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[DYK343]

26. If the code descriptor of a HCPCS/CPT code includes the phrase “separate procedure,” the procedure is subject to NCCI PTP edits based on this designation. The CMS does not allow separate reporting of a procedure designated as a “separate procedure” when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach.

So a hammertoe correction is not 7 separate procedures like I learned at ACFAS billing and coding?
Damn.

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[air bud]

Do you bill for both capsulotomy and flexor tendon release? I've only billed it as a perc flexor tendon release but I almost always do a capsulotomy as well.

Know people that do. Never have never will

 

[GreenHousePub]

Do you bill for both capsulotomy and flexor tendon release? I've only billed it as a perc flexor tendon release but I almost always do a capsulotomy as well.

What sort of capsulotomy are you doing? Like a plantar PIPJ one? Why?

 

[air bud]

What sort of capsulotomy are you doing? Like a plantar PIPJ one? Why?

You just plunge the blade/needle deeper. It's honestly hard not to do it when you do the tenotomy if doing right at the joint.

 

[Feli]

Yeah, these work well (assuming flexible or semi-flexible). I only do them for tuft of digit ulcers, pre-ulcer callus, or significant pain on the tuft of the toe. A lot of patients come to a follow appt asking if I can do all lesser toes bilateral (no, unless they have bona fide tuft pain or callus and they fail accommodative insoles). With proper selection, I think I'm over 90% on having the office release work well enough to not need OR. Rigid contractures are obvious, but you have to realize when the HAV or cavus or whatever is going to crash your results and they are just better as OR cases.

I usually do plantar PIPJ with 18ga and try to get both tendons and the capsule (28232 since I visualize the tendon and bandage it, etc), try to miss the digit arteries, bandage with Kling and 1" coban in max dorsiflex for a few days with surgical shoe, then alcohol clean + band aid qd prn by pt and no soak... f/u 1-2wks. I figure they scar down but in a lengthened position (similar to plantar fasciotomy, TAL, etc).

I don't bill for any skin plasty or capsulotomy on any of the office stuff... those are OR codes in my estimation. I do that occasionally for OR hammertoe repairs of sublux 2nd PIPJ, etc (bill 28308, 28285, 28270). I don't add the the EHL tendon Z-lengthen code (I just consider that part of the 28270). If anyone tells you the 28285 includes the 28270, that is wrong, though... that is plain as day in AAOS and AOFAS coding handbooks that hammertoe is PIPJ and capsulotomy is MPJ (if done separately).

This fits in a jobs thread since all jobs need this... unless you're straight salary, then you board a 4th digit tendonectomy for OR, send the pt for H&P clearance, and block off 2hrs of that morning (make it the whole morning!) and don't even bother coding it since it doesn't matter?

 

[PeaJay]

I do 4-5 office tendon release for every 1 OR PIPJ fusion.

There are many uses. Mallet toe (rigid or flexible) can be addressed if you hit the capsule. Tuft wounds, pain, pre-ulcerative callusing (intralesional hemorrhage), HT in non-operative patients (have to be clear in limited expectations for more rigid deformities), heck I’ve done them for regular HT.

I am clear with expectations. The trade of better position for loss of motion is made clear. When I explain the post op course for PIPJ fusion versus tendon release most are sold on in office. I also explain that we don’t necessarily burn any bridges either in that we can go in and do PIPJ work later if their result is incomplete.

 

[ExperiencedDPM]

26. If the code descriptor of a HCPCS/CPT code includes the phrase “separate procedure,” the procedure is subject to NCCI PTP edits based on this designation. The CMS does not allow separate reporting of a procedure designated as a “separate procedure” when it is performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach.

Exactly. And modifier 59 does NOT negate that edit.

 

[ExperiencedDPM]

Yeah, I used to mess around with a 15 blade and obviously incorrectly bill it as an open procedure. Now billing correctly as perc and amazingly easy with just a needle. I used to mess around with putting a dressing on and stitches and a surgical shoe and now it's just a needle in a Band-Aid and wear a regular shoe and see you later.

