The Free Online Podiatry Coding Class - Student Doctor Network

[PODIATRYCRAZE]

Hi students, residents, fellows, and podiatrists. This is PODIATRYCRAZE your host for the Free Online Podiatry Coding Class.

I am a younger doctor who is above average in coding knowledge for my cohort, but far behind compared to the experienced guys on here who also happen to regularly post. Disclaimer: I do not claim to have all the correct answers. Let’s leave it to the guys who have been in practice and survived audits over the years.

Why? We were all trained well clinically and surgically. Never saw one of us go to jail for hurting a patient. I have however seen a handful of stories where coding caused a lawsuit ending in millions of dollars lost and prison time.

I learned how to code from my attendings, others learned differently from their teachers. Different jobs have different coding policies. Different doctors have a different opinion on which ones are correct versus incorrect.

How will it work? The idea is to post a regular case, some easy, some hard. Schedule could be daily, weekly, periodically? We will see what the interest is and play it from there. If I miss a session, please someone else post a case in my place. Healthy disagreements and discussions are welcome!

Starting off easy:

HPI: New patient 60F diabetes, otherwise healthy comes in with referral from primary about mild numbness in feet. 8/10 monofilament test. Good pulses. Regular toenails, not fungal but a little long.

Treatment: Educated on neuropathy and diabetes. Courtesy nail trimming. Follow up as needed. Patient declines oral medications at this time since her symptoms are not bothering her.

Answer in format

ICD:
CPT:
Typical reimbursement: (Optional)

Discussions arguments and justifications

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[PODIATRYCRAZE]

ICD: E11.40 Diabetes with neuropathy
CPT: 99203 office visit
Reimbursement: $90?

 

[HardRoadPaved]

Ummm.... So no. I disagree with "easy"

ICD:
E11. 40 is non specific and avoid ending icd in 0 as much as you can. The cheif complaint is the sensations. The diabetes history should be investigated further (ie well controlled, duration of illness). Instead you're treating the paresthesias so R20.2. What if the numbness is a radicular issue?

Then, you mentioned that there is loss on mono filament exam in 2 places. Now this is a risk issue to the patient. What if you "trimmed" the nail was neuropathic?

CPT:

Number and complexity of issues:
- paresthesias and now you need the source. However the source must be referred either for better DM management or if structural to a back specialist (pain management, ortho etc)
Amount of Data Reviewed/ordered:
- Seems like your scenario you didnt do anything... but I would read the PCP note, get the A1c data and trend it and if the source of parethesias draw that link. I would look into ordering vitamin b12 levels and other sources of neuropathy that get missed by basic tests.
Risks of complications/Patient management:
Sounds like you recommended medication. So if you then prescribe. Leave it up to patient to take the medication. Then mention you'll monitor what ever system is at risk when they are on it.

This was a great case to get into level 4 category as you have possibly more than your scenario leads on to believe. But most DPMs are like w/e, see ya level 3 come back in 6 months-year.

You also missed shoes if your clinic does it. No mention of ortho exam in your scenario.

Now in addition if this is a commercial payer you dont need class findings to trim nails. 11719 can be used. Otherwise without tropic changes and one more C finding, you dont have criteria to manage the nails. WTF is a "Courtesy trim?" I hate podiatry courtesy stuff. Your time is money.

Reimbursement:

Peanuts level 3 and wasted time to trim their nails.

Or 99204, 11719 vs ABN care, A5500/A551X + selling any OTC stuff like vitamin b pills

I learned how to code from my attendings, others learned differently from their teachers.

Something I'd def tell a jury one day....

You have to read the LCDs/Coverage policies for your area for every payer (if you're in private practice especially). End of story. Stop relying on well if it worked for them it can work for me mentality.

 

[DYK343]

Ummm.... So no. I disagree with "easy"

ICD:
E11. 40 is non specific and avoid ending icd in 0 as much as you can. The cheif complaint is the sensations. The diabetes history should be investigated further (ie well controlled, duration of illness). Instead you're treating the paresthesias so R20.2. What if the numbness is a radicular issue?

Then, you mentioned that there is loss on mono filament exam in 2 places. Now this is a risk issue to the patient. What if you "trimmed" the nail was neuropathic?

CPT:

View attachment 379090
View attachment 379091
Number and complexity of issues:
- paresthesias and now you need the source. However the source must be referred either for better DM management or if structural to a back specialist (pain management, ortho etc)
Amount of Data Reviewed/ordered:
- Seems like your scenario you didnt do anything... but I would read the PCP note, get the A1c data and trend it and if the source of parethesias draw that link. I would look into ordering vitamin b12 levels and other sources of neuropathy that get missed by basic tests.
Risks of complications/Patient management:
Sounds like you recommended medication. So if you then prescribe. Leave it up to patient to take the medication. Then mention you'll monitor what ever system is at risk when they are on it.

This was a great case to get into level 4 category as you have possibly more than your scenario leads on to believe. But most DPMs are like w/e, see ya level 3 come back in 6 months-year.

You also missed shoes if your clinic does it. No mention of ortho exam in your scenario.

Now in addition if this is a commercial payer you dont need class findings to trim nails. 11719 can be used. Otherwise without tropic changes and one more C finding, you dont have criteria to manage the nails. WTF is a "Courtesy trim?" I hate podiatry courtesy stuff. Your time is money.

Reimbursement:

Peanuts level 3 and wasted time to trim their nails.

Or 99204, 11719 vs ABN care, A5500/A551X + selling any OTC stuff like vitamin b pills



Something I'd def tell a jury one day....

You have to read the LCDs/Coverage policies for your area for every payer (if you're in private practice especially). End of story. Stop relying on well if it worked for them it can work for me mentality.

If I did all that my billers would only bill the 11719 as "with any procedure the H&P is included".
Ill bill it as a 99213 w 11719 but they auto drop the 99213.
0.17 wRVU total for this visit ($8.84)
Big payday for me.

I never trim the nail. Ever. The second I trim a nail is the second I start doing charity work.

Yes my billers suck and I dont agree with them but corporate is corporate and I have fought them and lost.

