Podiatry Coding & Billing Alert

Be sure to pay attention to ICD-10 guidelines and the reason for the visit.

Chronic pain is a complex medical condition characterized by persistent, long-lasting pain that is often resistant to conventional treatments. Paying close attention to the provider’s documentation will be useful to guide you through the correct code sequence when working any chronic pain claim. But if you follow the four steps outlined below, you’ll easily be able to document both the primary diagnosis and the chronic pain along with the accompanying office/outpatient evaluation and management (E/M) level and correct code for the procedure performed. Reporting this detailed coding will accurately reflect the patient’s condition and the medical services provided during the encounter.

Scenario: An established patient is experiencing pain in the toes on their left foot. The patient is unaware of any injury to account for the pain. The patient has a history of chronic pain which is unrelated to the visit today. The podiatrist ordered two X-ray views of the patient’s foot to rule out any fracture and to rule out any pain from another area of the foot radiating to the toes. The podiatrist did not see a fracture, so they advised the patient to elevate the foot as they are able to help with the pain and to prevent further inflammation. The podiatrist spent 27 minutes on the date of the encounter with the patient. The podiatrist also performed a medically appropriate history and exam.

Step 1: Decide on Time or MDM to Calculate E/M Level

MDM: It’s important the physician gets reimbursed in a way that most accurately accounts for their work and expertise. Let’s figure out how this encounter might level if you were to use medical decision making (MDM).

Remember: The encounter must meet two of the three elements of MDM: number and complexity of problems, data to be reviewed and analyzed, and risk.

The patient has a new problem of pain in the left toes with no identifiable cause, and a history of chronic pain which was stable. This would be considered a low level of problem complexity. As far as data points, the doctor ordered two X-ray views of the patient’s foot. However, if the practice owns the X-ray equipment and bills for the X-rays separately, you will not be able to count the points for the data MDM element into your level calculation. Lastly, the risk level of MDM is minimal as there was no fracture found, and the management plan (foot elevation) is conservative and non-invasive.

So, if you use MDM to calculate the E/M level of this encounter, the moderate level of the problem and low level of risk to manage it leads you to 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …).

However, as the podiatrist spent 27 minutes with the patient performing a medically appropriate history and exam and creating a treatment plan, you can justify billing a higher-level E/M code for this patient encounter, in this case 99213 (Office or other outpatient visit for the evaluation and management of an established patient … When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter).

Step 2: Choose Appropriate CPT^® Code(s)

X-ray: Per the documentation, the podiatrist ordered and interpreted an X-ray of the left foot with two views to verify there was no fracture. “Too often we find that documentation fails to provide which views were taken for justifying the code for the appropriate views. If it is documented that two views are taken, best practices to justify the payment would be to say ‘dorsal-plantar and oblique views of the left ankle were taken.’” says Jennifer McNamara, CPC, CCS, CPMA, CRC, CDEO, COSC, CGSC, COPC AAPC Approved Instructor, CEO and physician education at Healthcare Inspired, LLC, in Bella Vista, Arkansas. To bill the X-ray service separately, you should report code 73620 (Radiologic examination, foot; 2 views).

You would also add modifier LT (left side) as this was performed on the left foot only.

Coding caution: You should not use 73630 (Radiologic examination, foot; complete, minimum of 3 views), as the podiatrist took two views, not three. Also, you should not use 73660 (Radiologic examination; toe(s), minimum of 2 views), as the podiatrist took images of the entire foot and not just the patient’s toes.

Step 3: Look at ICD-10 Options

After finishing the X-rays, the podiatrist was unable to find a definitive cause for toe pain. So, as the patient was diagnosed with pain in their left toes, you’ll code M79.675 (Pain in left toe(s)). Additionally, because the patient has an unrelated history of chronic pain, you would code G89.29 (Other chronic pain). Since the patient’s reason for the visit was unrelated to the chronic pain, you would sequence G89.29 after M79.675, which is the primary diagnosis and the reason for the visit.

Step 4: Putting the Claim Together

For this encounter, you should report the following codes:

• 73620-LT
• 99213
• M79.675
• G89.29

Things to consider:

According to ICD-10 guideline I.C.6.b.ii, you would not list a code from category G89.- (Pain, not elsewhere classified) at all if the pain is not already documented as acute, chronic, postprocedural or neoplasm-related within the patient’s file. Also, remember that there isn’t a precise timeframe for when acute pain becomes chronic and to refer to the provider’s documentation for more accuracy.

Per section I.C.6.b of the ICD-10 guidelines, codes in category G89 may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain. The guidelines go on to explain that if the encounter is for any reason except pain control or pain management, and a related definitive diagnosis has not been established by the provider, you should assign the code for the specific site of the pain first, followed by the appropriate code from category G89.