And yeah the OR is what pays my bills....1800 to 2300 for a private practice Brostrom. 1500 to 1900 for a lapidus....800 bucks for 20902 you better believe I am harvesting bone graft for almost every fusion....

If you are harvesting bone from the calcaneus, it should be coded 20900. I was just involved in reviewing an audit for a DPM who billed 20902 100% of the time and all grafts were calcaneal.

He wrote the insurer a very larger refund check. I know and have heard all the arguments, but 20900 IS the appropriate code for a calc graft for a Lapidus.

Don’t believe me? I’ll see you at the audit.

 

[HardRoadPaved]

If you are harvesting bone from the calcaneus, it should be coded 20900. I was just involved in reviewing an audit for a DPM who billed 20902 100% of the time and all grafts were calcaneal.

He wrote the insurer a very larger refund check. I know and have heard all the arguments, but 20900 IS the appropriate code for a calc graft for a Lapidus.

Don’t believe me? I’ll see you at the audit.

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Bingo. Couldn't imagine the payback on that if he did it a hundred times.

 

[king22]

Do you bill for both capsulotomy and flexor tendon release? I've only billed it as a perc flexor tendon release but I almost always do a capsulotomy as well.

Why wouldn't you bill for the capsulotomy instead? It pays more.

 

[air bud]

If you are harvesting bone from the calcaneus, it should be coded 20900. I was just involved in reviewing an audit for a DPM who billed 20902 100% of the time and all grafts were calcaneal.

He wrote the insurer a very larger refund check. I know and have heard all the arguments, but 20900 IS the appropriate code for a calc graft for a Lapidus.

Don’t believe me? I’ll see you at the audit.

So what about bone graft from calc for ankle or STJ where you make multiple passes? Also, don't do for lapidus or MPJ because I want to get them WB soon. Also question for you - suppose doing a triple and need a ton. Don't get enough from calc - go to ankle and take more. Bill 2 codes...?

 

[ExperiencedDPM]

So what about bone graft from calc for ankle or STJ where you make multiple passes? Also, don't do for lapidus or MPJ because I want to get them WB soon. Also question for you - suppose doing a triple and need a ton. Don't get enough from calc - go to ankle and take more. Bill 2 codes...?

There are always exceptions and if you are performing multiple passes for a major or large graft, that would be acceptable as long as the documentation supports the code. Obviously you wouldn’t need a major or large for many procedures.

I would not recommend billing 20900 and 20902 during the same encounter. And as per the article above, there is NCCI policy that dictates that the graft must come from a distant site. If audited and your STJ fusion graft comes from the calcaneus, some may consider that local bone.

And the amount of incisions made during a procedure has no bearing on whether or not a procedure is approved. That is a major myth.

 

[air bud]

There are always exceptions and if you are performing multiple passes for a major or large graft, that would be acceptable as long as the documentation supports the code. Obviously you wouldn’t need a major or large for many procedures.

I would not recommend billing 20900 and 20902 during the same encounter. And as per the article above, there is NCCI policy that dictates that the graft must come from a distant site. If audited and your STJ fusion graft comes from the calcaneus, some may consider that local bone.

And the amount of incisions made during a procedure has no bearing on whether or not a procedure is approved. That is a major myth.

Sorry, to clarify I took from both tibia as well as calcaneus

 

[ExperiencedDPM]

Sorry, to clarify I took from both tibia as well as calcaneus

I understand. But since the amount you needed could have been harvested from just the tibia, I would not agree that it’s okay to bill both. That would make it too easy for docs to say “oops, don’t have enough from the calc, so now I have to take from the tibia and what a shame that now I’ll have to bill BOTH”.

 

[air bud]

I understand. But since the amount you needed could have been harvested from just the tibia, I would not agree that it’s okay to bill both. That would make it too easy for docs to say “oops, don’t have enough from the calc, so now I have to take from the tibia and what a shame that now I’ll have to bill BOTH”.

I can't believe you would insinuate that podiatrists would abuse something like that...
Ok what about today when I did a gastroc, didn't get as much improvement as I would have liked, so I then did a TAL (yes called it perc since triple hemi). This happens 2 percent of the time? Bill both? Or just one? And then just the lower paying TAL since that is the one that got the desired correction?

