Podiatry Coding & Billing Alert

If you don't know the ins-and-outs of coding cutting edge procedures, you risk getting left in the dust as podiatric medicine continues to involve. A new technique, however, doesn't always mean a new, corresponding CPT code.

What is Topaz: "The TOPAZ MicroDebrider is a tool which utilizes Coblation® technology to perform a small incision in the fascia and is considered an alternative to the use of standard surgical instruments such as scalpels, low frequency electrocautery, and so forth," according to CPT Assistant, September 2009. This technology enables the physician to "microdebride" soft tissue present within the tendons of the knee, shoulder, elbow, ankle, and foot. Read on to unravel the mystery surrounding Topaz procedure coding and billing.

Don't flip through CPT or HCPCS looking for a Topaz code, because there isn't one. The TOPAZ MicroDebrider is a tool and not a procedure, says Hoda Henein, CHBME, CPL, president and CEO, Active Management in College Point, N.Y.

Do this: Select a code based on the actual service the physician performs and which anatomy the service involves. CPT Assistant instructs you to do this for procedures involving Topaz and this has also been the position of the American Academy of Orthopaedic Surgeons (AAOS) since April 2006, adds John F. Bishop, PA-C, CPC, president and CEO of Bishop & Associates Inc. in Tampa, Fla.

Example: If your podiatrist uses the Topaz microdebridement wand to complete an Achilles tendon repair, explains Henein, based on the nature of the repair you would select either:

• 27654 -- Repair, secondary, Achilles tendon, with or without graft, or

• 27658 -- Repair, flexor tendon, leg; primary, without graft, each tendon.

Podiatrists also often use the Topaz wand for plantar fasciotomies. If this is the case, says Henein, select either:

• 28208 -- Repair, tendon, extensor, foot; primary or secondary, each tendon, or

• 28220 -- Tenolysis, flexor, foot; single tendon.

Billing note: You will receive payment only for the procedure code you report, and no additional reimbursement for use of the Topaz wand, notes Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.

Watch out: Receiving reimbursement for the primary procedure code when using Topaz isn't always a piece of cake. Coders could run into a problem if the podiatrist primarily uses the Topaz wand to debride an Achilles tendon, says Beresh. If the dictation refers only to use of the Topaz wand for debridement, payers may deny the claim, Beresh adds. (This isn't usually the case when reporting a plantar fasciotomy with use of a Topaz wand.)

Case in point: Anthem Blue Cross/Blue Shield has a written policy of non-payment when using Topaz, which  the carrier considers to be a technology that is "investigational and not medically necessary" for the treatment of musculoskeletal conditions. See the policy at www.anthem.com/medicalguidelines/va/f5/s10/t2/pw_a084765.pdf.

Remember: Rules may be different for different payers, so always check with the carrier for the most upto-date coverage information.

If you want to be daring, some coders claim success with reporting an unlisted procedure code when the Topaz tool is involved.

"Some [practices] have been billing the coblation procedure with an unlisted code," says Henein, such as:

• 28899 -- Unlisted procedure, foot or toes, or

• 27899 -- Unlisted procedure, leg or ankle.

If you go this route, make sure to get pre-authorization or coverage information prior to performing the procedure, and include the op report and a letter of explanation along with your request and documentation, counsels Henein.

Tip: The physician's documentation should include the research and benefits of this procedure over others, Henein adds.

Try this: Henein suggests including a note to this effect: TOPAZ is a quick, simple and minimally invasive medical technique now available for the treatment of tendons and fascia. The TOPAZ MicroDebrider utilizes patented Coblation technology, designed to specifically treat tendons and fascia. To date, over five million Coblation procedures have been performed. The TOPAZ technique has been associated with quick return to daily activities allowing for significant improvement in patient outcomes. Since launching with expanded indications for Tenotomy in 2005, TOPAZ has offered a minimally invasive alternative for thousands of patients for the treatment of tendons and fascia.

Bottom line: Demonstration of medical necessity and your op-reports must be on par with Medicare's guidelines for any procedural documentation, Henein concludes.

Second opinion: The unlisted procedure code would be correct to use, but chances of being paid are slim, comments Beresh.

Most carriers as far as I know do not cover this treatment, adds Richard Odom, DPM, CPC, practicing podiatrist in Spanish Fort, Ala.