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 [...]