Orthopedic Coding Alert

Keep tabs on details to help justify more extensive treatments later.

Plantar fasciitis -- a condition in which the plantar fascia becomes inflamed and painful -- is the most common form of heel pain and can be treated many different ways. Keep up with the latest on correct diagnosis and treatment options so you'll have a paper trail to support medical necessity at every level.

Start With a Single Diagnosis

With heel pain affecting nearly 2 million Americans and ranging from mild discomfort to debilitating pain, it's not uncommon for a patient to call on your orthopedist before visiting a podiatrist, especially if your surgeon has treated the patient for other problems. Most plantar fasciitis pain is located close to where the fascia attaches to the calcaneous, or heel bone.

The exact cause is unknown, but once your physician diagnoses plantar fasciitis you'll report diagnosis 728.71 (Plantar fascial fibromatosis) says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

Know the Most Likely Injection Options

Your physician will begin by treating the patient's plantar fasciitis conservatively with pain relievers, home exercises, night splints, or rest. He then will alter the plan as needed.

Next step: Your physician might administer a cortisone injection directly to the plantar fascia. Code this treatment with 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]). You can also code for the medication, such as J0702 (Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg) for Celestone Soluspan.

Tip: Keep an eye on multiple procedures or services during the same encounter, such as an injection followed by strapping to further alleviate pain (29540, Strapping; ankle and/or foot). You might be able to report both services because the injection and strapping provide different therapeutic effects, but check your payer's guidelines before submitting your claim. Correct Coding Initiative (CCI) edits list 29540 as a component of 20550.

Therefore, for payers who follow CCI, you would need to append modifier 59 (Distinct procedural service) to 29540 and include documentation showing the two services are distinct and separately billable.

Don't Be Shocked By No Shock Wave Pay

Physicians sometimes successfully treat plantar fasciitis with extracorporeal shock wave therapy (ESWT) if injections and more conservative treatments fail to relieve the patient's pain. The theory behind ESWT is that shock waves stimulate healing by promoting revascularization. Report ESWT with 28890 (Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia).

Heads up: Some payers reimburse for ESWT, but others don't. "Coverage for this procedure is fairly rare," says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network. "Many payers deem it an investigational procedure."

Prepare: Have clear documentation of other treatments that have failed over a period of months to help support your physician's choice of ESWT. If the payer does not cover ESWT, obtain an advance beneficiary notice (ABN) from the patient prior to the procedure.

See Surgery as the Last Resort

In most cases, plantar fasciitis does not require surgical treatment to stop pain and reverse damage. If all other treatments fail, however, your orthopedist might feel that the patient requires surgery. Surgical fascia release procedures fall into three categories:

• Endoscopic plantar fascia release (29893, Endoscopic plantar fasciotomy)

• Open plantar fasciectomy such as 28060 (Fasciectomy, plantar fascia; partial [separate procedure]) or 28062 (... radical [separate procedure])

• Open plantar fasciotomy such as 28008 (Fasciotomy, foot and/or toe) or 28250 (Division of plantar fascia and muscle [e.g., Steindler stripping] [separate procedure]).

Although endoscopic approaches are more common for some procedures, know your open codes because the open approach is more common for surgical fascia release. "This is probably because of concern about nerve injury if the procedure is done endoscopically," explains Bill Mallon, MD, an orthopedic surgeon and medical director of Triangle Orthopaedic Associates in Durham, N.C.

Surgeons might also opt for the open approach if they don't know exactly what will be needed during the case, Parks adds.