Questions for Podiatry's Leaders

[HardRoadPaved]

I am with you on ingrowns. I like them too and the billing is very straight forward. Hard to screw it up. 99204 + 11730 or 11750 (T modifier).
The billing is very straight forward and it always pays except if you forget the T modifier.

For me, a 99204 + 11750. Medicaid pays the lowest of around $220 and highest is Aetna (through an IPA) which reimburses about $750 for the same procedure. Average is around $350-$400 for the rest. Pays more than a toe amp or I&D at the hospital. Surgery for bunion or hammertoe reimburses close to $700 for most insurance and even less for medicare. You see why I will rather spend all my time in clinic.

How do you document a 99204 out of decision to do a minor procedure like 11730?

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[Feli]

How do you document a 99204 out of decision to do a minor procedure like 11730?

It works until it doesn't.

I do 99203 for cellulitis or hav or whatever, and the proc code.

He could try 99204 based on time if seeing that few pts/day (15-20), but most ppl sure can't.

I would need a couple other significant cc's to hit 99204 on most new pt ingrown. Maybe a diab new pt for shoe rx and onycho rx and bunion xr is 99204, but that's minority of 11730/50 pts for me. Maybe I undercode... dunno.

 

[icebreaker32]

highest is Aetna (through an IPA) which reimburses about $750 for the same procedure.

Every podiatrist's dream is to do about 15 of these a day, everyday at that reimbursement. If it was actually an attainable business model for most, podiatry would be more desirable and competitive than going into dermatology.

Nope.....RFC for about a hundo that requires calling the PCP for last DOS and lots of denials is more common.

 

[Shiyuan]

If I ever start a practice it will be “The Ingrown Toenail Institute of America”. Crank out dem 11750s baby! 🥸

 

[dtrack22]

Hard to screw it up. 99204 + 11730 or 11750 (T modifier).

Yeah, you’ll get money clawed back at some point if you’re billing all of these as level 4’s. Certainly some could be justified, but the real issue is the lack of problem points within the MDM criteria

Moderate
• 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or

• 2 or more stable chronic illnesses; or

• 1 undiagnosed new problem with uncertain prognosis; or

• 1 acute illness with systemic symptoms; or

• 1 acute complicated injury

 

[Adam Smasher]

If the patient has diabetes and a paronychia and gets a matrixectomy, I believe a 992x4 is appropriate.

Theoretically this is a diabetic foot infection (chronic problem with exacerbation) which we all know would legitimately lead to toe amputation if ignored long enough.

A matrixectomy is a minor procedure. In a patient with risk factors (like DM2), the risk is elevated from low to moderate.

I always spell this out explicitly in my progress notes so any auditors will know I have the components of a level 4 e/m.

 

[heybrother]

Yeah, you’ll get money clawed back at some point if you’re billing all of these as level 4’s. Certainly some could be justified, but the real issue is the lack of problem points within the MDM criteria

Moderate
• 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or

• 2 or more stable chronic illnesses; or

• 1 undiagnosed new problem with uncertain prognosis; or

• 1 acute illness with systemic symptoms; or

• 1 acute complicated injury

I have a feeling this is the 3rd time we've had this exact same discussion. A prior discussion revolved around inappropriate use of "undiagnosed new problem with uncertain prognosis" as if plantar fasciitis was the same as a lump in a breast. We should code more 4s. This one doesn't fly. The funniest part about this is that no one would bat an eye at a 99203 here and based on the rates that code would still be extremely well reimbursed.

 

[dtrack22]

We should code more 4s. This one doesn't fly.

I would agree with @Adam Smasher above. If you have a “sick” patient with an acutely infected toe (not just a painful ingrown in a well controlled diabetic with intact protective sensation), sure, a level 4 seems entirely appropriate. I think that can rise to the level of meeting problem point criteria.

Of course, the healthy 12 year old, even with acute infection, or the patient who was referred after already being placed on PO abx by their Primary, does not. Which means for most of us, a majority of avulsions and matrixectomies being performed are not level 4 visits. I code plenty of level 4s. I got into many an argument with an in house biller at one of the podiatry practices I worked for. I’m a big supporter of the idea that Podiatrist under code in general (from an e/m standpoint at least). I just can’t see how even a small majority of ingrown visits rise to a level 4 is all

 

[Boba Foot]

I’m a big supporter of the idea that Podiatrist under code in general (from an e/m standpoint at least). I just can’t see how even a small majority of ingrown visits rise to a level 4 is all

I recently went to a new PCP for a yearly visit and was coded as a 99204. I have no ongoing health issues except sleep apnea treated with CPAP. I told her I can occasionally have intermittent chest discomfort and she gave me an EKG which was normal. 99204. Made me realize I’m probably under coding.

