Codingline Oakland Strictly Coding Seminar. Disclaimer. Disclaimer 10/15/2010. Not everything we say is true

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1 Codingline Oakland Strictly Coding Seminar Presented by Harry Goldsmith, DPM Tony Poggio, DPM Disclaimer Not everything we say is true Disclaimer Some of you will find nuggets of information that you didn t know coding and reimbursement information that will change your practice for the better Some of you will find out that you have been making good money billing wrong and you are not going to be happy C'est la vie 1

2 What s New in 2010/2011? No Cut in Medicare Fees until December 1 If Congress doesn t pass a temporary fix December % decrease in Medicare fees across the board January 1 that changes to a 29.6% decrease 2

3 PECOS January 3, 2011 is the effective date What does that mean for those who have not successfully been included in PECOS? Cannot refer, prescribe, or certify under Medicare (and have the other entity get paid) PECOS For ECS application: For paper application: More info: pdf pdf PECOS Check PECOS list: Enroll/downloads/OrderingReferringReport. pdf If there are any changes in profile, you must switch to EFT; can still get paper EOMB Information on CPMA and APMA website 3

4 Consultations As you are aware, one can no longer bill consultations under Medicare However, you still may for most non Medicare Consultations For Medicare, use E/M service codes for Office E/M codes: ; Initial hospital care E/M codes: Initial nursing facility care E/M codes: * If you are the admitting doctor, add an AI modifier Consultations If the level of the Medicare initial hospital or nursing home E/M service does not meet the detailed history and exam straightforward or low complexity decision making levels, you bill the series follow-up E/M code that does meet what you did. 4

5 Consultations For non Medicare, use the available CPT consultation codes: Office consultations: Hospital or nursing home consultations: Consultations Nothing will change for 2011 Diabetic Therapeutic Shoe Documentation Issue 5

6 Diabetic Therapeutic Shoe Documentation Prescribing Doctor Certifying MD/DO Supplier Issue: What the right code for billing custom foot orthotics? Custom Foot Orthotics 6

7 Custom Foot Orthotics L3000 RT L3000 LT AOPA Guide L3010 L3020 7

8 L3030 L3000 8

9 Custom Foot Orthotics New CPT Codes for 2010 New CPT Codes for

10 CPT Code Changes for 2011 CPT Code Changes for CPT Code Changes for

11 New ICD 9 Codes for 2011 V13.68 Personal history of (corrected) congenital malformations of integument, limbs, and musculoskeletal systems V Personal history of retained foreign body fully removed V49.87 Physical restraints status New ICD 9 Codes for 2011 V90.01 Retained depleted uranium fragments V90.09 Other retained radioactive fragments V90.10 Retained metal fragments, unspecified V90.11 Retained magnetic metal fragments V90.12 Retained nonmagnetic metal fragments V90.2 Retained plastic fragments V90.31 Retained animal quills or spines New ICD 9 Codes for 2011 V90.32 Retained tooth V90.33 Retained wood fragments V90.39 Other retained organic fragments V 8 R i d l f V90.81 Retained glass fragments V90.83 Retained stone or crystalline fragments V90.89 Other specified retained foreign body V90.9 Retained foreign body, unspecified material 11

12 Revised ICD 9 Codes for 2011 V07.8 Other specified prophylactic or treatment measure V07.9 Unspecified prophylactic or treatment measure E017.0 Roller coaster riding (where did the injury occur) And What About ICD 10? ICD 10 CM October 1, years to get ready 12

13 ICD 10 CM ICD 9 codes are numeric characters 3 5 in length; there are about 13,000 codes ICD 10 codes are alphanumeric 3 7 characters in length; there are about 68,000 codes ICD 9 CM ICD 10 CM ICD 9 CM ICD 10 CM Category - Etiology/Anatomic Site/Severity Extension 13

14 ICD 9 CM ICD pain in limb ICD 10 CM R52.0 acute pain R52.1 chronic intractable pain R52.2 other chronic pain R52.9 pain, unspecified Generalized pain NOS M25.5 pain in joint M79.6 pain in limb ICD 9 CM ICD 10 CM V49.71 Lower limb amputation status, great toe Z Acquired absence of right great toe ICD 10 CM Fracture codes require a 7 th character The fracture extensions are: A - Initial encounter for closed fracture B - Initial encounter for open fracture B Initial encounter for open fracture D - Subsequent encounter for fracture with routine healing G - Subsequent encounter for fracture with delayed healing K - Subsequent encounter for fracture with nonunion P - Subsequent encounter for fracture with malunion S - Sequelae 14