- - -

In the above scenario I would probably bill a 99213/03. Can stretch it to a 99214 but thats reaching for ways to bill a 99214. You can legally get the data points to bill a higher level but it seems a bit of a stretch.

- - -

E11. 40 is non specific and avoid ending icd in 0 as much as you can

Interesting. Never heard this before. Higher diagnostic has higher complexity?

 

[HardRoadPaved]

That really sucks but your billers don't want to fight 25/59 modifiers. It's just not worth it. However for the PP docs out there, each dollar matters. I just can't stand doing things for "free." I tell those patients it's my time and my staff who cleans the nipper.

For the leveling of visits, it's only stretching when you don't have the data points or complexity. Agreed not best to fudge ever but the scenario begs that not enough investigation was done by the doc so level 3 is all theyll get. But a case like that opens a lot of doors for those who care/have time.

Always pick the most specific icd10 whenever billing. It's a good habit to be in. Very important with the injury "S" codes.

 

[heybrother]

I think people have hit a variety of interesting points.

(1) Unspecified codes are a path to non-payment. I'm not sure where you are practicing, but I can tell you that commercial payors in my area will deny certain unspecified codes (you get paid when you specify / correct and resubmit). Hallux valgus unspecified - likely denied. Rheumatoid arthritis unspecified - probably still paid. Variations of unspecified chronic kidney disease or PVD - likely still paid. Scott and White in Texas will deny the unspecified "neuralgia and neuritis, unspecified" code (looks like M79.2) every time.

(2) My understanding is unspecified codes for many things exist because a coder / biller / whatever went through the note and couldn't tell what the patient's specified diagnosis was based on the language in the note. The doctor didn't specify, therefore the coder couldn't pick.

(3) I was considering starting my own thread for this, but I'm just going to stick it here. I think there are a lot of codes we use that we fall back on that don't truly demonstrate the true deterioration of a patient. An older patient presenting for the first time with mild PVD - using the PVD codes probably doesn't matter ie. I73.9 or .89 or whatever. But if you are trying to demonstrate "rest pain" or "claudication" - your EHR may act like the "PVD" diagnosis is appropriate but it isn't. You need to search under the atherosclerosis codes and you can find truly spelled out and specified codes that demonstrate the level of tissue injury, complication, necrosis, etc. I70.213 is a far more specific code... Similarly the ulcer sets have very specific codes for demonstrating tissue death ie. "necrosis of bone".

(4) I use Athena and when I type in buzzwords trying to get a diagnosis it has a bad tendency to pick garbage codes (irrelevant or wrong ICD-10 codes) that have been tagged with those buzzwords (they look appropriate until you check the actual code). You have to know where to look. I had a non-union awhile back. I searched for edit: non-union instead of just going through the drop-down fracture codes. Athena picked pseudoarthrosis which BCBS auto-denies. We went back and forth until I realized the issue was my ICD-10 code. The issue resolved when I went into the specific fracture set and picked the non-union code.

(5) The patient was referred to you as a diabetic with numbness. You will have to decide for yourself whether you wish to pick a diabetic neuropathy code.

(6) You'll have to ask yourself what "declines medication" means. Prescription drug management can exist even if the patient declines the medication. Consider - the patient relates to you tingling in their feet at night that wakes them. You review their prescriptions, discuss the dosing and complications of gabapentin taken once a day before bed, and the patient ultimately declines. That's potentially different than the patient saying "doc I don't need anything" from the get go.

(7) As noted above, obviously this patient will need an expensive vitamin pill for life to treat their neuropathy. Bonus points for an overpriced ineffective laser regimen.

(8) In case you should find yourself at your state conference listening to someone telling you to biopsy this patient repeatedly to check the progress of your laser, vitamin regimen - small fiber neuropathy is a diagnosis of exclusion. Its probably the last thing you do, not the first you do. Many insurances want NC/EMG first, won't pay for it on diabetics / people with known causes of neuropathy, and won't cover retesting to check "progress". As usual, Medicare is behind the curve and that's who most people are probably dinging / ...defrauding.

(9) You should definitely talk to other people about "courtesy nail trimming" and what not. Its always fascinating to hear other people's take on this. You are not alone in doing it - the words "nails were trimmed as a courtesy to the patient" is burned into my brain. However, there are no shortage of people in this profession who will straight tell a patient "no" / "I don't do that". No one else is medicine is offering free services and no one else in medicine is tripping over themselves to trim nails for $30. Pedicurists charge more than that. Remember - we didn't pick that price - Medicare picked it for us because they don't value us. Value yourself. Orthopedists aren't making $800K trimming grandmas toenail. The words that should be burned into your brain if you want to offer this service are "I'm happy to do that for you but there will be a charge at the front desk". Patients do want this service. People might even need this service. It is not a covered service for most patients and if you want to offer it you should charge them appropriately. If you believe a 99203 is worth $90 on average then consider what your finances could be if you charged an extra $75-85-105-whatever. Consider that this will be money that you don't have to wait for. It will deposit in your bank account tomorrow. Square takes 6% less than Athena does. It can't be denied or audited after the fact. Yes, you will piss some patients off. You may even get some bad reviews. But we need to disassociate free care from our practices. Value yourself. Charge for your services. Your day will be a lot easier to tolerate when $90-100 visits become $180-200 visits. A lot of historic podiatrists would have lied and just charged Medicare for it. They were choosing to subject themselves to Medicare's poor reimbursement.

(10) Last thing. The coder people on high will tell you that there is no such thing as a "diabetic foot exam". They will claim that visits like this can't be charged for. There is no one out there who is not charging for these visits. In their defense, I suppose I get what they are saying - there is no code for "diabetic foot exam". That said - presumably when you are charging for an evaluation and management you need to ensure you demonstrate actual management of the diabetic foot.

 

[heybrother]

You have to read the LCDs/Coverage policies for your area for every payer (if you're in private practice especially). End of story. Stop relying on well if it worked for them it can work for me mentality.

Bingo. I was at a conference recently where Jeff Lehrman was talking. He didn't call us about by name, but he probably was talking about us here (or maybe the IPED people). He really, really, really would like for everyone to know their jurisdiction and read the actual LCDs and coverage for your area rather than just listening to random people on the internet saying yes or no to things. I can't fault him for this. There's a link on the internet to a very old looking Medicare page saying a certain code can only be billed in a surgery center / hospital / facility etc. I showed him that and the first thing he said was "you're in Novitas, that's not from Novitas".

