVey has coding seminars around the country.  I know Dr. Ward has spoken for them in the past and it would be great finding one of the seminars that is put on by a Podiatrist.  Codingline is another source of great information.  To get up to speed the fastest I would first visit a local Podiatrist's office and meet with their staff.

 

Question.  I am still learning the electronic claims billing and would like to know how to code for hammertoes.  Two were done on one foot and one on the other.  Thankyou.
 
Debbie McGovern
David McGovern D.P.M.

The Answers:

Rick Horsman, DPM:

Each toe operated is separately billable, but you must indicate to the insurance plan that they are indeed separate. This is done via digit-specific T modifiers:
 
T1 for the left 2nd
T2 left 3rd
T3 for left 4th
T4 for left 5th
 
T6 for right 2nd
T7 for right 3rd
T8 for right 4th
T9 for right 5th
 
So, if the doctor operated upon the left 2nd and 3rd, and the right 3rd and 5th, coding would be:
 
28285-T1
28285-T2
28285-T7
28285-T9
 

Scott Schroeder, DPM:

In billing hammertoes the T modifiers should be used to indicate which toe has been operated on.  TA= the left hallux, T1=2nd left, T2=3rd left, T3=4th left, T4=5th left T5=Right hallux, T6= 2nd right, T7=3rd right, T8=4th right and T9 5th right.
 
If you were billing the second and third left toes and the fourth right one ideally you should be able to bill 28285-T1, 28285-T2, and 28285-T8 with your ICD-9 code being 735.4 for a hammertoe.  Unfortunately, some insurance companies still want the -59 modifier on the second and third procedures, so you would bill 28285-T2, 28285-T3-59, and 28285-T8-59.  This is the way we do it in our office and we have had very few problems.

The Answers:

Rick Horsman, DPM:

CPT /HCPCS offers two codes:
L4360 Pneumatic walking brace.... they don't care if it's hinged or not, or gel-padded or not. Medicare allowance is about $283.74.
L4386 NON-pneumatic walking brace.  Again, they don't care if it's hinged or not, or padded with gel or not.  Medicare allowance is about $127.20
L2112 is a prefab tibial fracture cast orthosis.  Fortunately, they did choose a "prefab" code (many offices try to use the custom made code, which is really fraudulent)... but this is NOT what these devices represent.
If in doubt, they should contact SADMERC, and get specific direction regarding appropriate coding for such devices.
I must state that manufacturer's reps are outrageously wrong in suggesting HCPCS codes.... But remember....if they are wrong, but you bill it that way.... YOU have a problem; NOT them.
The alternative is L2999, unlisted lower extremity orthosis.  The disadvantages of that code should be self-evident

Scott Schroeder, DPM:

In regards to Jenny's question about cast boots, the HCPCS code that best describes the boots she is using is L4386.