15 Scope of Practice Issue This has been corrected and payments made May assist non podiatric surgeries and be paid if an asst is allowed Diagnostic i tests (vascular, neurologic) Per med necessity, no R/O Physical therapy cap Signature Requirements Must be clear as to what provider rendered the service Patient name must be clearly on chart l i l Develop signature log Handwritten, electronic and digital signature OK wnloads/mm6698.pdf 15

16 Place of Service (POS) Accuracy Adult day Care 99 Assisted living 13 Skilled Nursing facility 31 Nursing home 32 Home 12 CMS 1500 Claim form Box 11: None Box 17: referring physician and NPI only Box 24K: only list NPI of provider rendering the service if in a group practice only Box 32: do not list NPI in this box Box 33: List NPI of individual/group CMS 1500 Claim form Box 19 Use for RFC date last seen Use to send paper supporting documentation Write FAX in this box Send info to

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18 House Calls POS 12 housebound patient Use this POS for DME Can bill house call E/M with procedures Use modifiers CANNOT repeatedly bill for house call E/M if no E/M service provided Cannot bill a travel surcharge for Medicare even if patient agrees Benign Lesions LCD Specific LCD May require secondary diagnosis Is lesion growing, causing pain, etc Injection Policy LCD Neuroma injection steroid Sclerosing injection anywhere on foot: sclerosing vs destruction???? =28271&lcd_version=19&show=all 18

19 Sclerosing Injections Nerve destruction vs. sclerosing injections 4 8% etoh vs. 40%etoh CPT destruction peripheral nerve CPT destruction digital plantar nerve CPT therapeutic/diagnostic injection CPT steroid injection Morton's neuroma Redeterminations can be faxed to days from initial determination date Beneficiary name, HIC#, item/service, date of service, name and signature of doctor Redeterminations Use redetermination request form Redetermination Reopening_Request_Form_(J1_MAC).pdf/$FIle/Redetermin ation Reopening g_ Request _ Form _(J1_ MAC).pdf )p Maximum 150 pages 60 day turnaround 19

20 OPS system The Online Provider Services (OPS) On PalmettoGBA's homepage click on J1 Part B MAC CA, HI, NV. On the J1 Part B MAC page pg there is a banner that states, "Introducing Online Provider Services. OPS system Register as a new user the first time you access the site. The system will issue you a user name automatically and you must then create a password (at least 8 characters long, at least one letter in CAPS and at least one symbol). You will need the amount of your last Medicare check and will be asked a secret question. RAC & CERT Audits Comprehensive Error Rate Testing (CERT) audits the carrier Recovery Audit Contractor (RAC) audits specific areas of concern to CMS (that would be you) Can appeal these audit request for $$ Checking POS, MD notes for DME 20

21 Medi Cal Podiatrists can still provide service 1) in nursing facility and 2) for children Medi Cal HMOs may be able to provide service with prior auth from HMO Cannot refuse to see ER patient solely due to insurance Will still be paid for Medi Medi Laboratory/Diagnostics For outside facilities, your chart should list the specific labs tests, diagnostic test your request. Simply stating blood tests/x rays ordered is insufficient. Chart should document the medical necessity for these tests. The lab diagnostic center may have to repay monies paid to them if your chart note does not have this information regardless of the medical necessity of the test your ordered Laboratory/Diagnostics Appropriate quality of the test Hard copy results Complete high quality report in chart comparable to radiologist, i vascular lb lab, etc. Check what is required i.e., ABI alone is insufficient 21

22 Laboratory/Diagnostics In your office document tests you performed in chart: X rays 2 views, 3 views, bilateral Arterial vascular extremity test right extremity Medical necessity of those tests routine bilateral x rays? non osseus problem, unrelated problem? Muscle testing? DME Bill Noridian, not Palmetto Place of service 12 You are supplier, not doctor Supplying other DPMs, the community? Supplying non podiatric supplies? Assignment status tied to Part B status Date of service: date you dispense the item. DME Document condition & medical necessity in chart Custom device vs OTC device? DME means durable replace every three years unless can document damage or change in Rx 22