 

[Sweatshirt]

Hi students, residents, fellows, and podiatrists. This is PODIATRYCRAZE your host for the Free Online Podiatry Coding Class.

I am a younger doctor who is above average in coding knowledge for my cohort, but far behind compared to the experienced guys on here who also happen to regularly post. Disclaimer: I do not claim to have all the correct answers. Let’s leave it to the guys who have been in practice and survived audits over the years.

Why? We were all trained well clinically and surgically. Never saw one of us go to jail for hurting a patient. I have however seen a handful of stories where coding caused a lawsuit ending in millions of dollars lost and prison time.

I learned how to code from my attendings, others learned differently from their teachers. Different jobs have different coding policies. Different doctors have a different opinion on which ones are correct versus incorrect.

How will it work? The idea is to post a regular case, some easy, some hard. Schedule could be daily, weekly, periodically? We will see what the interest is and play it from there. If I miss a session, please someone else post a case in my place. Healthy disagreements and discussions are welcome!

Starting off easy:

HPI: New patient 60F diabetes, otherwise healthy comes in with referral from primary about mild numbness in feet. 8/10 monofilament test. Good pulses. Regular toenails, not fungal but a little long.

Treatment: Educated on neuropathy and diabetes. Courtesy nail trimming. Follow up as needed. Patient declines oral medications at this time since her symptoms are not bothering her.

Answer in format

ICD:
CPT:
Typical reimbursement: (Optional)

Discussions arguments and justifications

I can't take anything you say seriously after you say "courtesy nail trim". I know you are young but your mustache must be large

 

[HardRoadPaved]

I can't take anything you say seriously after you say "courtesy nail trim". I know you are young but your mustache must be large

Treading dangerously close to lotioning the feet right after.

 

[Feli]

I can't take anything you say seriously after you say "courtesy nail trim". I know you are young but your mustache must be large

You really have no choice in PP... or most hospital jobs, if that's the norm (sure is at most VAs, variable at others).

If the RFC nail care is a covered service (MCR or Adv plans), you can bill it if you follow LCD and guidelines for RFC.
If it's not covered (basically any other insurance), then it's a cash svc or free service or a service you don't do... up to the doc (if owner) or the hospital/office mgr or owner.

A 60F would not be MCR (unless they somehow qualified early with disability... very super rare), so it'd be 99203 or 99204 for example at hand, depending what other pertinent problems and how much you reviewed or Rx (rad or lab tests, DM shoes, DME, pharma Rx, etc)... just like @HardRoadPaved already said.

....HPI: New patient 60F diabetes, otherwise healthy comes in with referral from primary about mild numbness in feet. 8/10 monofilament test. Good pulses. Regular toenails, not fungal but a little long.

Treatment: Educated on neuropathy and diabetes. Courtesy nail trimming. Follow up as needed. Patient declines oral medications at this time since her symptoms are not bothering her. ...

...Further, no diabetic pt should ever be PRN follow up for foot care/exam. That is really bad medicine. It is also terrible practice management! They were sent to you or called your office for DM edu and risk eval... so, follow the literature and do at least annual DM foot exams, even if they are very low risk with good HbA1c and no current need for Rx shoes. You will keep your schedule fuller and not look clueless to the PCPs or Endos who refer those exams to you.

Nowhere in any DM guidelines do you PRN any diabetic. Check IWGDF page 9 for most common guidelines on DM follow up frequencies. It's sad how many DPMs don't know this; our residencies need a ton of work (although this should be even student-level knowledge). Teach the diabetic pts what to look for and re-appoint them in 12mo, 6mo, 4mo, 3mo, or even sooner if their situation dictates (use the EBM to decide based on ulcer hx, PVD, neuropathy, deformity). Let them know they can call anytime if they have an issue or injury. Quit with the PRN thought. Follow the EBM.

 

[heybrother]

For private practice, some large commercial insurers will reimburse systemic covered care (1105x, 1172x, etc) if you document it exactly as you document Medicare. I've attached an example below from BCBS of RI where its pretty clear they've essentially taken a stance identical to Medicare.

https://www.bcbsri.com/sites/default/files/polices/Routine%20Foot%20Care%20and%20Nail%20Debridement_Final_V1.1_0.pdf

Agree with Feli concerning the annual visit. I make it a point to explain to the patient how they came to qualify for an annual visit and I try to make sure the patient feels like they are getting good value at these visits. Patients routinely have $60-85-100 copays.

 

[Adam Smasher]

...Further, no diabetic pt should ever be PRN follow up for foot care/exam. That is really bad medicine. It is also terrible practice management!

I'll be the contrarian then.

I used to do "annual foot evals" for non neuropathic DM. The only patients who actually kept those visits were the ones with $0 co-pays. And when they came, the exam boiled down to ensuring that the feet were still solidly connected to the ankles. It seems entirely arbitrary for the literature to advocate that your feet should be screened just because the earth has orbited the sun one more time. The singular act of me doing a neurovascular check and reminding pts to check their feet is a VERY low yield intervention.

At this point, the loyalists will cite literature claiming the pts who go for their annual foot screenings are less likely to suffer complications down the road. Congratulations! You've proven that people who are conscientious about their health are healthy! Come back to me after you re-learn selection bias.

"But Dr Smasher! the IWDGF says this:"

Wait what's that say on the bottom?

So much for your ebm...

Reappointing these patients for an annual 99212 is only good practice management if you're struggling to fill your schedule. This is the chiropractic approach ("get em in and keep em coming"). Maybe think instead about why you're struggling to get NPs into that slot and you won't need to do annual make-work foot screenings.

And don't get me started up on magic shoes...

 

[PODIATRYCRAZE]

This is perfect. Exactly the type of responses that we need. Great variety of thought. Main takeaways from this are, there are in fact multiple ways to bill this encounter just like there are multiple ways to treat the patients. Full on investigation which may or may not be warranted that could require multiple healthcare resources versus a minimalistic approach. Which one is best for the patient? It depends on a case to case scenario. Thanks again to all who gave input, you are teaching many readers how to give good care, get paid appropriately, and make a good name for our profession. Once I start taking these tips I might have to owe some of you a fancy dinner with all the extra income I will be making.