I also went to an urgent care in December after getting sawdust in my eye and couldn’t feel like I could get it out. The doc pressed on my eye, told me to move it against pressure and flushed it out. Was also billed as a 4.

Some of our office procedures are more technical and invasive than these and yet we are paranoid to bill 4’s. Are people actually getting audited for justified 4’s or have we just been reading too much PM News with foot baths being billed as 4’s?

 

[Adam Smasher]

I recently went to a new PCP for a yearly visit and was coded as a 99204. I have no ongoing health issues except sleep apnea treated with CPAP. I told her I can occasionally have intermittent chest discomfort and she gave me an EKG which was normal. 99204. Made me realize I’m probably under coding.

I also went to an urgent care in December after getting sawdust in my eye and couldn’t feel like I could get it out. The doc pressed on my eye, told me to move it against pressure and flushed it out. Was also billed as a 4.

Some of our office procedures are more technical and invasive than these and yet we are paranoid to bill 4’s. Are people actually getting audited for justified 4’s or have we just been reading too much PM News with foot baths being billed as 4’s?

Request a treatment summary. Then I would call either the drs or your insurance and tell them they upcoded, because those are not level 4 encounters either unless they embellished heavily.

Also, wear safety glasses while woodworking, I don't do anything anymore without them.

 

[Feli]

...Some of our office procedures are more technical and invasive than these and yet we are paranoid to bill 4’s. Are people actually getting audited for justified 4’s or have we just been reading too much PM News with foot baths being billed as 4’s?

As mentioned, there certainly are some 99204 ingrown visits. Making every single one that level is very likely to make the office into a tallest blade of grass, though. It is virtually impossible to have decision complexity for 99204 on most basic ingrowns (kids, healthy adult, maybe unhealthy but basically no other foot complaint, already on abx from ER, specifically already referred for that complaint, etc). It is possible to try 99204 based on time if one sees low volume.

In the end, a lot comes down to what peers (same specialty / tax category) are doing. DME is probably the biggest example lately, but it can apply for any procedure code/set. That is doubly so if one sees any kind of volume or stays above peers for an extended period (many more of certain code/codes, higher avg E&Ms vs peers, way more XRs or DME or whatever).

....Keep in mind nearly anything can work for a few years (upcoding, bad surgery, procedures never done, prefab DME billed as customs, gross overutilization of testing, etc etc). Nothing gets tagged and investigated the very next week after the visit was billed or even right after it was paid. This is why the 'hot tips' for coding are usually newer ideas, codes from a different specialty that podiatry is now starting to hammer on, etc. It's the longer term trends (usually vs peers) or patient complaints that usually attract the magnifying glass. The mag glass isn't always disaster, but it's stressful and can result in big claw backs, wasted time sending audit charts, attorney consult fees, or much worse if the documentation isn't there or the codes were wrong, not done, or level not supported. I wouldn't say it's 'paranoid' to code WNL to peers; most ppl just don't want to make themselves low hanging fruit to even start that payer eval or audit process... they'd rather just keep the golden goose humming along happily.

 

[air bud]

If the patient has diabetes and a paronychia and gets a matrixectomy, I believe a 992x4 is appropriate.

Theoretically this is a diabetic foot infection (chronic problem with exacerbation) which we all know would legitimately lead to toe amputation if ignored long enough.

A matrixectomy is a minor procedure. In a patient with risk factors (like DM2), the risk is elevated from low to moderate.

I always spell this out explicitly in my progress notes so any auditors will know I have the components of a level 4 e/m.

Medicare defines chronic as 1 year. Even if we use 4 weeks a la Achilles ruptures....still not chronic.

The idea of a toe amp from an ingrown is absurd. It is a simple problem. There are a million other ways to get level 4s. And I bill a lot of level 4s. 4s are very easy when part of a MSG and having easy access to past labs, ultrasound,x-ray mri notes etc.

 

[Adam Smasher]

Medicare defines chronic as 1 year. Even if we use 4 weeks a la Achilles ruptures....still not chronic.

The idea of a toe amp from an ingrown is absurd. It is a simple problem. There are a million other ways to get level 4s. And I bill a lot of level 4s. 4s are very easy when part of a MSG and having easy access to past labs, ultrasound,x-ray mri notes etc.

Their diabetes probably has gone on for > 1 year so it's chronic. So has the onychocryptosis. It gets infected, that's an exacerbation.