23 Diabetic Shoes Are Not DME Patient must qualify Diabetic is that enough? Vascular, neurologic, foot deformity, amputation You can Rx diabetic shoes, but treating MD must certify (certificate of med necessity) Medically necessary shoes/inserts may be supplied every calendar year. Diabetic Shoes Use diabetic approved shoe codes Custom shoe A5501 (diabetic) Depth shoe A5500 (Diabetic) Prefab insoles (not heat molded) A5510 (Diabetic) Prefab insoles (heat molded) A 5512 (Diabetic) Custom molded insoles A5513 (Diabetic) Longitudinal insoles with arch and filler for amputated portion foot L5000 DME AFOs, walking boots not covered for ulcers ABN Use RT and LT (bill two lines) for bilateral items Use KX modifier when you have met all requirements ws/docs/2008/07_jul/kx_modifer_usage.html 23

24 DME RA modifier Replacement of beneficiaryowned DMEPOS due to the expiration of the equipment s reasonable useful lifetime or to loss, irreparable damage, or when the item has been stolen RB modifier Replacement parts furnished in order to repair beneficiary owned DMEPOS EMR/EHR Government incentive program to encourage docs to use EMR ($44 K Medicare) meaningful use Incentives decrease over next few years EMR/EHR Select EMR programs that have meet CMS criteria mmission announces first onc atcb onc atcb certifications 24

25 PQRI Physician Quality Reporting Initiative (PQRI) Voluntary at this time Must report on 80% of patients that fit parameter Bill two lines, one with service one with corresponding G code, $ PQRI If for some reason you cannot perform a designated measure on an otherwise qualifying patient, there are modifiers you can use to indicate this. 1P Performance measure excluded due to medical reason: not indicated (i.e. missing limb or other reason, or contraindicated (i.e. patient allergy etc) 2P Performance measure excluded due to patient reason: patient declined (for religious, social, religious reasons, etc) 3P Performance measure excluded due to system reasons: resources to perform services unavailable, insurance coverage/payor related limitation; other reasons attributable to health care system PQRI (the small print) PQRI Measure # 1, Hemoglobin A1C measure in Diabetics in poor control PQRI Measure # 4, Screening for fall risk PQRI Measure #20, Timing for antibiotic prophylaxis PQRI Measure #21, Selection of appropriate antibiotic, first generation cephalosporin PQRI Measure #22, Discontinuation of prophylactic antibiotic non cardiac cases PQRI Measure #25, History obtained regarding melanoma PQRI Measure #27, Counseling of Melanoma self examination PQRI Measure #42, Counseling on Vitamin D, Calcium intake and exercise PQRI Measure #114 Asking about Tobacco Use PQRI Measure #115 Advising patient to quit smoking PQRI Measure #124 Using Electronic Health Records PQRI Measure #125 Adoption of E Prescribing PQRI Measure #126 Diabetic Foot and Ankle Care, Peripheral Neuropathy evaluation PQRI Care, evaluation shoe gear Measure #127 Diabetic Foot and Ankle of PQRI Measure #128 Universal weight screening and follow up PQRI Measure #129 Universal Influenza Vaccine screening and follow up PQRI Measure #130 Universal documentation and verification of current medications in the medical record PQRI Measure #131 Pain assessment prior to initiation of patient treatment PQRI Measure #132 Patient co development of treatment plan PQRI Measure #138 Melanoma, Coordination of Care PQRI Measure #142 Osteoarthritis: Assessment of Use of Anti Inflammatory or Analgesic over the Counter Medication PQRI Measure #154 Falls, Risk Assessment PQRI Measure #155 Falls: Plan of Care PQRI Measure #163 Diabetes Mellitus: Foot Exam PQRI Measure #186 Wound Care: Use of Compression System in Patients with Venous Ulcers 25

26 Miscellaneous Coding Guidelines, Info Global Surgical Guidelines What s in, what s out? Global Surgical Guidelines What s in, what s out? Local anesthetic injections in Dressing changes in Follow up visits in Related minor procedures e.g., I&D of suture abscess mostly in Related pain management in Initial cast, splint, strapping at surgery in 26

