Case Presentation

1. Case Presentation Brian Gardner DPM

2. Case • 45 y/o male presents to clinic 3 weeks s/p R Lapidus bunionectomy with new onset pain to L heel and an ingrown toenail to the L hallux as well. You evaluate the patient and he has very painful plantar fasciitis L ft and you perform a steroid injection L heel and you also perform an avulsion of the ingrown toenail to the L hallux. Lapidus appears great on x-ray, but the wound has dehisced because the patient got the bandages wet and you have to re-suture the wound closed in clinic..

3. Case • You appropriatly treated the patient and he goes on to have a terrific result but you incorrectly billed/ coded this visit and the insurance company denied the claim and you did not get paid a dime for all the time spent.

4. Billing and Coding • Improper billing/coding can cost you a significant amount of money (undercoded, denial of claims). • Improper billing/coding can lead to audits and potential legal problems. • Billing/coding has become much more complicated and is always changing. • You will be expected to know this on day #1 after you finish residency although you have never received any formal training. Good Luck!

5. Billing/Coding • ICD9 diagnosis codes • CPT codes - Evaluation and management - Procedure codes * CPT codes must correlate with correct diagnosis codes.

10. New Patient Visit • 99201 problem focused (10 min) • 99202 problem focused (20 min) • 99203 detailed (30 min)

12. Established Patient • 99212 Problem focused (10 min) • 99213 Expanded problem focused (15 min) • 99214 Detailed (25 min)

14. Office Consultation Codes • Consultation codes require that the patient be referred for a specific problem • In HPI state that “the patient is seen in consultation with Dr. ------- for (specific problem)” • Must send a copy of note to referring doctor * Consultations pay more than a new patient visit

15. Emergency Room Codes • 99281 Problem focused • 99282 Expanded problem focused (low to moderate severity) • 99283 Expanded problem focused visit (moderate severity) • 99284 Detailed (high severity, requires urgent evaluation but does not pose threat to life of physiologic function) • 99285 Comprehensive (high severity and pose an immediate threat to life or physiologic function)

16. Inpatient Consultation CodesInitial Visit • 99251 Problem focused (20 min) • 99252 Expanded problem focused (40 min) • 99253 Detailed (55 min) • Use these codes for the first initial hospital visit whether they be a new or established patient to you. Do not use these for follow up visits. These codes are for the non-admitting physician

17. Inpatient Consultation VisitFollow up Visits • 99231 problem focused • 99232 expanded problem focused • 99233 detailed

18. Observation Care Discharge • 99217 This code is used by physician to report all services provided to patient (discharge instructions, final examination)at discharge from observation status . • Disharge date must be different than initial date when beginning observation status.

19. Nursing Facility CodesInitial Visit • 99304 Detailed • 99305 Comprehensive • Problem focused codes deleted * These facilities provide medical services. (Skilled nursing care facilities, long term care faciliites, rehabilitative and psychiatric treatment center.

20. Nursing Facility CodesFollow up Visit • 99307 Problem focused • 99308 Expanded problem focused • 99309 Detailed

21. Assisted Living Facility(Rest Home) New Visit • 99324 Problem focused (20 min) • 99325 Expanded problem focused (30 min) • 99326 Detailed (45 min) • Established Visit • 99334 Problem focused (15 min) • 99335 Expanded problem focused ( 25 min) • 99336 Detailed (40 min) * These facilities do not provide medical services

22. Home Visits • New Visit • 99241 Problem focused • 99342 Expanded problem focused • 99343 Detailed • Established visit • 99347 Problem focused • 99348 Expanded problem focused • 99349 Detailed * Specific regulations on qualifications for home visits. (Patient are homebound due to medical conditions)

23. Telephone Calls • 99371 simple (report labs/test, coordinating medical care with other health care professionals) • 99372 intermediate (provide advice/treatment to established patient for new problem) • 99373 complex lengthy discussion with patient /family over complex or serious conditions

24. Nail Avulsions • 11730 Avulsion • 11732 additional avulsions Case • Avulsion of hallux nail b/l and R 2nd • 11730 TA (L hallux) • 11732 T5 (R hallux) • 11732 T6 (R 2nd)

25. 17000 Destruction of benign lesion (1) 17003 Destruction of benign lesions (2-14) 17004 Destruction of Bengin lesions (>15) Case Cryotherapy of 4 warts in clinic Bill 17000 17003 17003 17003 Warts

26. Global Period • Surgical Procedure - Any visit/treatment within 90 days after surgical procedure is considered part of surgical fees and cannot be billed. • Chemical matrixectomy’s have a 10 day global period • Fractures that are treated nonsurgically can also be billed as a global code which is 90 days. * x-rays, fracture boots and casting supplies can be billed for during a global period.

