Podiatry Coding & Billing Alert

Focusing on the language used in medical notes is key to coding correctly.

When it comes to dealing with foot-related issues such as cysts, callouses, or routine foot care, many patients initially consult their primary care physician. It’s quite common for individuals to avoid seeing a specialist like a podiatrist for what they perceive as minor foot problems.

However, the terminology and procedures associated with these minor foot issues can often be complex and difficult to comprehend.

Here are a few key points to keep in mind when you are faced with these types of encounters.

Identify Lesion Removal Versus I&D

The language in the notes can sometimes cause confusion when it comes to whether a cyst was excised or drained. The key is to understand the procedures.

Let’s say the podiatrist’s notes say: “Removed a 2.5 x 2 cm sebaceous cyst by incision from patient. Made a 2 mm vertical incision in the middle of nodule. Removal of large amount of sebaceous material. Then cleaned the wound and placed a single 4-0 Ethilon suture. The patient is to follow up for suture removal in 1 week.” Is this actually a cyst removal, as the language states, or is this really incision and drainage (I&D)?

If you interpret the procedure as a removal, you might consider reporting a code such as 11403 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm), assuming the cyst was on the patient’s foot or ankle. Based on how the procedure itself is described though, this was an I&D procedure that calls for 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single).

Look at the details: Even though the podiatrist said that they “removed” the cyst “by incision,” they did not remove (or “excise”) the cyst itself. An excision means to cut something out. That’s not what happened during this procedure. Instead, the podiatrist made a 2 mm incision into the cyst and removed sebaceous material from the cyst rather than removing the cyst itself. Generally, if the cyst is removed or excised, the provider’s note should say that they made an incision around the area and incised down to the subcutaneous tissue, or they made an incision the length of cyst and peeled the cyst sac out from underneath the skin.

According to Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, CEO of Healthcare Inspired LLC, in Bella Vista, Arkansas, “My suggestion is to educate the provider to always clarify ‘incision versus excision’. These are very different concepts. Incision indicates that a small amount of tissue is being removed. For example, an incisional biopsy removes a portion of a tumor or lesion. In the case of an excision the entire abnormal area, plus some of the surrounding normal tissue, is removed. For example, a skin excision removes all layers of damaged skin tissue, including the epidermis, dermis, and subcutaneous fat layer. So, a cyst can have incision and drainage if the intent is to drain it. Excision is the entire cyst being removed,” she says.

Understand the Difference Between Paring and Removing

Paring can be a stand-alone procedure, but it can also be part of a removal procedure. That’s when things can sometimes get tricky for a coder. First, let’s define the two terms:

Paring: Providers often use this procedure for the treatment of corns or callouses. It involves slicing off the top layers of the skin lesion, usually with a scalpel, to reduce the size of the lesion or completely remove it. This procedure is typically less invasive and may not require stitches. This would commonly be coded to 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion), 11056 (… 2 to 4 lesions), or 11057 (…more than 4 lesions)

Note: Paring is sometimes referred to as “shaving.” However, there are separate codes (11300-11313) for shaving of epidermal or dermal lesions. Per CPT^®, “shaving is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision.”

Removal: This often refers to the complete excision or destruction of the lesion, which is a more invasive procedure. Excision often involves the provider cutting into the skin to completely remove the lesion, then closing the wound with stitches. Or as CPT^® puts it, “Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed.” Destruction typically involves ablating (i.e., removing) the lesion through other means such as electrosurgery or cryosurgery. These methods are typically used for larger or deeper lesions. Lesion removal by excision is coded differently than removal by destruction, and both are coded differently than paring.

Warts are a common lesion requiring removal, and usually call for 17110 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) or 17111 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions).

Caution: Sometimes, a patient will come in for wart removal but the warts themselves present with a raised, calloused area that the podiatrist will shave down prior to the administration of the destruction agent. However, paring 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion) with 17110 for the same treatment location is not appropriate.

“This is considered double-dipping. The paring of the lesion is part of the overall treatment for the removal of the wart with liquid nitrogen, therefore, we would only be able to bill CPT^® 17110 and not in addition to 11055 for the same treatment area,” says Erin Hall, CPC, CPCD, coding lead at MediRevv, A Tegria Company in Coweta, Oklahoma.

Modifier alert: Not coincidentally, the National Correct Coding Initiative (NCCI) edits bundle the two codes unless the edit is appropriately overridden with a modifier, such as modifier 59 (Distinct procedural service), to indicate separate lesions.

Look for Payer Frequency Rules

Some patients, particularly older ones, will see their primary care practitioner for routine foot care. As people age, it becomes increasingly difficult for them to even reach their feet, let alone care for them. Corns, calluses, and toenails can become painful if ignored.

However, pay attention to how frequently a patient is coming in for these services. According to Medicare (www.cms.gov/ medicare-coverage-database/view/article. aspx?articleId=57957), codes 11055, 11056, and 11057 are included in routine foot care. They allow these codes as medically necessary once every 60 days if an exception to the routine foot care exclusion applies (e.g., the patient has a systemic condition such as diabetes mellitus that may justify more frequent coverage). Though individual payer rules may vary, Medicare considers the following services routine:

• The cutting or removal of corns and calluses: 11055-11057
• The trimming, cutting, clipping of nails: 11719 (Trimming of nondystrophic nails, any number)
• The debridement of nails: 11720 (Debridement of nail(s) by any method(s); 1 to 5) and 11721 (… 6 or more)
• G0127 (Trimming of dystrophic nails, any number)

Other hygienic and preventive maintenance care, which includes cleaning and soaking the feet, using skin creams to maintain skin tone of either ambulatory or bedridden patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot

Note: Unless payers have a specific policy in place for something, they’ll usually default to Medicare’s policy on things, said Christopher Chandler, MHA, MBA, CPC, CGSC, technical manager of documentation and coding for Intermountain Healthcare, in his recent Virtual HEALTHCON session “Let’s Talk About Feet.” There are exceptions to this, however. “You’ll have to check with your more common payers and find out what they do. But it’s a safe assumption that if they don’t have their own policy, they’re probably adhering to Medicare’s policy,” Chandler adds.

Lara Kline, AS, BS