Podiatry Coding & Billing Alert

Here’s what should be your primary diagnosis — and it isn’t gout.

When a patient hobbles into your podiatrist’s office, you might wonder whether the primary diagnosis should be difficulty in walking, pain in the ankle, stiffness of the joints or gout. The key will be in your provider’s documentation.

Pain will be the primary diagnosis, advises Daniel Waldman, DPM, FACFAS of Blue Ridge Foot Centers, Asheville, NC and President, Blue Ridge Podiatry Association, PA. “I would code pain as the primary diagnosis and then list gout,” he says. If the patient’s primary complaint is pain in the foot/feet, you would be coding it as:

•    M79.671 — Pain in right foot
•    M79.672 — Pain in left foot
•    M79.673 — Pain in unspecified foot
•    M79.674 — Pain in right toe(s)
•    M79.675 — Pain in left toe(s)
•    M79.676 — Pain in unspecified toe(s).

On the other hand, if the primary complaint is pain in the joints, you need to code it as:

•    M20-M25 — Other joint disorders
•    M25.5 — Pain in joint
•    M25.57 — Pain in ankle and joints of foot
•    M25.572 — Pain in left ankle and joints of left foot
•    M25.571 — Pain in right ankle and joints of right foot
•    M25.579 — Pain in unspecified ankle and joints of unspecified foot.

The “patient’s past medical history of gout and symptoms of redness, pain and swelling (indicates that she) should definitely seek immediate medical attention. This also goes for anybody without a history of gout and in both cases elevated uric acid levels would need to be ruled out,” says Waldman.

“Looking for the underlying cause can be difficult without an in depth past medical history and review of symptoms and medications and consultation with the patient’s primary care provider. In my practice I help patients manage through their acute pain episodes and then coordinate care with the patient’s primary care physician to control further attacks. I order lab work to check uric acid levels and measures of inflammation along with CBC and metabolic panel. Joint aspirations can be done as the most definitive diagnostic test. However, it is rare that I feel that this test is necessary based upon clinical findings in the patient’s past medical history,” Waldman points out.

Your codes of choice for such examination would be:

•    20600 — Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); without ultrasound guidance
•    20604 — Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting
•    20605 — Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
•    20606 — Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting
•    73620 — Radiologic examination, foot; 2 views
•    73630 — Radiologic examination, foot; complete, minimum of 3 views
•    73650 — Radiologic examination; calcaneus, minimum of 2 views
•    77077 — Joint survey, single view, 2 or more joints (specify).

“I saw many cases of gout which presented with the patient having pain, swelling, redness and difficulty in walking… Most often it was at the 1^st MPJ (i.e. the joint between the metatarsal bones of the foot and the big toe), but often seen in the ankle. It could (also) be seen in the joints,” shares Arnold Beresh, DPM, CPC, CSFAC, of Dr. Arnold Beresh, PLC of Newport News, VA.

The choice of codes in “ICD-10 codes for idiopathic (gout) are M10.071 for right and M10.072 left feet. If the podiatrist wishes to pursue the underlying cause it is up to them to find more specific code. In my practice I normally just list idiopathic, and if there is an underlying cause may change this along with any information from the patient’s primary care physician,” Waldman says.

“The difficulty is pinpointing the etiology of the gout issue. Most DPM’s will see acute episodes that present as severe pain. Determining the specific cause (lead, Rx’s, metabolic problems) is a challenge. Idiopathic gout diagnosis is likely the best route for initial encounter until determining factor can be identified,” says Waldman. “In chronic cases it is best to refer to patient’s primary care MD or endocrinologist,” he adds.

You need to check the podiatrist’s notes to see whether there is any mention of renal impairment or whether the gout is idiopathic. Idiopathic gout will be coded as:

M1A.07 — Idiopathic chronic gout, ankle and foot
M1A.072 — Idiopathic chronic gout, left ankle and foot
M1A.071 — Idiopathic chronic gout, right ankle and foot
M1A.079 — Idiopathic chronic gout, unspecified ankle and foot.