Podiatry Coding & Billing Alert

Case Study:

Report Multiple Codes to Ace this Evaluation and Management, X-ray, DME Scenario

Published on Fri Feb 18, 2022

Hint: You will base E/M service on either the MDM level or time.

Your podiatrist probably sees many patients in the office where they have to perform X-rays to diagnose injuries, as well as dispense durable medical equipment (DME) to help patients heal from these injuries.

Take a look at the following scenario from Jordan Meyers, DPM, partner at Raleigh Foot and Ankle Center and consultant at Treace Medical Concepts, Inc. in Raleigh, North Carolina, to make sure you know exactly which CPT^®, HCPCS, and ICD-10-CM codes to report.

Scenario:

An established patient came into the office with persistent left dorsal foot pain. She dropped a heavy object on their foot two months ago. The patient had previously seen a podiatrist at a different practice who diagnosed them with a compression fracture. The patient was given a surgical shoe at that practice, but the pain has been persisting. The patient’s foot is painful and tender, and their pain is constant. The podiatrist performed a medically appropriate history and exam. The podiatrist spent 22 minutes total time on the date of the encounter. The podiatrist performed X-rays with three views: AP, lateral, and MO. The podiatrist did not see any fractures or dislocations. Adequate alignment and bone stock was noted. The podiatrist diagnosed the patient with localized edema and metatarsalgia. It was decided that the patient would use a TriLok™ brace because they have seen little improvement in the past two months wearing the surgical shoe, which was on recommendation from a previous provider. This ankle orthosis is prefabricated, off-the-shelf.

Step 1: Choose Appropriate E/M Code

Your first step is to choose the correct evaluation and management (E/M) code for this office visit. According to the medical documentation, this is an established patient, the podiatrist spent 22 minutes total time on the date of the encounter, and the podiatrist performed a medically appropriate history and exam.

The appropriate code that fits this case is 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.).

Coding tip: You should choose the office and other outpatient E/M service level based on the total time or medical decision making (MDM) level in the code descriptor. In this case, the podiatrist spent 22 minutes with the patient, so you are coding based upon time. Code 99213 fits this scenario because its time range is 20-29 minutes, per the descriptor.

Step 2: Remember to Report X-ray Code

The podiatrist also performed X-rays to rule out fractures and dislocations.

For the X-ray service, you should report 73630 (Radiologic examination, foot; complete, minimum of 3 views)-LT (Left side) because the podiatrist documented that they took three X-ray images of the patient’s foot.

The podiatrist also documented what type of views he took: AP (anteroposterior), lateral, MO (medial oblique). According to 73630’s code descriptor, to report this code, the physician must have taken a minimum of three X-ray images.

Step 3: Include ICD-10-CM Codes

The podiatrist diagnosed the patient with localized edema and metatarsalgia in their left foot. You should report R60.0 (Localized edema) and M77.42 (Metatarsalgia, left foot) as the diagnosis codes on your claim.

Step 4: Submit This Code for DME

The patient also received DME in the form of an ankle foot orthosis. The patient had a weakness of their foot that required stabilization for medical reasons. The use of the orthosis had the potential to benefit the functionality of the patient.

You should report code L1902 (Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf) for the ankle foot orthosis (AFO).

AFO defined: An AFO is a brace the patient wears on their lower leg and foot to stabilize the ankle in normal anatomical position. This AFO is generally covered for patients who are ambulatory or able to walk but need stabilization of the foot and ankle for a medical reason and will receive functional benefit from the use of this orthosis. You should always check with your payer for their specific guidelines.

Don’t miss: When you are billing for a DME code, L1902 in this case, most insurance companies require you to submit a separate claim, says Jeri L Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia.

“The reasoning for this is the place of service [POS] will be 12 [Home] as opposed to 11 [Office] for your other charges. The claim also requires you to enter the ordering provider,” Jordan explains. “If the patient is under Medicare, the KX modifier [Requirements specified in the medical policy have been met] must be used to indicate that the supplier has ensured the coverage criteria for the DMEPOS [Durable Medical Equipment, Prosthetics, Orthotics, and Supplies] billed is met and that documentation does exist to support the medical necessity of item. Documentation must be available upon request.”

Step 5: Report These Codes on Your Claims

In summary, you will report two claims for this scenario. On the first claim, you should report the following codes: