Podiatry Coding & Billing Alert

Warning: Incorrect diagnosis codes and modifiers could be leading you astray.

If you're getting the same podiatry denials all the time -- whether the dollar amount in question is large or small, it might be time to review your ICD-9 coding practices.

The solution to your problem may be as simple as reminding yourself of these 3 important insights when reporting ICD-9 codes.

1. Be Careful of Your CPT/ICD-9 Combos

For one, you might be guilty of listing incorrect CPT/ICD-9 code combinations on the claim form. If patients have more than one condition, obviously several ICD-9 codes would be required. Here's the catch: Each individual CPT code must correctly align with a proper ICD-9 code, says Anthony Poggio, DPM in Podiatry Today.

Example: A patient presents with fasciitis (729.4, Fasciitis unspecified) and a verruca plantaris (078.12, Plantar wart). An injection code (20550, Injection[s]; single tendon sheath, of ligament, aponeurosis [e.g., plantar fascia]) should match up with fasciitis and the skin destruction code (17110, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemorsurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions, or 17111, ...15 or more lesions) should match up with the verrucae. If the CPT/ICD-9 codes get switched (i.e., listing a skin destruction CPT code with a fasciitis diagnosis code), this will not make any sense, and your claim will be denied, says Poggio.

2. Stick to Necessary ICD-9 Codes Only

See that Box 21 on you claim form? Make sure you list only the ICD-9 codes that are necessary in that box. The more diagnosis codes you list, the more the payer might get confused.

Example: If the patient is diabetic and has a neuroma that is injected (64455, Injection[s], anesthetic agent and/or steroid, plantar common digital nerve[s] [e.g., Morton's neuroma), list only the neuroma diagnosis (355.6, Lesion of plantar nerve, Morton's metatarsalgia, neuralgia, or neuroma) since the neuroma is the basis for payment of the injection, not the diabetes (250.x).

Do this: If you'd like to apply a multiple procedure rate reduction to the second, third or any additional sites injected, you would attach modifier 51 (Multiple procedures) to 64455. This code is subject to the standard payment adjustment rules for multiple procedures, according to the Medicare Fee Schedule database. To clarify that the physician did the injections at different sites, you should submit 64455 for the first site injected, and 64455 with modifier 59 (Distinct procedural service) -- to show that a different site was injected, and modifier 51 -- to indicate multiple procedures were performed -- for subsequent injection sites.

Here's another example. Your podiatrist treats a painful ingrown nail via debridement. You should use the appropriate pain (729.5, Pain on ambulation) and nail (110.1, Mycotic toenails) diagnoses that the carrier allows. If one lists diabetes and peripheral vascular disease (PVD) on the claim as well, the computer may look for a Q code, which is required for diabetes with PVD but not for a painful condition.

3. Keep Yourself Updated With Code Changes

Perhaps the most practical thing to do is to make sure that the ICD-9 and CPT codes are valid at the time of service. Medicare no longer will offer a grace period for changes in ICD-9 codes. It is essential to stay on top of new coding changes. Since there may be more than one way to list a certain diagnosis, you should best check with the carrier about which codes it allows. You may have your procedure codes documented and proven medically necessary, but if you report the wrong ICD-9 code, it is useless, as surely the payer will deny your claim.

Likewise, Sort through Your E/M

Reporting E/M codes appropriately is just as important as listing the right ICD-9 codes, and just as confusing to some people. One specific problem that has often come up is in the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The trick is to only use the modifier 25 on the E/M service when performing an E/M service and a procedure on the same day.

Extra: Every procedure has a component for evaluation and management included in the reimbursement fee. Once your physician established the diagnosis, and indicates no significant change in treatment protocol, then an E/M service may not be payable separately from the procedure one has performed.

In general, you are not required to add modifier 25 to the E/M service when billing a new patient visit code and a procedure performed on the same day. The code descriptor itself implies that it is a new problem. But nail codes 11720 (Debridement of nail[s] by any method; one to five), 11721 (...six or more), G0127 (Trimming of dystrophic nails, any number), and 11719 (Trimming of nondystrophic nails, any number) are an exception. Due to the CCI edit, you should append modifier 25 to the initial visit E/M code to allow proper payment for both services.