FYI, in residency, we had to amputate a toe on a shut-in with a neglected paronychia

It will stand to scrutiny, that's all that counts

 

[air bud]

Their diabetes probably has gone on for > 1 year so it's chronic. So has the onychocryptosis. It gets infected, that's an exacerbation.

FYI, in residency, we had to amputate a toe on a shut-in with a neglected paronychia

It will stand to scrutiny, that's all that counts

You are not managing their diabetes. By this definition every diabetic patient would therefore satisfy that requirement. The problem here is not their diabetes it is the ingrown nail that is not chronic.

Here is a legit level for ingrown nail that I did the other day.

75-year-old lady concerned for peripheral vascular disease and diabetic comes in with an acutely infected nail. She is on 10 mg daily of Xarelto for a fib. It was pretty acutely infected so I decided to go ahead and remove it without a matrixectomy as minimally traumatic as possible
-I reviewed the primary care referring note. I checked her labs to see what her a1c was. I looked at a past arterial Doppler that was in the system performed 6 months ago showing appropriate blood flow. Boom I satisfied that category. In my note I documented that I did all three of these things that is three data points.
- I performed a ingrown nail removal with risk factors.

In theory, maybe it actually doesn't qualify as minor surgery is considered a 10-day global and a 11730 has a zero day global. Basically minor surgeries a 10-day global major surgeries in 90 day. So this is maybe a minor surgery with risk factors. A matrixectomy would have been minor with risk factors.

I hate to make @ExperiencedDPM the referee around these parts like we do with @diabeticfootdr in any academia/school discussion but....


Edit - this is what I mean when I say it is much easier to bill at a higher level when you are in a msg. If you were in private practice you might have seen the referring doctors note but you would not have had easy access to the arterial Doppler or the labs (most likely).

 

[dtrack22]

Their diabetes probably has gone on for > 1 year so it's chronic.

But you aren’t treating their diabetes (ie managing insulin), it’s simply a comorbidity. That’s not the argument to make it a level 4.

 

[Adam Smasher]

Even if you're not managing their insulin/metformin, we pay a lot of lip service to the notion that diabetes requires multidisciplinary management and podiatrists are an ever so important part of this team.

And if you don't buy that, E11.628 diabetic foot infection sounds like a chronic foot problem to me.

And if you don't buy THAT, idgaf. I don't need to convince you, I just need to convince whatever RN eventually audits my charts. Dunno why they would go after me when there's flagrant upcoding like @Boba Foot 's pcp

 

[HardRoadPaved]

75-year-old lady concerned for peripheral vascular disease and diabetic comes in with an acutely infected nail. She is on 10 mg daily of Xarelto for a fib. It was pretty acutely infected so I decided to go ahead and remove it without a matrixectomy as minimally traumatic as possible
-I reviewed the primary care referring note. I checked her labs to see what her a1c was. I looked at a past arterial Doppler that was in the system performed 6 months ago showing appropriate blood flow. Boom I satisfied that category. In my note I documented that I did all three of these things that is three data points.
- I performed a ingrown nail removal with risk factors.

In theory, maybe it actually doesn't qualify as minor surgery is considered a 10-day global and a 11730 has a zero day global. Basically minor surgeries a 10-day global major surgeries in 90 day. So this is maybe a minor surgery with risk factors. A matrixectomy would have been minor with risk factors.

My only issue is a 11730 for an acutely infected nail.... 10060/1 is more appropriate.


Global period is not the only way to assess minor vs major
11730 still is surgery as it is invasive.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

Surgery (minor or major, elective, emergency, procedure or patient risk): Surgery–Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification. Surgery–Elective or Emergency: Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures. Surgery–Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.

 

[air bud]

View attachment 366468

My only issue is a 11730 for an acutely infected nail.... 10060/1 is more appropriate.

View attachment 366468

My only issue is a 11730 for an acutely infected nail.... 10060/1 is more appropriate.

Yeah, honestly I don't ever use that code I always just use the avulsion or matrixectomy code this might be a blind spot for me. I still don't think this is a complicated injury and in my instance you can get to a four without relying on that.

An ingrown nail is an acute simple problem. There are no systemic issues. Yes co morbidities may exist.

 

[heybrother]

(a)

(b) Coding Pearls: How to Code for Treating a Paronychia | TLD Systems

(c) CMS has historically had very specific guidance on I&Ds. Some of the guidance is supersede/retired but some is still in effect. I'm more than willing to concede there may be circumstances where an I&D is definitely happening but I watched some of my attendings bill call a 10061 what was very clearly a 11730. I won't even touch what the difference is between a 10060 and 10061

EDIT: Most recent link.