27 Global Surgical Guidelines What s in, what s out? Decision for surgery out (well, mostly) Subsequent cast, splint, strapping applications out Casting supplies out Return to the operating room out Unrelated care/surgery out DME out Just Touching on Modifiers What is the Difference Between? Modifier 59 and Modifier 51? Come on, really, what is the difference? 27

28 Is There Actually a Rule on Sequencing Modifiers Is it RT 59 or 59 RT? Does it really matter? How Do You Deal With Staged procedures in a global period? 58 Modifier Appended to the staged procedure code Does not require a return to the operating room The post op global period shifts to the staged p p g p g procedure; beginning from that point 28

29 How Do You Deal With Related complications in a global period? 78 Modifier Unplanned Return to the Operating Room for a Related Procedure During the Postoperative Period Generally considered a complication situation requiring a returned to the operating room 78 Modifier CMS requires that the operating room be equivalent to the original surgery (e.g., original: ASC with the return: hospital outpatient OR) The global period continues from the original The global period continues from the original procedure s global period 29

30 How Do You Deal With Unrelated procedures in a global period? 79 Modifier Unrelated Procedure or Service by the Same Physician During the Postoperative Period Applied to surgery code(s) The global period begins with the 79 modified procedure(s) Modifiers GA not med necessary and there is a signed ABN CAM walker for ulcer Too frequent RFC GY not a covered service by statute No ABN required, non covered RFC, sx shoe GZ not med nec and there is no ABN p 30

31 How Do You Deal With? Unrelated E/M service with minor procedure (I&D) in a global period of some other surgery? CPT 9921x CPT Unlisted Codes You've gotta ask yourself a question: Do I feel lucky? Well, do ya? E/Ms I only bill CPT and CPT 99213s in my office Every time a patient comes in, I feel I am due an E/M in addition to whatever else I may have done Just to be sure, we attach a 25 modifier to our E/M codes 31

32 25 Modifier Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. 24 Modifier Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period What is the Difference Between? Modifier 25 and Modifier 57? 32

33 Evaluation & Management Services Guide 1-3/>3 1/2-9/10 1/2-3 E/M Documentation Billing E/M using time: Must document total time spent, and a statement that over 50% of the time was spent in counseling 33

34 Coding & Documentation Coding & Documentation Review of Systems (ROS) No big deal wrong Coding & Documentation 34

35 Coding & Documentation Coding & Documentation 35

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39 Coding Dermatologic Procedures Coding Dermatologic Procedures CPT Coding Dermatologic Procedures CPT CPT

40 Coding Dermatologic Procedures CPT CPT Partial or complete Possible incisional length requirements Local anesthetic block Coding Dermatologic Procedures CPT CPT CPT additional Coding Dermatologic Procedures CPT CPT CPT Indented code Already reduced in $ Does not require 59 40

41 Coding Dermatologic Procedures Matrixectomy CPT Coding Dermatologic Procedures Matrixectomy CPT Partial or complete Destruction/elimination of the matrix ( root ) Local anesthetic block Any method Coding Dermatologic Procedures Matrixectomy CPT Would not be billed with CPT (wedge excision of skin of nail fold [e.g., for ingrown toenail]) 41

42 CPT Wedge excision of skin of nail fold (e.g., for ingrown toenail) DeVries, Surgery of the Foot, 2 nd Edition, 1965 Laceration Repairs Simple Repair superficial (involving skin and superficial subq) Intermediate Repair layered repair (involving skin, deeper subq, and superficial fascia) Complex Repair more than layered closure debridement, scar revision, retention sutures, etc. Laceration Repairs CPT CPT 12007: Simple repair of superficial wounds of the extremities (including feet) CPT CPT 12037: Repair, intermediate, wounds of extremities CPT CPT 12047: Repair, intermediate, wounds of feet 42

43 Laceration Repairs CPT CPT 13122: Repair, complex, legs CPT CPT 13133: Repair, complex, feet And Laceration Repairs CPT 12020: Treatment of superficial wound dehiscence; simple closure CPT 12021: Treatment of superficial wound dehiscence; with packing CPT 13160: Secondary closure of surgical wound or dehiscence, extensive or complicated And How Do You Code Laceration Repairs? Measure the length of each laceration Record each laceration repair as in the simple, intermediate, or complex group Add the sum of each laceration within each group to give you a single length for all the lacerations in that group Now look up the code representing that group 43