I will do a better job of highlighting the actual patient scenarios. Left many details out which I meant to be implied as normal findings, such as the missed orthopedic exam, but for future cases I will be more clear about this.

Many of us hardly ever actually bill for this kind of service, and instead leave it up to our billers so this is a step up in difficulty. Inpatient consult

HPI: 44F in ICU unresponsive, significant past medical history Type 2 diabetes, end stage renal disease, hemodialysis MWF, right partial 1st ray amputation 3 weeks ago by a podiatrist at a different hospital (chronic wound became infected with septic joint), admitted for cardiac arrest. No acute infection at surgical site, skin edges healed with scabbing, DP and PT pulses present, passive range of motion within normal range, unresponsive to neurology and orthopedic testing. From chart checking you are able to tell she is capable of ambulation prior to this, no notes regarding diabetic shoe use.

Treatment: Sutures removed, some scab taken off, sign off and follow up with surgeon outpatient or if your location is more convenient she can switch over to you.

Some things to note, this is outside the global period (0 days), and since you are a completely different provider (not in the same practice as original surgeon), global period would not apply to you anyways. This is my understanding.

 

[PODIATRYCRAZE]

Being honest I never even put ICD10s on my inpatient visits. Is this a mistake?

ICD: R26.89 Ambulatory dysfunction

CPT: 99223 Comprehensive H&P inpatient

Reimbursement: $50?

 

[Adam Smasher]

Being honest I never even put ICD10s on my inpatient visits. Is this a mistake?

ICD: R26.89 Ambulatory dysfunction
CPT: 99223 Comprehensive H&P inpatient
Reimbursement: $50?

I usually make a problem list for everything that has bearing on the consultation. Usually diabetes with foot ulcer plus cellulitis plus/minus a PAD code. Heybrother is right about using I70.2xx and being specific.

In your scenario, the consultation is more of an "on-board" consult. Hard to justify the 99223 and probably not a 99222. Diagnosis: Z47.81. If you make a bunch of soft recommendations about diabetic foot evaluations, offloading, wound care, etc you could swing a 99221 but your patient's admission ultimateley has nothing to do with you. If she's homeless, you have "social determinants of care" that up the complexity of the visit, however. Personally, I would just communicate recommendations with the nurse/hospitalist over the phone about it rather than consume time to actually write a nothing note.

 

[HardRoadPaved]

Being honest I never even put ICD10s on my inpatient visits. Is this a mistake?

ICD: R26.89 Ambulatory dysfunction
CPT: 99223 Comprehensive H&P inpatient
Reimbursement: $50?

Brah.... level 3?

and at that level 3 for ambulatory dysfunction...? She didnt have issues ambulating!

I think you kinda missed the boat on your own scenario. You were consulted for management of a surgical site. Sutures were still present. So you made a clinical decision to remove them.

ICD 10: any code relating to the soft tissue infection as you are signing off that there is no need for further abx if not already done so.
CPT: 99221 + 15853 (yep you can get paid to remove those sutures)

 

[air bud]

Did you use the terms medication management? Chronic unstable condition? I am assuming you were talking about gabapentin. Patient declines it, so what you discussed it. Level 4.
Don't touch the nails unless they ask them figure out a way to decline. Not vasculopathic then GTFO. I am getting better in recent years. Even 90 year old granny gets declined these days. Easy to do when their adult son is not in the room.

 

[air bud]

Yearly diabetic foot exams are a joke. Are you vasculopathic? Do you history of ulcer with a crazy deformity? Yeah. Will allow, maybe even every 6 months. Normal foot no ulcer an diabetic, that is for PCP to worry about

 

[Feli]

Yearly diabetic foot exams are a joke. Are you vasculopathic? Do you history of ulcer with a crazy deformity? Yeah. Will allow, maybe even every 6 months. Normal foot no ulcer an diabetic, that is for PCP to worry about

Ye grand hospital foot healers of little faith...
the fabled PP satchel brimming with PCP loyalty and legendary golden pile of insurance checks in thee mailbox and interwebz bank account filled with talismans shall neverest arriveth. 🧙‍♀️

 

[PODIATRYCRAZE]

Couple things, I spoke to my biller and yes inpatient CPT codes do need to be associated with an ICD10. So let's continue on with these lessons to help make their lives easier and make sure our work gets reimbursed. Got a good curriculum schedule idea. 3 sessions per week, Monday Wednesday then Thursday/Friday. 1 outpatient coding (office, house calls, wound center, nursing homes), 1 hospital coding (ED, floor consults, rounding), 1 surgical. So today's will be surgical.

HPI: 41M with no significant past medical history besides 10 years of bilateral bunion pain finally took the leap to get it taken care of. Intermetatarsal angle was minor, and he only really had pain at the site of the medial eminence. XR has no met primus elevatus, and clinically had good range of motion.

Treatment: Right foot Austin procedure was performed using 1 headless screw, Akin was originally planned but found to be unnecessary after the Austin. Standard surgery, hoping for no postoperative complications. He purchased a surgical shoe from your office a few weeks ago for $20 and brought it with him today. Decided to just to right foot today, see if he likes the outcome and then do left later

Any other necessary quick clinical tips that could be done preoperatively, intraoperatively, or postoperatively and billed for are welcome.

 

[PODIATRYCRAZE]

ICD: M20.11 Hallux valgus

CPT: 28296 Distal metatarsal osteotomy

Reimbursement: $400?

 

[Feli]

Couple things, I spoke to my biller and yes inpatient CPT codes do need to be associated with an ICD10. So let's continue on with these lessons to help make their lives easier and make sure our work gets reimbursed. Got a good curriculum schedule idea. 3 sessions per week, Monday Wednesday then Thursday/Friday. 1 outpatient coding (office, house calls, wound center, nursing homes), 1 hospital coding (ED, floor consults, rounding), 1 surgical. So today's will be surgical.

