Dermatology Coding Alert

Tip: Report same-day debridements separately

Reporting 29580 for Unna boot applications is simple enough, but it's not the whole story: You may also be able to claim associated procedures -- or be surprised to find that some services you thought were separate are included.

Begin With the Dx

As with any claim, you should support your Unna boot service (29580, Strapping; Unna boot) with a documented and applicable diagnosis, says Suzan Hvizdash, BSJ, CPC, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. Most payers will cover the procedure for a very limited number of diagnoses, including varicose veins of lower extremities (454.0-454.2) and lower-limb ulcers, except decubitus (707.10, 707.12-707.19).

Some payers will accept additional diagnoses, such as atherosclerosis of extremity with ulceration (440.23) or sprains and strains of the ankle and foot (845.00-845.19).

Best advice: Covered diagnoses for Unna boot applications vary greatly from insurer to insurer, so you'll have to look to your individual payer for guidance. Payers often update their policies on the different diagnoses. You should check with them from time to time for any additional updates or information, Hvizdash says.

Unsure? Get a Waiver

If the dermatologist provides an Unna boot for indications or diagnoses that the payer does not approve (for instance, the surgeon may use an Unna boot as a burn dressing in some cases), you should ask the patient to sign a waiver (for Medicare, an advance beneficiary notice, or ABN).

You should ask for the waiver before providing the service. The waiver will make the patient aware that he -- rather than the insurer -- will be responsible for the cost of the service.

Report E/M With Caution

In most cases, you should not report an E/M service at the same time as an Unna boot application. For instance, guidelines set forth by Cahaba, a Medicare contractor in Alabama, Georgia and Mississippi, specify, "Unless a separate and distinct service is performed other than CPT 29580, an E/M in addition to CPT 29580 is noncovered."

If the patient has a new or different complaint that necessitates a separate and significant E/M service, however, you may report an appropriate E/M service (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), Hvizdash says.

You should attach a separate diagnosis to the E/M service to further differentiate it from the "inherent" E/M service included in the Unna boot application.

Don't Forget Debridements

If your dermatologist provides debridement prior to applying the Unna boot, you may report the debridement separately (for example, 11040, Debridement; skin, partial thickness), Hvizdash says. The debridement diagnosis is typically the same as that to support the Unna boot (for instance, 454.0, Varicose veins of lower extremities; with ulcer).

Exception: A nonphysician practitioner (NPP) may apply an Unna boot "incident-to" and under the "direct personal supervision" of the dermatologist. Under incident-to guidelines, direct personal supervision means the surgeon must be in the same suite -- but need not be in the same room -- as the NPP during the procedure.

Many NPPs, however, cannot report debridements using 11040-11044 (nurse practitioners and physician assistants may report 11040-11044 in some states, depending on scope-of-practice laws). If the NPP provides debridement prior to applying the Unna boot, you must report 97597 (Removal of devitalized tissue from wound[s], selective debridement, without anesthesia [e.g., high-pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], with or without topical application[s], wound assessment, and instruction[s] for ongoing care, may include use of a whirlpool, per session; total wound[s] surface area less than or equal to 20 square centimeters) or 97598 (... total wound[s] surface area greater than 20 square centimeters), as appropriate to the size of the wound.

Turn to 50 for Bilateral Boots

When medical necessity warrants, the dermatologist may apply an Unna Boot to each leg, says Gary W. Barone, MD, associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock. In such cases, you should report 29580 appended with modifier 50 (Bilateral procedure), rather than billing for two separate units of 29580. Payers will reimburse such bilateral procedures at 150 percent of the usual allowable amount.

Payer tip: Some carriers request that you append modifier LT (Left side) or RT (Right side) to indicate which leg the dermatologist treats when he applies the Unna boot to only one leg. Check with your individual insurer for its guidelines.

Include Supplies, Removal With Service

You should not bill separately for supplies when reporting 29580. Medicare and other payers will pay separately for casting and splinting supplies, but Unna boots do not fall into this category. Instead, payers include the cost of all Unna boot supplies (bandages, straps and paste) in their payment for 29580, Hvizdash says.

You cannot report a separate service for removing the Unna boot. Careful: Coders sometimes report 29700 (Removal or bivalving; gauntlet, boot or body cast) for this service, but this is incorrect. Noridian Medicare, for instance, specifically instructs, "Removal of Unna boot is not a separately reimbursable service. Code 29700 is not appropriate to report this service."