MCD Search

The Redesigned MCD Search Page lets you search on a keyword, code, or document ID

www.cms.gov

 

[air bud]

I use epic now and obviously other EMR will allow you to take a picture. Things like this I think are a great use of uploading pictures to the chart to provide justification and CYA. I have even started doing it for some nail Care when it is clearly significantly elongated thick fungal painful. I don't see these patients back for follow-ups but I think a great use of pictures when the nail is digging into the skin and five times as long as it should be.

 

[dtrack22]

Even if you're not managing their insulin/metformin, we pay a lot of lip service to the notion that diabetes requires multidisciplinary management and podiatrists are an ever so important part of this team.

Podiatry’s professional marketing (justifying our existence) doesn’t really have any bearing on CMS E&M rules though. The “M” stands for management. You get credit for managing the condition. And there are things that we do that can be considered a part of the management of their neuropathy for example. But it would be like someone coming in for fungal nails and you claiming that your review of their mammogram should count as a data point. It’s a data point, and you reviewed it, but it wasn’t part of managing their onychomycosis and wouldn’t count towards complexity of the onychomycosis.

And if you don't buy that, E11.628 diabetic foot infection sounds like a chronic foot problem to me.

It just depends on timing of onset. It can be chronic, it can also be a newly diagnosed acute issue. In the case of a new ingrown toenail, it’s probably not “chronic” in most cases.

Again, I think it’s relatively easy to get to a 4 on ingrown patients with comorbidities that increase their risk, but the examples above just aren’t automatic justifications for it. In a health network, hospital, MSG setting where you have access to most of their medical chart, air bud probably has the easiest way get an audit proof level 4.

 

[heybrother]

Small aside - one of the things that always interests me is what code an EHR pulls when you type in a variation of a disease process. For example - adam indicated 628 above indicated "diabetic foot infection" - the internet in general identifies that as above - "with other skin complications". Without beating a dead horse here - the most specific code for a toenail infection is paronychia.

Other codes I've seen issues with similar "specific names" as shown in the EHR but with non-specific ICD-10 codes pulled:
-If I type "sinus tarsi syndrome" the codes that my EHR pulls are just "pain" codes ie. pain in ankle or whatever

-There are VERY specific PVD codes out there but if I type rest pain, claudication etc a lot of the times my EHR names it those conditions but only pulls the very non-specific I79. In fact if you search you can find very specific atherosclerosis extremity codes that spell out with claudication or with rest pain etc.

-Swelling often shows very non-specific codes.

-Don't even get me started on coding for benign or pigmented lesions - my EHR pulls very non-specific useless codes that won't get paid unless you call it what it is.

-Last of all - to the best of my knowledge all variations of plantar fibromas and plantar fasciitis code to the exact same code.

 

[PeaJay]

I reviewed the primary care referring note. I checked her labs to see what her a1c was. I looked at a past arterial Doppler that was in the system performed 6 months ago showing appropriate blood flow. Boom I satisfied that category. In my note I documented that I did all three of these things that is three data points.

Just make sure to interpret the A1c/labs just listing it does not suffice. You have to say “ a1c is elevated and thus will be at higher risk of delayed healing. Consulted patient on increased risk profile”. Our billers/compliance have been on PCPs about this.

 

[dtrack22]

Just make sure to interpret the A1c/labs just listing it does not suffice. You have to say “ a1c is elevated and thus will be at higher risk of delayed healing. Consulted patient on increased risk profile”. Our billers/compliance have been on PCPs about this.

Same with imaging (that isn’t done in your clinic or you aren’t the one billing the professional component for the read). It’s an independent review and so you need to document your findings, can’t just say “I reviewed the MRI with the patient.”

 

[air bud]

Same with imaging (that isn’t done in your clinic or you aren’t the one billing the professional component for the read). It’s an independent review and so you need to document your findings, can’t just say “I reviewed the MRI with the patient.”

But you are getting 2 point for independent. Just 1 for review. You don't get 2 points for reviewing a1c and saying this will make the ulcer most likely not heal as well. So I don't see why you need to mention the number

 

[dtrack22]

But you are getting 2 point for independent. Just 1 for review. You don't get 2 points for reviewing a1c and saying this will make the ulcer most likely not heal as well. So I don't see why you need to mention the number

It’s independent interpretation of tests ordered by another physician. Why does an A1c not count?

 

[heybrother]

It’s independent interpretation of tests ordered by another physician. Why does an A1c not count?

They had to add a bunch of text after the fact, but the companion guide to the E&M table states:

"Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level."

 

[Sweatshirt]

What happened to questions for podiatry's leaders? Start your own coding thread goddam