44 Laceration Jubilee Blue Simple Repair 1) 1.1 cm 2) 2.3 cm TOTAL: 3.4 CM Red Intermediate Repair 1) 4.7 cm 2) 2.8 cm 3) 5.1 cm TOTAL: 12.6 CM Yellow Complex Repair 1) 7.4 TOTAL: 7.4 CM Laceration Jubilee Blue Simple Repair TOTAL: 3.4 CM CPT Red Intermediate Repair TOTAL: 12.6 CM CPT Yellow Complex Repair TOTAL: 7.4 CM CPT Excision of Benign & Malignant Lesions CPT (benign) CPT (malignant) 44

45 0.2 cm each 2 cm 2 cm cm cm = 2.4 cm Coding Dermatologic Procedures Miscellaneous Dermatologic Issues 45

46 I&D of Paronychia If I resect a portion of nail to treat a paronychia, can I bill CPT 10060? Well To bill CPT 10060, you ve got to have an abscess (collection of pus) CPT vs. CPT Exactly how do you define a complicated toe abscess? Wound Care 46

47 Wound Care Reimbursement The key pieces of reimbursement are Benefit inclusion Coding Coverage Payment All 4 pieces are needed for proper and consistent reimbursement Wound Care/Treatment Sample of Outpatient Procedures for DFU¹ 1% 30% Evaluation & Management Debridement 69% Skin Substitutes ¹Based on a sample of 1,947,891 Medicare claims in the Hospital Outpatient Setting Reimbursement Benefit inclusion Policy language Who decides? Medicare? Individual MACs Group Plans? Employer/Insurer 47

48 But Where Do Policies Come From? Actually, with Medicare (and some payers) policy, guidelines, definitions come from: OPPs (other payer policies) Standard dof care Medical necessity Peer reviewed literature Practice guidelines Professional organizations Value, Efficacy Medicare LCD Sample Article for Apligraf Related to LCD L26003 (A46092) Approved for use in the treatment of non infected partial and full thickness skin ulcers due to venous insufficiency, i.e., venous stasis ulcers (VSUs), and full thickness neuropathic diabetic foot ulcers 48

49 Apligraf Apligraf Apligraf 49

50 Apligraf Apligraf CPT Coding Apligraf 50

51 Fixation Q4101 Skin substitute, Apligraf, per sq cm 152 Billing Apligraf Apligraf is supplied in single unit of 7.5 cm circular disc (approximately 44 sq cm) size and is billable based on a per sq cm unit. The units field on the CMS 1500 form should reflect increments of 44 sq cm (for each package used)

52 Wastage Document the exact amount of the product used along with: Date and time. Amount of product used. Amount of product wasted. The reason for the wastage. 154 Wastage Example of billing Apligraf: Apligraf is supplied as a single dose unit of 44 sq cm. Assume 20 sq cm of Apligraf are applied to a wound. The billing for the product would be as follows: Q4101 KX LT (or RT) [20 x Average Wholesale Price ($32.716) = $654.32] Q4101 JW [24 X Average Wholesale Price ($32.716) = $785.18] Modifier "JW" drug amount discarded/not administered to any patient Documentation 52

53 Documentation Legible detailed relevant history, physical examination, treatment plan Test results Medical correspondence Photographs 157 History Tell us about the patient s contributing medical history and history of present illness. How d the chronic wound get there? What s been happening to it? What has been done to it by others? What have you done to it? And why? What cha going to do to it? And why? 158 Ulcer Characteristics Location Size Depth Base Tunneling Odor Infection presence Classification

54 Documentation Before using advance wound care products or considering skin substitute products, document how you got to this point and why you consider the procedure medically in the patient s best interest