HPI: 41M with no significant past medical history besides 10 years of bilateral bunion pain finally took the leap to get it taken care of. Intermetatarsal angle was minor, and he only really had pain at the site of the medial eminence. XR has no met primus elevatus, and clinically had good range of motion.

Treatment: Right foot Austin procedure was performed using 1 headless screw, Akin was originally planned but found to be unnecessary after the Austin. Standard surgery, hoping for no postoperative complications. He purchased a surgical shoe from your office a few weeks ago for $20 and brought it with him today. Decided to just to right foot today, see if he likes the outcome and then do left later

Any other necessary quick clinical tips that could be done preoperatively, intraoperatively, or postoperatively and billed for are welcome.

It's an individual call, but I don't do surg velcro shoes for early post-op bunions (or much of anything OR, besides some soft tissue surgery)... they don't immobilize EHL and FHL, so you're inviting wound issues or edema. It's dumb on many levels... a pt who slips down the stairs or stumbles hard with surg shoe will have fractured osteotomy site, but one with a boot on will just have a sore bottom, surgery foot basically fine.

CAM boot + NWB for a couple weeks will get less pain, less edema, better results (and better codes).
Pre op 99214 + L4361 (later EvenUp) + possible E1043 + 97116 is a lot better than just the 9921x and surg shoe, huh?
It's both better pt outbomes and better prac mgmt to do the tall pnuemo boot.
Short boots are suboptimal to immobilize the lower leg muscles and risk tibia fx with a bad fall, but they are basically a way for the office to cheap out to make $5 more. Sure, they can be used for bigguns with injuries or to protect wound bandages due to tree trunk leg ppl having too big calf girth for tall boots (same ppl are usually too high BMI to be good candidates for elective surgery).

You get 4 icd codes per CPT, so pain is a good secondary or 3rd line code on any proc (OR or office).
One icd code is too close to none. I would strongly suggest 2 or 3 appropriate ortho codes (M20.11 in this bunion 28296 case, can add M21.16X1 and/or M25.571) + pain code tagged to each CPT (with proper mods!) on all OR stuff. Giving your biller 2+ options will minimize payer rejects and give them ammo to re-submit bundling non-pays without having to ask you.

 

[Feli]

Being honest I never even put ICD10s on my inpatient visits. Is this a mistake? ... .

...Couple things, I spoke to my biller and yes inpatient CPT codes do need to be associated with an ICD10.

Yes, of course you need ICD for inpt CPTs.... outpt ones... office ones... OR ones... house call ones... any.

ICD and CPT are built to work together. They're obviously designed that way (even if AMA doesn't expressly say that in orig manuals). The links/combos that will get paid and the crosswalks are critical (and hardest part of coding... why stuff like certain manuals/newsletters and books and APMA Coding RC are so valuable).

There are a few CPT/HCPCS that dont' need mods, but they all need ICDs.

 

[Boba Foot]

I used to do "annual foot evals" for non neuropathic DM. The only patients who actually kept those visits were the ones with $0 co-pays. And when they came, the exam boiled down to ensuring that the feet were still solidly connected to the ankles. It seems entirely arbitrary for the literature to advocate that your feet should be screened just because the earth has orbited the sun one more time. The singular act of me doing a neurovascular check and reminding pts to check their feet is a VERY low yield intervention

This basically just summed up a “yearly physical” by a PCP for younger healthy people too though. Except they take blood for some 20 different markers that are usually normal.

I commonly feel like preventative visits are somewhat pointless with mostly uncomplicated diabetics but you’re not really doing it to find the normal people, you’re trying to catch the borderline patients before they sink into the deep end. A lot of preventative visits are very low yield, but if you can catch a diabetic vasculopath at claudication before they’re in gangrene and send them for intervention then it justifies the 20 other low yield follow ups you’ve seen

 

[Feli]

This basically just summed up a “yearly physical” by a PCP for younger healthy people too though. Except they take blood for some 20 different markers that are usually normal.

I commonly feel like preventative visits are somewhat pointless with mostly uncomplicated diabetics but you’re not really doing it to find the normal people, you’re trying to catch the borderline patients before they sink into the deep end. A lot of preventative visits are very low yield, but if you can catch a diabetic vasculopath at claudication before they’re in gangrene and send them for intervention then it justifies the 20 other low yield follow ups you’ve seen

Bingo.

The DM foot evals sent to any DPM are 3 things:

1. educate pt, exam, tell them what to look for, shoes or XR or PAD test or etc if needed, make relationship if they have a future problem, determine recommended f/u duration
2. get a paying visit out of it (duh)
3. report back to the PCP, gain goodwill in city/hospital/etc

I have worked in hospital settings, PP, MSG group (mostly Endos)... DM foot exams refers will always be there.
I still get them (even though I don't market to that aspect of pod at all anymore). It's unavoidable and a good practice builder, though. I'd never just PRN them. Never have. I don't really care if they show up in a year (if that's the guidelines f/u interval), but I would not be crazy enough to have them go back to PCP or Endo saying that "podiatry didn't do anything, they told me I'm fine and they don't need to see me." The PCP or Endo is sending the patients to podiatry because they know the guidelines: all DM pts should have pod, ophthalmo, nutritionist, etc relationship (and they don't want to or don't know how or probably just don't have time to do annual DM foot exam properly themselves).

People who don't get that are kinda missing the boat (both good pt care and team/refer game)... or they're salary DPM and just wanting to thin their schedule? Dunno.

 

[Shiyuan]

PRNing is appropriate IMO if:

1) “Healthy” DM (no PAD/neuopathy, A1c <7)
+
2) Their PCP/Endo is already checking their pulses, SWM, etc. at those visits.

Other than checking for skin stuff, what else more am I offering them at a “yearly foot check”?

And just for completeness sake, only a small subset of my patients meet both of these categories. Few and far between! I still do offer to see these patients qYearly, but leave it up to them.

 

[Feli]

...Other than checking for skin stuff, what else more am I offering them at a “yearly foot check”? ...

It depends... what did you learn in school? (or since)
Ability to fix their puncture wounds, sprains, pre-ulcer hammertoes and met head lesions, nail issues, arthritis F&A, footwear recs, 1000 other things. So, you offer them the relationship with someone who has those skills.

