Orthopedic Coding Alert

Coding accurately for services provided in the treatment of the foot requires careful planning through every step of the billing process. Navigating through Medicares very specific language of policy coverage, as well as that of HMOs, and determining which modifiers your carriers want are some of the proactive steps coders can take to ensure reimbursement for common foot treatments.

Carriers inappropriately bundle foot surgery because procedures are often conducted on several toes during the same operative session. Use the correct modifiers to avoid inappropriate rebundling of surgical services that should be paid separately. Moreover, CPT codes that cannot be reported separately when performed on the same area of the foot can be reported and should be reimbursed when performed in separate regions of the foot or on separate toes. For example, an orthopedist may perform a debridement on one or more toes (11042, debridement; skin, and subcutaneous tissue) on a diabetic patient with infected wounds on the feet. Since each toe is a separate surgical site, rather than one large area of debridement, this code can be reported more than once.

Billie Jo McCrary, CPC, CCS-P, CMPC, practice manager of Wellington Orthopaedic and Sports Medicine, a six-office practice with 18 physicians in Cincinnati, reports that often, payers reject multiple codes for multiple toes because they automatically perceive it as a duplicate claim. Lets say we do the same surgery on three different toes, McCrary says. The carrier rejects two of the three as duplicate because they do not recognize the modifiers we use. McCrary says this is especially common when the practice submits the procedural code with modifier -59 (distinct procedural service). With some carriers, we always have trouble with modifier -59, even though it is the correct modifier to use with multiple debridement. Instead, McCrary has found that the HCPCS Level II modifiers for toes (e.g., -T1, left foot, second digit, -T2, left foot, third digit, etc.) are more readily accepted by crriers. Unfortunately, McCrary adds, it seems that no matter what modifiers we use, we have to do an awful lot of appeals that seem unfair. Because she can anticipate claims denials for multiple toe procedures, McCrary has found that the best line of defense is to send the claim on paper the first time it is submitted, meaning the surgery is carefully documented and explained prior to a denial. You do the extra work before or after, she says. But either way, foot claims are a lot of extra work.

The HCPCS modifiers are especially helpful when working with Medicare patients. For non-Medicare patients, your carriers manual or a phone call to an adjuster should determine which modifiers the carrier wants. Technically, modifier-59 should prevent inappropriate rebundling, but its appearance on a claim form often causes claims to pend before they are even looked at. Also bear in mind that if multiple foot or toe procedures are scheduled for different days, modifier -58 (staged or related procedure or service by the same physician during the postoperative period) is used. For multiple debridements on different days, the 11042 would be submitted as many times as it was done, and each claim after the first would be appended with a -58 modifier. This modifier would also apply to such procedures as delayed wound closure and pin removal that took place during the global period of the initial surgery.

Medicare and Routine Foot Care

Orthopedic surgery practices that employ a foot and ankle specialist need to be thoroughly familiar with Medicare guidelines to ensure proper payment for covered services. It is equally important to identify circumstances when services may not be covered, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., so that the patient can be informed prior to provision of the service and an advance beneficiary notice (ABN) can be obtained. The ABN is an acknowledgment between patient and provider that certain services may not be covered by Medicare. A correctly executed and signed ABN transfers responsibility for payment directly to the patient for those services.

Medicare does not cover foot care that it deems routine, except under certain circumstances. The following services are considered by Medicare to be routine foot care, and therefore not a covered benefit:

The cutting or removal of corns and calluses;

The trimming, cutting, clipping or debriding of nails; and

Other hygienic and preventive maintenance care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients and any other service performed in the absence of localized illness, injury or symptoms involving the foot.

Examples of codes classified as routine foot care include:

11055 paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion

11719 trimming of nondystrophic nails, any number; and

11721 debridement of nail(s) by and method(s); six or more.

Medicare recognizes circumstances when it is medically necessary for a physician to render these services and allows reimbursement when specific conditions exist. Routine foot care services are payable when the patient has an underlying systemic disease of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk.

Systemic conditions for which routine foot care will be covered include, but are not limited to:

Diabetes mellitus (250.xx)
Atherosclerosis of the extremities with gangrene (440.24)
Pernicious anemia (281.0)
Buergers disease (thromboangiitis obliterans) (443.1)
Pellagra (265.2)

Note: This list is an example only. Each Part B carrier has a list of appropriate ICD-9 codes to link to covered foot care services. Check your carriers manual, or for a complete list go to www.lmrp.net.

Stout points out that for many of the approved conditions, routine procedures are covered only if the patient is under the active care of a doctor of medicine (MD) or osteopathy (DO) who documents the condition. For example, a diabetic patient with peripheral neuropathy (250.6x and 357.2) has a callus shaved (11055, paring or cutting of benign hyperkeratotic lesion [e.g., corn or callus]; single lesion). According to the policy-limitations section of the Medicare Carriers Manual (MCM), this service is only eligible for reimbursement if the patient has been under active treatment with an MD or DO for the complicating disease process (in this case, diabetes) during the six-month period prior to rendering the routine foot care service, or comes under treatment shortly after the service is rendered. These specifications must be met and verified with the primary care physician and documented on the claim form.

More Medicare Modifiers

Medicare created three modifiers to identify patients who fit the criteria for reimbursement for routine foot care:

-Q7 one Class A finding
-Q8 two Class B findings
-Q9 one Class B and two Class C findings

The classes are different symptoms that must be present for Medicare to pay for routine foot services. The physician must document the appropriate combination of these conditions to append the modifier. The classifications are as follows:

Class A:
Nontraumatic amputation of foot or integral skeletal portion thereof

Class B:
Absent posterior tibial pulse
Advanced trophic changes as evidenced by three of the following:

1. Hair growth (decrease or absence)
2. Nail changes (thickening)
3. Pigmentary changes (discoloring)
4. Skin texture (thin, shiny)
5. Skin color (rubor or redness)

Absent dorsalis pedis pulse

Class C:

Claudication
Temperature (e.g., cold feet)
Edema
Paresthesias
Burning

For example, the diabetic patient who presents for callus removal has three calluses on the great, second and third toes of the right foot. The physician notices at least two Class B findings, which meet the criteria for the -Q8 modifier to be appended to the procedural codes.

The -Q8 in turn tells the Part B carrier that although the service rendered was routine, the circumstances or symptoms leading to the service were not routine. The calluses are removed, and the encounter is coded as follows:

11055-T5-Q8
11055-T6-Q8
11055-T7-Q8.

The corresponding ICD-9 codes are:

250.6X diabetes with neurological manifestations
357.2 polyneuropathy in diabetes.

McCrary notes that when describing conditions of the feet, it is essential to use the exact wording of the policy. In other words, if the policy description says, discoloring, dont record yellowing. Use the words that your carrier wants to see, McCrary says. Its a lot of extra work for a little reimbursement, but its the only way Medicare will pay for the service. Occasionally, McCrarys staff will even take a picture of the affected foot or feet, and send that along with the claim.

The following documents have regulations regarding routine foot care:

HCFA Medical Policy P-1I: Coverage Requirements for Routine Foot Care

HCFA Medical Policy P-3F: Debridement of Mycotic Nails

Title XVIII of the Social Security Act, Section 1862 (a)(13)(C)

Medicare Carriers Manual, Section 2323 and Section 4120

Code of Federal Regulations, Part 411.15, subpart A.