Podiatry Coding & Billing Alert

Give up Apligraf application codes 15430, 15431 in favor of new G codes.

It's that time of the year once again, and providers are preparing for the 2011 CPT updates that will come their way beginning Jan. 1. For podiatry, the big change focuses on two new codes to report diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity.

Quick fact: CPT will introduce over 200 new codes in 2011 with the aim of helping you code more accurately than ever. The changes affect several categories, from dermatology to orthopedics to cardiology, and more. You should be strictly implementing the changes on or after Jan. 1, or else you might welcome the new year with unwanted denials.

G0440-G0441 Are In the Spotlight for Diabetic Foot Ulcer Care

Get ready to use temporary G codes when reporting diabetic foot ulcer treatment involving tissue cultured skin substitutes to the lower extremity for a Medicare beneficiary in 2011. CPT 2011 introduces G0440 (Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less) and G0441 (...each additional 25 sq cm) to put an end to the confusion providers put forth the different global periods for two tissue cultured skin substitute codes.

Example: A patient presents to the office with a history of diabetes and neuropathy. He has been treated for the past 6 weeks for an ulcer with minimal results from standard conservative care. An exam reveals an ulcer under the fifth metatarsal head. The ulcer measures one centimeter in diameter and shows necrotic tissue at the base. The podiatrist performed a debridement, sharply removing it with scalpel and picking up at the skin margins and necrotic tissue. There is no exposure of the muscle or bone. If the podiatrist prepared for an application of Dermagraft or Appligraft, placing the substance in sterile normal fashion and then bandaging in standard fashion, you would use G0440, explains Richard D. Odom, DPM, ABPS, CPC, a podiatrist in Spanish Fort, Ala.

In the past, you've coded Apligraf application involving up to 5 treatments over a 12-week period with 15430 (Acellular xenograft implant; first 100 sq cm or less, or 1 percent of body area of infants and children) or 15431 (...each additional 100 sq cm, or each additional 1 percent of body area of infants and children, or part thereof [List separately in addition to code for primary procedure]). On the other hand, you've billed 15360, 15361, 15365, and 15366 for Dermagraft, which is applied weekly, up to 8 treatments over 1to 12-week period.

Consequence: This caused providers to use one product over another to gain financial incentive. "General surgeons, podiatrists, plastic surgeons, and wound care specialists were concerned that Apligraf had a 90 day global period versus Dermagraft, which had a 30 day global period," Marc Hartstein, deputy director for the Hospital and Ambulatory Policy Group for the Center for Medicare in his presentation with Kenneth Simon, senior medical officer for Center for Medicare "Medicare Physician Payment Schedule 2011 Changes and Beyond" presented during the CPT and RBRVS 2011 Annual Symposium.

The debut of G0440 and G0441 will clarify the confusion as new codes will be worked on and valued during 2011. This will pave the way for CPT 2012 to offer Category III codes that will replace the 2011 G codes.

76880 Out, 76881-76882 In

For your ultrasound coding needs in 2011, you can forget about 76880 (Ultrasound, extremity, nonvascular, real time with image documentation). CPT 2011 deletes this code to give way to two new codes:

• 76881 -- Ultrasound, extremity, nonvascular, real-time with image documentation; complete
• 76882 -- Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific

A complete procedure (76881) includes real time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft-tissue structures, and any identifiable abnormality. A limited study (76882) involves examining the extremity where a specific anatomic structure such as a tendon or muscle is assessed. You would also use 76882 to evaluate a soft-tissue mass that may be present in an extremity where knowledge of its cystic or solid characteristics is needed.

Remember: When the podiatrist performs spectral and color Doppler evaluation of the extremities, you should use the appropriate code (93925-93926, 93930-93931, 93970 or 93971) in conjunction with 76881 or 76882. Meanwhile, CPT 2011 revises and revalues codes for noninvasive physiologic studies of the upper or lower extremity arteries:

• 93922 -- Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (e.g., for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels)
• 93923 -- Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (e.g., for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more level(s), or single level study with provocative functional maneuvers (e.g., measurements with postural provocative tests, or measurements with reactive hyperemia)
• 93924 -- Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (i.e., bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study.

You will find 93922-93924's code descriptors clearly differentiating between a limited study and a complete bilateral study, with additional instructions on how to appropriately report these codes.

Example: A podiatrist performs extremity arterial vascular study on the left foot. You should code this service with 93922- 52. In this case, the service involves studying only one side of the body (unilateral), but 93922's descriptor clearly indicates "bilateral noninvasive physiologic studies." Because you aren't reporting the full service as defined, you'll need to appendmodifier 52 (Reduced services) to the service code.

Don't Forget Debridement and Active Wound Care

You'll never have to worry about choosing between a debridement code and an active wound code. CPT 2011 saves the day by revising debridement code guidelines to clarify the confusion.

"Depth is the only documentation item you need to determine the correct code," explained Chad Rubin, MD, FACS, American College of Surgeons AMA Specialty Society Relative Value Scale Update Committee (RUC) Alternate Member with Albert E. Bothe, Jr. MD, FACS, American College of Surgeons, AMA CPT Editorial Panel Member at their joint presentation "General Surgery."

Active wound care, which has a 0 day global period, refers to active wound care of the skin, dermis, or epidermis. For deeper wound care, you should use debridement codes in the appropriate location.

For example, codes 11040 (Debridement; skin, partial thickness) and 11041 (Debridement; skin, full thickness) havebeen deleted. The parenthetical note under the codes' deletion reads, "For debridement of skin, i.e., epidermis and/or dermis only, see 97597 and 97598."

The codes are then revised to reflect this change:

• 97597 -- Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
• 97598 -- Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, totalwound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).

Debridement codes' revisions include:

• 11010 -- Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin and subcutaneous tissues
• 11011 -- Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle
• 11012 -- Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone
• 11042 -- Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm orless
• 11043 -- Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
• 11044 -- Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less.

Helpful: CPT 97597 has mainly been reworded to make clear how active wound care is separate from integumentary wound care, says Bothe.

In addition, CPT 2011 guidelines include two requirements for active wound care management:

• Intent: "Active wound care procedures are performed to remove devitalized and/or necrotic tissue and promote healing."
• Contact: Direct patient contact is required.