55 Routine Foot Care aaagggghhh!!! Routine Foot Care 55

56 Routine Foot Care Problems #1 Audited set of codes for podiatrists Not reviewing, understanding, following the carrier routine foot care LCDs Routinely finding more than 5 nails to debride Failure to appreciate that a nails needs to be thick in order to be debrided Not documenting all the required details Routine Foot Care Nails CPT (1 5) debridement of thick nails (total # of nails) CPT (6 10) debridement of thick nails (total # of nails) CPT (1 10) trimming of normal nails G0127(1 10) trimming of dystrophic nails Combos: CPT 11720/11719 CPT 11720/G0127 Routine Foot Care Pain? CPT trimming 1 corn/callus any type CPT trimming 2 4 corns/calluses any type CPT trimming i 5+ corns/calluses any type These are total # of lesions, not foot specific 56

57 Routine Foot Care Pain? Must document pain EVERY time patient complaint; not produced by palpation E/M every time? Do not pre schedule patients for future pain appointments Non ambulatory patients difficulty walking? Routine Foot Care Problems Correct Coding Initiative (CCI) Edits Routine Foot Care Problems How do you bill 1) an office visit (CPT 99213) 2) debridement of 3 nails 3) trimming of 7 nails 3) trimming of 7 nails 4) cutting of 2 corns, and 5) debridement of a full thickness ulcer? 57

58 Routine Foot Care Problems How do you bill an office visit (CPT 99213), debridement of 3 nails, trimming of 7 nails, cutting of 2 corns, and debridement of a full thickness ulcer? CPT CPT CPT CPT CPT Routine Foot Care Problems How do you bill an office visit (CPT 99213), debridement of 3 nails, trimming of 7 nails, cutting of 2 corns, and debridement of a full thickness ulcer in a qualified routine foot care patient (Q8)? CPT CPT Q8 CPT Q8 CPT Q8 CPT Routine Foot Care Problems How do you bill an office visit (CPT 99213), debridement of 3 nails, trimming of 7 nails, cutting of 2 corns, and debridement of a full thickness ulcer in a qualified routine foot care patient (Q8)? CPT CPT Q8 (Column 2 to CPT 11041) CPT Q8 (Column 2 to CPT 11719, 11056) CPT Q8 CPT (Column 2 to CPT 11056) 58

59 Routine Foot Care Problems How do you bill an office visit (CPT 99213), debridement of 3 nails, trimming of 7 nails, cutting of 2 corns, and debridement of a full thickness ulcer in routine foot care patient? CPT CPT (?) CPT Qualifying Routine Foot Care Just what does decreased or absent hair really mean? Routine Foot Care (RFC) At Risk: Vascular Q7, Q8, Q9 Neurologic Immunocompromised Immunocompromised Anticoagulation coumadin/heparin only 59

60 Routine Foot Care Questions Who will pay me for my RFC services if the insurance company does not? How come when my previous podiatrists billed Medicare, he/she got paid? What are fee schedule regulations for noncovered RFC? What is the most frequently billed codes? What is the most frequently audited services for podiatrists? Coding Dermatologic Procedures Musculoskeletal Coding 60

61 Bunions & Hallux Valgus oh my Doctor, I Can t Understand Why My Feet Hurt Sculpture Produced By Molding 61

62 Hallux Abductovalgus Bunionectomy Codes CPT: Hallux Valgus (Bunion) Correction, hallux valgus (bunion), with or without sesamoidectomy; CPT simple exostectomy (eg, Silver type procedure) CPT Keller, McBride, or Mayo type procedure 62

63 CPT: Hallux Valgus (Bunion) Correction, hallux valgus (bunion), with or without sesamoidectomy; CPT resection of joint with implant CPT with tendon transplants (eg, Joplin type procedure) CPT: Hallux Valgus (Bunion) Correction, hallux valgus (bunion), with or without sesamoidectomy; CPT with metatarsal osteotomy (eg, Mitchell, Chevron, or concentric ti type procedures) CPT This procedure includes a distal metatarsal osteotomy. AAOS states that this procedure includes: arthrotomy, synovial biopsy, tendon release or transfer, synovectomy, capsular release and reconstruction, removal of additional exostoses in the area of the joint, internal fixation, articular shaving, arthroscopy, removal of bursal tissue, repair of released tendon, implant insertion, local bone graft and allows additional coding and report for: phalangeal osteotomy to correct deformity, harvesting and insertion of bone graft from distant site (separate skin or fascial incision), and ankle tendon lengthening. American Academy of Orthopaedic Surgeons (August 2002 Bulletin) Bunionectomy Coding 63

64 CPT: Hallux Valgus (Bunion) Correction, hallux valgus (bunion), with or without sesamoidectomy; CPT Lapidus type procedure CPT by phalanx osteotomy CPT by double osteotomy Hallux Varus Coding There is no single code for hallux varus repair. You bill what you did sort of: Metatarsal osteotomy? CPT Soft tissue release only? CPT (Reconstruction, angular deformity of toe, soft tissue procedures only) or CPT Phalangeal osteotomy? CPT CPT: Hallux Valgus (Bunion) Here s one you don t think about CPT Arthrodesis, with extensor hallucis longus transfer to first metatarsal tt neck, great toe, interphalangeal joint (eg, Jones type procedure) 64

65 Bunionectomy Coding How do you bill an Austin type bunionectomy with fusion of the first metatarsal medial cuneiform joint? CPT CPT (23.65 RVUs) or CPT CPT (21.97 RVUs) Bunionectomy Pearls Only one bunionectomy per foot, please There is no code for subchondral drilling Bunionectomy Pearls Fixation is included with exception of external fixator use BUT you d better be prepared to explain the medical necessity and standard of care issues for its use 65

66 Bunionectomy Coding How do you bill a McBride type bunionectomy with a closing base wedge osteotomy? CPT CPT Bunionectomy Coding How do you bill a McBride type bunionectomy with a opening base wedge osteotomy with an allograft? CPT CPT Bunionectomy Coding How do you bill a Lapidus type bunionectomy with an osteotomy of the proximal hallux phalanx? CPT CPT (23.32 RVUs) or CPT CPT (21.02 RVUs) 66

67 Bunionectomy Coding How do you bill for a bunionectomy with 3 osteotomies one base, one distal met, and one proximal phalanx? CPT CPT Bunionectomy Coding How do you bill an Austin type bunionectomy with fusion of the first metatarsal medial cuneiform joint? CPT CPT (23.65 RVUs) or CPT CPT (21.97 RVUs) Bunionectomy Coding How do you bill a Lapidus type bunionectomy with an osteotomy of the proximal hallux phalanx? CPT CPT (23.32 RVUs) or CPT CPT (21.02 RVUs) 67

68 Bunionectomy Coding How do you bill for a bunionectomy with 3 osteotomies one base, one distal met, and one proximal phalanx? CPT CPT Scarf Bunionectomy How do you code a scarf type bunionectomy? CPT Bunionectomy with TightRope is just a bunionectomy 68

69 Coding with Implants CPT for 1 st MPJ implant CPT (unlisted) for lesser MPJ implant CPT for inter digital implant CPT or S2117 for subtalar arthroereisis implant Coding Hammertoe Procedures Hammertoe 69

70 A Rose By Any Other Name Hammertoe, Mallet Toe, Clawtoe, Cocked Up Toe, Overlapping Toe, Curly Toe What is a toe worth? Hammertoe Coding CPT CPT CPT CPT CPT CPT CPT

71 CPT Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) No bone of contention 5 th digit correction Hallux varus Abducted or adducted digit at MTPJ Hammertoe Dislocation (at the MPJ) I have a patient with a hammertoe which she says has been present for years. Can I bill the MTPJ release as an open treatment of dislocation? Fractures: You Crack Me Up 71

72 Fracture Coding Ms. Jones presents with a non displaced closed fracture of the base of the 5 th metatarsal Fracture Coding Initial Global Fracture Code Use Initial fracture E/M + 57 X rays Global Fracture Code Cast supplies Cast shoe A La Carte E/M+ Coding Initial fracture E/M X rays Application of initial cast Cast supplies Cast shoe Fracture Coding Cast Check Global Fracture Code Use Application of subsequent cast Cast supplies A La Care E/M+ Coding Application of subsequent cast Cast supplies 72

73 Fracture Coding Injury? Global Fracture Code Use X rays Application of subsequent cast Cast supplies A La Carte E/M+ Coding E/M X rays Application of subsequent cast Cast supplies Bottom Line Fracture Coding The correct way to code fracture treatment is with the use of the appropriate global fracture code Multiple Fracture Coding How would I code the closed reduction of 2 adjacent metatarsal fractures? CPT CPT

74 Miscellaneous Stuff Questions? Codingline For subscription information 74

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