You mainly offer the DM foot exam:
You will pick up a sub 1st callus pre-ulcer and Rx shoes and insoles before the pt will develop a bruise or ulcer.
You will pick up forefoot neuropathy before they will and tighten to q6mo or q3mo.
You will recommend a tendonotomy for a 3rd toe tuft pre-ulcer before pt will get a wound and osteo.
You'd notice heel fissure or stage 0 Charcot or a pigmented lesion way before the pt would.
You'd realize calf cramps walking the dog with trace PT is more than MSK and could really make an impactful refer.
The list goes on and on.

The DM exam is just a reminder to them from the EMR text reminder: "how are the feet doing?" That is the whole point of preventative care.

A ton can change in a year... ppl gain weight, start to eat crap, get divorced, different shoes for a new job, PCP changes, Endo retires, medical issues, MVA or fall, CVA, whatever. Take your pick. Diabetic ppl have a lot more potential then non-DM for rapid health changes since lion's share of DM2 are overweight/obese and the physio is altered.

Guidelines are guidelines for a reason. The DM exam visits are 100x more medically useful and impactful than most non-DM quasi-fraud RFC, which is the bulk of visits for most TFPs. If you clear your sched of anything, jettison those nonsense visits for fairly healthy 65F "pedicure" visits. The DM exams are much more legit - even if you just do your exams, note WNL, educate a bit, 9921x and "see you in about a year."

...Again, if you are in PP, this is common sense: help the pt, follow the guidelines, build your office.
Even if you are "academic" hospital pod on a fat salary with almost zero incentive to be busy, it's still good medicine...
And, building your clinic volume will also get you another approved DPM hire and maybe q4 instead of q3 call.
So, there's that.

 

[Shiyuan]

It depends... what did you learn in school? (or since)
Ability to fix their puncture wounds, sprains, pre-ulcer hammertoes and met head lesions, nail issues, arthritis F&A, footwear recs, 1000 other things. So, you offer them the relationship with someone who has those skills.

You mainly offer the DM foot exam:
You will pick up a sub 1st callus pre-ulcer and Rx shoes and insoles before the pt will develop a bruise or ulcer.
You will pick up forefoot neuropathy before they will and tighten to q6mo or q3mo.
You will recommend a tendonotomy for a 3rd toe tuft pre-ulcer before pt will get a wound and osteo.
You'd notice heel fissure or stage 0 Charcot or a pigmented lesion way before the pt would.
You'd realize calf cramps walking the dog with trace PT is more than MSK and could really make an impactful refer.
The list goes on and on.

The DM exam is just a reminder to them from the EMR text reminder: "how are the feet doing?" That is the whole point of preventative care.

A ton can change in a year... ppl gain weight, start to eat crap, get divorced, different shoes for a new job, PCP changes, Endo retires, medical issues, MVA or fall, CVA, whatever. Take your pick. Diabetic ppl have a lot more potential then non-DM for rapid health changes since lion's share of DM2 are overweight/obese and the physio is altered.

Guidelines are guidelines for a reason. The DM exam visits are 100x more medically useful and impactful than most non-DM quasi-fraud RFC, which is the bulk of visits for most TFPs. If you clear your sched of anything, jettison those nonsense visits for fairly healthy 65F "pedicure" visits. The DM exams are much more legit - even if you just do your exams, note WNL, educate a bit, 9921x and "see you in about a year."

...Again, if you are in PP, this is common sense: help the pt, follow the guidelines, build your office.
Even if you are "academic" hospital pod on a fat salary with almost zero incentive to be busy, it's still good medicine...
And, building your clinic volume will also get you another approved DPM hire and maybe q4 instead of q3 call.
So, there's that.

I agree, but from my experience most patients that get diabetic foot exams from their PCP +/- endo unlikely to see you for the same “exam” a few months later. Most of this subset of pts just call me when they need me… urgent same-day slots always available for things you listed.

But then again, I primarily live in the Medicare Advantage world, so there’s that 🤪

Also…. Random thought… Maybe everyone can just wear carbon fiber plates in their shoes to avoid foreign bodies? 😅

 

[HardRoadPaved]

If I scheduled my patients a year out then I'd have so many holes. Same goes with nail care. Too many no shows.

Just call me if you need me. Would rather plug my schedule and be available to people who care about their health.

I think this is where health systems win over the PP doc because the PCP has in their EMR that they didnt do their yearly eye or foot screen.

 

[dtrack22]

You will pick up a sub 1st callus pre-ulcer and Rx shoes and insoles before the pt will develop a bruise or ulcer.

We are talking people who are fine for yearly visits. People who would stratify into this category do not qualify for DM shoes and inserts

You will pick up forefoot neuropathy before they will and tighten to q6mo or q3mo.

So can their PCP. It’s a quality measure for them.

You will recommend a tendonotomy for a 3rd toe tuft pre-ulcer before pt will get a wound and osteo.

Again, not in a sensate patient who stratifies into the yearly foot exam category

You'd notice heel fissure or stage 0 Charcot or a pigmented lesion way before the pt would.

The patient will also notice a heel fissure because they hurt. And the non-neuropathic patient isn’t getting charcot

You'd realize calf cramps walking the dog with trace PT is more than MSK and could really make an impactful refer.

PCP should recognize claudication symptoms, but this is reasonable

"how are the feet doing?" That is the whole point of preventative care.

Preventative foot examinations are not a reimbursable service in and of themselves

I do tell healthy DM patients that someone should check their sensation and pulses once a year. Luckily our templates don’t schedule out that far. I tell all of them that if their PCP does a good job of looking at and asking about their feet once a year that they don’t need to have me repeat the exam and let PCP or Endo refer as needed.

 

[Feli]

We are talking people who are fine for yearly visits. People who would stratify into this category do not qualify for DM shoes and inserts


So can their PCP. It’s a quality measure for them.


