Coding Pearls

“My billing team and I have a difference of opinion. If we apply more than one graft, they have been using modifier -76. It is getting paid, but I am not sure that is the appropriate use of the modifier. I just assumed that we would bill for total units. However, each graft has a unit number. So, if we bill double the units, we need a way to alert the insurance company why the units are doubled. This is why we started using the 76 modifier. Any input would be appreciated.”

“I have a question concerning Medicare’s rules when billing for repeat CPT 11750. What is the recommendation for billing these for a regrowth following a previous CPT 11750? In another scenario, on the same subject, what if the procedure needs to be performed on a nail border that is adjacent to one that was already billed? Can and should we use an ABN and upon denial, bill the patient?”

“How are fracture care codes used? If a patient comes into the clinic with a fracture that you plan on eventually operating on, can you bill a closed fracture care code and then bill the surgical code when the open reduction and internal fixation is performed in the operating room?”

“So, to be clear you can never use L3000KX for a diabetic with neuropathy and diabetic ulcers even if secondary will pay.”

By Dr. Michael G. Warshaw, DPM, CPC

“Can one appropriately bill a debridement code, such as CPT 11042, each time when applying a skin substitute if indicated in a hospital, outpatient wound care clinic?”

“I think it is time for this topic to resurface. Being a coder/biller for a number of podiatrists around the U.S., I am finding that some are still scheduling “annual diabetic foot exams” as a routine on all of their diabetic patients. They are then performing a “full physical exam” and trying to bill an E/M. Sometimes this coincides with callus or nail treatment, at which time they want to add the 25 modifier. Of course, I am telling them that Medicare does not pay for an “annual diabetic foot exam” and that it is not a benefit and as such should be CASH. Has anything changed?”

“Has anyone else noticed Novitas is not approving E/M codes for treating onychomycosis medically? I saw a patient for evaluation of a discolored toenail. She was concerned it might be a fungal infection and wanted to treat the condition before it worsened. I obtained an H/P, a specimen for culture and discussed treatment options depending on culture results. I billed CPT 99212 with diagnosis code B35.1. The EOB read $0 payment. Code 49 “These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Any advice?”

“I had a patient present to the clinic with multiple, minimally displaced toe fractures. She has Medicare and we are planning to treat all four of these conservatively. When and how do I use CPT code 28510?”

Based upon an article that is posted within The American Institute of Healthcare Compliance website, it is important to note that the OIG is Auditing for Abusive Dermatology Claims. The Office of the Inspector General (OIG) is auditing dermatologists for billing an E/M service on the same date of service that a minor surgical procedure (ie. postoperative global period of 0 or 10 days) is performed. Medicare only covers Evaluation & Management (E/M) services on the same day as a minor procedure if a physician/surgeon performs a significant and separately identifiable E/M service that is unrelated to the decision to perform the minor surgical procedure. In order to bypass the CCI edits or the Correct Coding Initiative edits and bill for the E/M service and the minor surgical procedure/CPT code on the same date of service, the 25 modifier needs to be appended to the E/M service.