27. Postoperative Visit • 99024 Postoperative visit (no charge) • If patient is out of global period then an office visit can be billed. • Always good to inform patients of global period so that they are aware.

29. Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service Case New patient with plantar fasciitis comes in and you perform a steroid injection. E+M 99203 (mod 25) 20550 Inj tendon/ ligament Modifier 25

30. Unrelated evaluation and management during a postoperative period Case Pt is 10 days s/p bunionectomy L ft and now complains of painful heel pain R ft. You diagnose plantar fasciitis but no proocedure perfomed. 99213 mod 24 Do not bill a postoperative visit Modifier 24

31. Unrelated procedure during a postoperative period Case Pt is 10 days s/p bunionectomy L ft and now complains of painful heel pain R ft. You diagnose plantar fasciitis and perform a steroid injection. 99213 mod 24,25 20550 mod 79 Modifier 79

32. Modifier 79 • Case • Patient with metatarsal fracture comes in and you treat it conservatively and code it as a global code. At week 3 the patient steps down hard on the fracture and now it is significantly displaced and you take the patient to the OR to fix. • 28485 (ORIF met) mod 79

33. Distinct Procedural Service * Place 59 modifier on procedure that has the least amount of reimbursment Case Established patient. You perform a steroid injection for neuroma and trim a painful callus. 64450 inj nerve 11055 trim 1 callus (mod 59) Modifier 59

34. Decision for surgery New diabetic pt presents to clinic and needs a emergent I+D in OR. 99203 mod 57 If modifier 57 is not used then Insurance carrier may include office visit as part of surgical fee and you will not get reimbursed for office visit. Modifier 57

35. J Codes • Case • You perform a steroid injection to R plantar fascia consisting of ½ cc of celestone and ½ cc 0.5% marcaine • 20550 inj tendon/lig • J 0702 (½ cc celestone) * More than 3 injections must be justified by the clinical record indicating a logical reason for failure of the prior therapy and why further treatment can reasonably be expected to succeed.

36. Diabetic Codes

37. Mycotic Nails • Nails can be treated regardless of whether or not there is any underlying systemic condition (diabetes, PVD) if there is pain or infection • Documentation must state that there is evidence of mycosis to the nail and pain/ infection • The term Debridment should only be used when treating dystrophic/mycotic nails but not a nondystrophic nail • The term Trimming can be used for dystrophic and nondystrophic nails

38. Routine Foot Care • Routine foot care is the debridement /trimming of toenails and the paring/cutting of corns/calluses in the absence of localized pain or infection. • Routine foot care can be provided by a physician for patients with underlying systemic conditions that would be at increased danger for infection and injury if a non-professional performed these services • Routine foot care can be provided every 61 days

39. Systemic Conditions that Might Qualify for Routine Care • Diabetes * • Chronic thrombophlebiits * • Multiple Sclerosis * • Arteriosclerosis obliterans • Buerger’s disease (Thromboangitis obliterans) • Peripheral neuropathies • Pernicious Anemia • Quadraplegia/Paraplegia • Malabsorption (celiac disease, topical sprue) • Patients that are immunocompromised or on anticoagulants do not qualify for routine care * These conditions require that the patient be seen and treated by PCP within the past 6 months. You must document approximate date of last visit with PCP and PCP’s UPIN number.

40. Q Modifiers • Q7 Class A finding (amputation) • Q8 Two class B findings • Q9 One class B finding and two class C

41. Conditions that do not Require a Q Modifier • Neuropathy • Quadraplegia/Paraplegia • Multiple Sclerosis • Chronic Thrombophlebitis

42. 11040 Debridement of skin partial thickness 11041 Debridement of skin full thickness Debridement of skin and subcutaneous tissue Size of ulcer does not matter Can only bill for the debridement of up to 4 ulcers per visit Must place a modifier to specify the area of debridment (LT left, RT right). If ulcer is on a digit, specify which digit T5. Billing for Ulcer Care

43. Billing For Ulcers • Clinical records must document indications for debridment (necrotic /fibrous devitialized tissue) • Specific level/depth of debridment must be documented. • Size, depth and location must be documented

44. Procedure code 11055 trim callus 1 11056 trim callus 2-4 11057 trim callus > 4 Diagnosis code 700 callus/corn 757.39 porokeratosis * Must also be associated with 729.5 (pain in limb) * Doesn’t need to be associated with other medical conditions (diabetes) Billing for Hyperkeratosis

45. Diabetic Shoes • L3250 Custom Shoes • Medicare covers one pair of shoes and 3 inserts per year (Private Insurance does not cover diabetic shoes) • Must be diabetic with neuropathy • Must have PCP’s note documenting diabetes • Bill for Each shoe (L3250 x 2)

46. References • CPT 2007 Professional Edition. American Medical Association. • Noridianmedicare.com