Again, not in a sensate patient who stratifies into the yearly foot exam category


The patient will also notice a heel fissure because they hurt. And the non-neuropathic patient isn’t getting charcot


PCP should recognize claudication symptoms, but this is reasonable


Preventative foot examinations are not a reimbursable service in and of themselves

I do tell healthy DM patients that someone should check their sensation and pulses once a year. Luckily our templates don’t schedule out that far. I tell all of them that if their PCP does a good job of looking at and asking about their feet once a year that they don’t need to have me repeat the exam and let PCP or Endo refer as needed.

I don't disagree, but your assumption here is that the patient status is static. "Are" is present tense.
Being currently sensate or currently without callus pre-ulcer or currently fitting into today's shoe or currently with good skin quality or currently with WNL CFT is not a guarantee of future status.

Things change. They can change very fast with DM (hence guidelines based on risk strat).
That is the whole point of EBM preventative care... annual physical with screen labs, annual mammo, annual c-scope, annual eye exam, foot exam, etc. The idea is to catch changes.

...At the end of the day, it's a personal choice. I don't think anyone (pod, PCP, patient) will go wrong following the guidelines.
It is no bother to cancel a follow-up pt who doesn't return a 2wk reminder text and fill that spot (which would be a double or triple book anyways since it's a fast appt).

In PP, the PCPs have choices, so I give them what they refer for... esp when they send good payer visits. If you get too busy, you just hire more help or associate or drop the bad payers.
In hospital pod, PCPs are usually much more locked in and will send anyways as all are hospital employ... and payers matter less.

 

[Feli]

...I think this is where health systems win over the PP doc because the PCP has in their EMR that they didnt do their yearly eye or foot screen.

For sure, 100%... that is exactly why a lot of MSGs and hospitals have hired DPMs. This is a great thing for podiatry... even if there are many "boring" low risk DM exam visits. There are many other more interesting visits that come with it also.

The groups and facilities want that MCR rate compliance booster for the exam check boxes, and it's a good sell point for pgy3s and DPMs trying to create a job of that type.

That being the DM foot exam stop sure beats the heck out of C&C work for HealthDrive or a crusty old moustache PP in most people's book. I did that for a few years for MSG that was mostly Endos... got to help a lot of ppl and fairl $ and surgery out of it also.

 

[dtrack22]

but your assumption here is that the patient status is static. "Are" is present tense.
Being currently sensate or currently without callus pre-ulcer or currently fitting into today's shoe or currently with good skin quality or currently with WNL CFT is not a guarantee of future status.

Not my assumption. I do expect every few years for your exam to show progression of some vascular and neurologic disease. But you aren’t catching or doing most of your examples, for patients who fall into the “yearly” foot exam group. Patients with pre-ulcerative calluses, Charcot, LOPS and deformity requiring DM shoes/inserts are virtually always already in a risk group where more frequent inspections and/or RFC is recommended or actually covered by insurance. Your examples were just very hyperbolic or extreme. I believe they should have some sort of routine foot monitoring, because they will always progress. I just don’t think I am the only person capable of providing the evaluation and so I don’t fault people who 💩 on the idea of their importance/value.

 

[Adam Smasher]

Let's say you're doing your annual foot screening and the pulse downgrade from a 2/4 to 1/4. What then? What actionable information have you uncovered? Do we refer every 1/4 for vascular consults?

Let's say it downgrades to 0/4 but there's no claudication/rest pain/tissue loss. Still vascular refer? Maybe yes, but I understand they won't treat asymptomatic PAD.

Let's say the monofilament exam downgrades from 10/10 points to 8/10 points. What then? Magic shoes? Not covered unless there's a callus or deformity (e.g. adductovarus pinky toe, lol) in play. And even then, the callus and the deformity already establish the need for the magic shoes, not the neuropathy.

We're already telling patients to check their feet daily and moisturize, etc. We're already telling them to keep their sugar controlled. What do you do if you uncover changes, tell them the same thing...just more strenuously?

Not to mention 1 year is PLENTY of time for someone to get into trouble.

 

[HardRoadPaved]

Can we be clear that "screening" is NEVER an e/m?

To have an e/m you need a chief complaint. Screenings are discretion of the health plan to cover and have separate codes.
use code G9226 and get paid peanuts.


This is why I find them to be a waste of time.

Foot care (for diabetes)

Find diabetic foot care coverage by visiting medicare.gov & get help with costs due to diabetic peripheral neuropathy, costs due to glaucoma care.

www.medicare.gov

You can get a foot exam once a year, as long as you haven't seen a footcare professional for another reason between visits.

 

[Adam Smasher]

To have an e/m you need a chief complaint.

What if the patient's chief complaint is "I want to see if I'm eligible for shoes?"

 

[DYK343]

What if the patient's chief complaint is "I want to see if I'm eligible for shoes?"

"I want to see if I am eligible for shoes"?

More like: "Hi doc im diabetic I am here for shoes."

 

[air bud]

A small subset of the population need their feet seen more often than they do. A very large majority of the population does NOT need to see a podiatrist on a consistent basis....

 

[HardRoadPaved]

What if the patient's chief complaint is "I want to see if I'm eligible for shoes?"

Sounds more like a chief request.

also I get more of "I want my free pair of shoes for this year"

 

[wakaflocka88]

Ever since I limited it to only TWO max “diabetic consult foot exam appts” per day, my RVU and MSK practice has significantly increased. I tell the staff - I don’t care if it’s for a foot exam, inquiring about possible nail care, or whatever BS they try to mask it as - it will go in only 1 of 2 slots for each day and that’s it.

Half the time, patients will sit in the chair and tell me they have no idea why they are here and they only came because “my pcp said so.”

 

[PODIATRYCRAZE]

HPI: New healthy patient 21M painful right ingrown hallux toenail to the medial border. No other complaints at this time

Treatment: Partial nail avulsion, follow up as needed

 

[PODIATRYCRAZE]

ICD: L60.0 Ingrowing nail
L03.03 Toe cellulitis

CPT: 11730 Partial nail avulsion
99203 Office visit

Reimbursement: $200? 25 Modifier

 

[air bud]

Anyone who needs to see ingrown follow ups doesn't have enough patients to be busy, has huge overhead and doesn't know what they are doing/are screwing patients.

