Podiatry Coding & Billing Alert

If you code nail debridement with an E/M, you could be headed for trouble street.

You have the chance to correct your documentation and billing patterns to keep your practice out of unwelcome scrutiny. Part B MAC Palmetto GBA has a new Comparative Billing Report (CBR) dealing with Medicare improper payments which can help you identify problem areas.

Background: In its CBR published June 22, Palmetto GBA outlined podiatric benchmarks related to nail debridement and E/M services. “Podiatry and E/M services was selected as a topic because various reports determined that Medicare has made inappropriate payments on claims for nail debridement services,” said the CBR in its “Frequently Asked Questions” section.

The reports showed that up to 60 percent of all podiatry services related to nail debridement “rendered during Calendar Year 2000” account for $51.2 million in improper Medicare payments. Due to this incredibly large number, the HHS Office of the Inspector General (OIG), the Centers for Medicare & Medicaid Services (CMS), and their affiliates have taken notice and are trying to rectify this issue by looking at the unusual billing statistics of over 8,000 providers in the specialty code of podiatry (48).

Example: A June 22 Department of Justice (DOJ) press release announced that Stephen A. Monaco, D.P.M., 59, of Broomall, PA was charged with attempting to defraud Medicare, Medicaid and four private victim insurance companies in a $5 million scheme. His fraudulent billing included claims “for podiatric procedures that were not provided, and podiatric procedures that were not performed, including injections, debridement (removal of dead, infected or foreign material to promote wound healing) and nail avulsions (removal of the entire or partial nail plate),” the press release said.

Additionally, the doctor has been charged with submitting claims “for medically unnecessary procedures and services that were not reimbursable by Medicare or the other insurance carriers,” the release added. 

Focus of the CBR: According to the CBR metrics, the report concerned four basic components that sought to quantify providers’ value. It focused on the number of nail debridement services concurrently billed with E/M services; percent billed as CPT^® code 11721; “average nail debridement services per beneficiary per year;” and the time spent per E/M visit, with or without modifier 25.

How It Was Compiled

“Claims with allowed services for CPT^® codes 11720, 11721, and 99210-99215, with dates of service for Jan. 1, 2015 - Dec. 31, 2015, were downloaded from the CMS Integrated Data Repository (IDR) and loaded into the Palmetto GBA Medicare Data Warehouse,” the report says. On April 11, Palmetto then took this information and analyzed the most current claims’ data from the IDR, which included “only Fee-for-Service (Original Medicare) Part B claims.”

These are the specifics of the codes Palmetto analyzed:

Debridement codes:

• 11720 (Debridement of nail[s] by any method[s]; 1 to 5)
• 11721 (Debridement of nail[s] by any method[s]; 6 or more) in relation to E/M codes
• 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient…)

Modifier

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service).

What the Report Revealed

Using the data and a variety of benchmarking equations, Palmetto shows how dividing the number of times you code for nail debridement by itself, with E/M services, with various E/M codes, and with modifier 25, and then dividing that by nail debridement alone and multiplying the total by 100, will give you the percentages you need to compare yourself and your practice with your peers.

Once calculations are complete and you have a “value rating,” the various tables allow you to see where you fall in the CBR’s “comparison outcomes.” The four different levels rate your standing as significantly higher than your peers, higher than your peers, not exceeding the value of your peers, or inconclusive due to lack of data.

What matters: If your value doesn’t necessarily fall into the “significantly higher” or “higher” categories, there’s nothing to worry about. The particular group of 8,000 were specifically chosen due to being significantly higher in one or more categories; thus, the results are altered by this abnormality.

Resource: For a comprehensive viewing of the study, charts, and statistics, visit http://www.cbrinfo.net/cbr201608.html. For more on the Monaco case, see https://www.justice.gov/usao-edpa/pr/delaware-county-podiatrist-charged-5-million-health-care-fraud-scheme.