 

[ExperiencedDPM]

I can't believe you would insinuate that podiatrists would abuse something like that...
Ok what about today when I did a gastroc, didn't get as much improvement as I would have liked, so I then did a TAL (yes called it perc since triple hemi). This happens 2 percent of the time? Bill both? Or just one? And then just the lower paying TAL since that is the one that got the desired correction?

If you performed the gastroc recession then you have all rights to bill for it (27687). As long as you didn’t abort the procedure, it is billable. Even you didn’t get the desired correction, that is independent of getting paid for it. If not getting the desired correction meant you shouldn’t bill or get paid, there would be a LOT of unpaid claims! If every bunionectomy that was under corrected didn’t get paid, the insurers would be saving a lot of money.

So, bill for the 27687 since you performed the procedure, even if your correction wasn’t ideal.

The percutaneous lengthening 27606 is an augmentation and not separately billable.

Procedures 27606 and procedure 27685 are under the “separate” procedure rule which means that it would have to be for a different pathology in a different anatomical location. So as per NCCI policy, both 27606 and 27685 would be inclusive to the 27687 if all procedures were for the “Achilles”/ gastroc.

Despite what a rep will tell you or a doctor in Florida who’s name rhymes with Spam, I assure you I’m correct.

 

[DYK343]

If you performed the gastroc recession then you have all rights to bill for it (27687). As long as you didn’t abort the procedure, it is billable. Even you didn’t get the desired correction, that is independent of getting paid for it. If not getting the desired correction meant you shouldn’t bill or get paid, there would be a LOT of unpaid claims! If every bunionectomy that was under corrected didn’t get paid, the insurers would be saving a lot of money.

So, bill for the 27687 since you performed the procedure, even if your correction wasn’t ideal.

The percutaneous lengthening 27606 is an augmentation and not separately billable.

Procedures 27606 and procedure 27685 are under the “separate” procedure rule which means that it would have to be for a different pathology in a different anatomical location. So as per NCCI policy, both 27606 and 27685 would be inclusive to the 27687 if all procedures were for the “Achilles”/ gastroc.

Despite what a rep will tell you or a doctor in Florida who’s name rhymes with Spam, I assure you I’m correct.

Can you go to the ACFAS billing and coding seminar and question everything they teach us young DPMs?
You will probably get thrown out. I would expect that going in. But I think you would enjoy yourself otherwise.
Also you will make PMNews. Which is worth it alone.

 

[ExperiencedDPM]

Nud

Can you go to the ACFAS billing and coding seminar and question everything they teach us young DPMs?
You will probably get thrown out. I would expect that going in. But I think you would enjoy yourself otherwise.
Also you will make PMNews. Which is worth it alone.

Don’t get me started on that course. The ACFAS should be ashamed charging for that course. The amount of misinformation in that course is astounding.

I had one of my former residents almost go bankrupt after following their recommendations and getting audited.

 

[air bud]

Nud

Don’t get me started on that course. The ACFAS should be ashamed charging for that course. The amount of misinformation in that course is astounding.

I had one of my former residents almost go bankrupt after following their recommendations and getting audited.

Why are you still practicing? You should just start teaching coding and do audits for insurance companies. I would take that gig.

 

[PTPuser]

I would love to attend that coding / billing course!

 

[DYK343]

Whats crazy to me is we have zero formal training in any of this. Sure there is a CPT book which is helpful and usually pretty straightforward but its also easy to misinterpret.

Surprised they dont have a mandatory formal billing/coding course at school or residency graduation for all medical professions.

"If you want to accept medicare you have to take our course on billing" or something along those lines. It would be a pain and I would grumble but it would also be helpful at the same time.

 

[619]

Sure there is a CPT book which is helpful and usually pretty straightforward but its also easy to misinterpret.

Sounds like the constitution or the Bible. Easy to read but vastly different interpretation. That's why we have rich lawyers (politicians) and rich preachers.

 

[air bud]

Sounds like the constitution or the Bible. Easy to read but vastly different interpretation. That's why we have rich lawyers (politicians) and rich preachers.

This is the way