 

[Adam Smasher]

LOL, some people schedule matrixectomy followups 2 weeks out (past the global) and think they've unlocked some secret billing hack

 

[Adam Smasher]

ICD: L60.0 Ingrowing nail
L03.03 Toe cellulitis
CPT: 11730 Partial nail avulsion
99203 Office visit
Reimbursement: $200? 25 Modifier

I'm pretty sure the 25 mod is not needed.

A pearl I picked up from a Lehrman webinar: document in separate paragraphs what was the clinical decision making (the e/m) and the procedure (the CPT), even for new patients

 

[Feli]

LOL, some people schedule matrixectomy followups 2 weeks out (past the global) and think they've unlocked some secret billing hack

I do 2wks f/u for ingrown procedures every time.

I don't see why not make a f/u if a procedure is done - a procedure which creates a wound and wound care f/u for the pt. I've never had a ENT or plastics or derm take off a lesion and tell me to remove the stitch myself or prn me. The only patients I might consider letting prn after an ingrown would be maybe a healthy health care worker who knows exactly how to take care of it and what to look for.

It is probably <5% that need abx on f/u ingrown visit... probably <5% that need wound 97597 debride... but at 2 weeks, nearly all of them are still healing and might need a review of the plan, local wound eval for maceration or contamination, more band aids and alcohol pads, ok as to when to return to various footwear or activity, etc. That is a visit my MA can basically do, so just double book them but see that they are doing fine. I then prn the vast majority of them at that 2wks visit, but you have the occasional who developed impressive cellulitis or hallux blister, maceration, whatever. Also, if you treat industrial job patients of any kind, many often need a work note saying the date when they no longer have an open wound (gives the ok for various chemical or radiation exposure areas)... impossible to do if you never see them back.

For diabetic ingrowns, I typically follow them until they are healed... usually 2wk check, then 6wks later (2mo from procedure).... then back to whatever schedule they're normally on based on DM risk level.

Also, I very seldom do avulsions... matrix (which does take a bit longer to heal) is the clear play if the nail is wide, curved, or they've ever had an ingrown in the past... why make them go through the same thing in a year or two? I really only do avulsions when it's a first-time ingrown with a normal nail shape (they likely just trimmed it wrong), a young peds pt, or elderly with infected/abscess nail but questionable circulation (be cautious with phenol there).

In a many paronychias with appreciable nail fold purulence, 10060 or 10061 (if requiring anesthesia, wCx, abx Rx, etc) can be fine and appropriate... and slightly to significantly more reimbuse or RVU than 11730.

ICD: L60.0 Ingrowing nail
L03.03 Toe cellulitis
CPT: 11730 Partial nail avulsion
99203 Office visit
Reimbursement: $200? 25 Modifier

Need a right/left 1/2 on the cellulitis... plus add another code or two or three on the E&M (whatever is appropriate).
9920x gets a -25, yes.
11730 needs a toe mod (-Tx)... I would do L60.0 ingrown and pain secondary M79.67x
Reimbursement is much higher if you do a 11750, but it's case by case.

I'm pretty sure the 25 mod is not needed. ...

It is needed.
E&M + procedure is the very definition of the 25 mod.
Maybe your biller and/or EMR is adding them after the fact.

Anyone who needs to see ingrown follow ups doesn't have enough patients to be busy, has huge overhead and doesn't know what they are doing/are screwing patients.

Pipe down, General Hospital. 👩‍⚕️ 🏥 👨‍⚕️

Not all of us have a biggun paycheck whether our schedule is full or empty... and a wait list of aspiring actress fracture and bunion and ankle OA pts. 🦴

 

[AttackNME]

Whenever you PRN someone, they don’t always see it as us trying trying to save them some money or a visit. It sometimes will look like we don’t care and we don’t want to see them again. I do offer to see my ingrowns for followup but I tell them if they feel like it’s healed and they’re busy, then I’m comfortable with them cancelling

 

[Adam Smasher]

From my observation, nondiabetic matrixectomy patients either heal uneventfully or eventfully, but they always heal. When it happens, that post-op infection happens around day 3-5, not day 14. By the time you reach day 14, they're in the clear. I've been accused of milking copays from patients after having them schedule a precautionary f/u.

For what it's worth, I've been PRN'ed after having a skin biopsy taken on me. Doc said he'd call me if it turned out to be anything. That was the last I saw of him ever again.

 

[Feli]

Whenever you PRN someone, they don’t always see it as us trying trying to save them some money or a visit. It sometimes will look like we don’t care and we don’t want to see them again. I do offer to see my ingrowns for followup but I tell them if they feel like it’s healed and they’re busy, then I’m comfortable with them cancelling

Exactly. Perfect approach.

You will lose patients if you prn too many (and I'm saying this as someone on a waitlist... so I prn as many as I reasonably can).
They will typically be lost to the competition, which is a bad look if that gets back to the PCP that Dr. Feli gave them an inject and an insole and prn... but Dr Attack took his time, Rx for PT, and they got better.

It is always much better to make a f/u appointment and tell them they can cancel if they are doing fine ("but please give us as much notice as you can so that we can give that spot to someone else"). This is as much about reading the patient as it is just the foot issue/progress. You have to put yourself into the mind of the person whose foot (or their kid's or spouse's or parent's or etc foot) was just injected, procedure was done, and they are leaving with wound instruction and a numb swollen toe.

Basically, in PP (or any office you want to grow), let them prn you.
I frequently put "3mo or PRN" or stuff like that on my f/u note to my desk, and they know to see what the pt would prefer or use their intuition when they mention "as needed." Some prefer that; many do not.

For ingrowns, I would say 90% of matrix 2wk f/u show for that visit... maybe 60% of avulsions (but again, I barely do those). Most who do not show cancelled when they got the reminder, and for the very few no-shows, it was a double book anyways.

 

[air bud]

I tell everyone they are more than welcome to come back at 2 weeks if they questions or concerns and I make sure they know I am sincere. I promise you they will heal just fine. Willing to die on this hill. It is a waste of patients money and time. Let's say 3-5 percent reasonably need to be seen again. Like doing an avulsion on a 85 year old that needs it but you don't want to do a matrixectomy because it will potentially be too damaging to the surrounding soft tissue and if it happens again when it regrow. Cross that bridge when you get there.