Podiatry Coding & Billing Alert

Are these myths costing you $70 per procedure?

Auditors look unkindly on podiatry offices that incorrectly code E/M services and nail debridement procedures performed during a single patient encounter -- but that doesn't mean you should pass up legitimate opportunities to code both. We've got the scoop on when you can report both services and the modifier that will make the grade.

Myth: You may never code for both an E/M and a nail debridement when submitting claims to Medicare.

Reality: The blanket statement that you may never report an E/M code and a nail debridement code together is simply not true. You absolutely can code and bill an E/M service and a nail debridement for a single patient encounter, depending on the situation.

Key: You must have documentation that the podiatrist performed two entirely separate services. Most carriers also require that you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate that the minor procedure is not included in the fee for the office visit.

Start With the Right Codes

Choose between two codes when submitting claims for nail debridement to Medicare: CPT 11720 (Debridement of nail[s] by any method[s]; one to five) and CPT 11721 (... six or more), depending on the number of nails the podiatrist debrides. Remember that in order for these services to be covered by Medicare, you must report class findings with either modifier Q7 (One Class A finding), Q8 (Two Class B findings), or Q9 (One Class B and two Class C findings).

Other nail codes affected by the Q codes are 11719 (Trimming of nondystrophic nails, any number) and G0127 (Trimming of dystrophic nails, any number), notes Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.

Use These Scenarios as Guides

Look at the following cases as examples of when you should separately report an E/M service and nail debridement if you have the necessary documentation.

Do separately report nail debridement and an E/M service if an established patient presents for a standard, routine nail debridement procedure and has another, entirely separate problem for which the podiatrist performs an E/M service. In this case, you would choose the appropriate nail debridement code and an office visit code (for example, 99212 for a level-two established patient visit) and append modifier 25 to the E/M code.

Do separately report nail debridement and a new patient E/M service if you fully evaluate a new patient and also perform a debridement service during that initial office visit. In this case, you do not need to append modifier 25 to the E/M service because it is the patient's first visit and an E/M service is necessary in order to obtain the patient's medical history and to perform a physical.

Example: The podiatrist treats an ulcer during a new patient's first visit. The patient returns for a follow-up visit for the ulcer, and during that follow-up the podiatrist notices that the patient has mycotic nails. He debrides the nails and evaluates the newly discovered condition. In this case, experts recommend reporting both the debridement and the follow-up E/M service. You would need to append modifier 25 to the code for the follow-up E/M.

Avoid These Pitfalls

Don't separately report an E/M and nail debridement if you have a patient who returns to the office every 10 weeks for the debridement. In this case, you should only report the appropriate nail debridement code, 11720 or 11721.

Don't separately report an E/M and nail debridement if the reason for the nail debridement is the same as the reason the podiatrist is evaluating an established patient in the first place. If the diagnosis codes for the debridement and the E/M service are too similar, many carriers consider the conditions too closely related and therefore not billable, she adds.

Example: An established patient presents with tinea pedis, 110.4 (Dermatophytosis; of foot). The podiatrist performs a level-three E/M service, during which he performs 11721. If you submit a claim for both 99213 and 11721, chances are good that the carrier will only reimburse you for the nail debridement -- a difference between $43.57 for 11721 and $70.46 for the E/M service.

Advice to Code By

When billing an E/M code with a debridement, you must have a good E/M note that shows that the podiatrist really did more than just debride the patient's nails, especially if the E/M takes place during a regularly scheduled nail debridement.

Documentation solution: For patients who regularly present for debridements, a chart note of "Patient returns for a nail debridement" will not support billing for an additional E/M service. A note that states, "Patient returns for nail debridement, patient is having problems with medication" or "Patient has developed pressure ulcer" will show that a new medical problem has arisen that requires its own distinct evaluation and management.

So go ahead and bill the E/M if your nail debridement appointment has an E/M service for an entirely unrelated problem. Just be sure to document the visit clearly and in detail.

Don't miss: Different Medicare carriers follow different rules for nail care, warns Beresh. So always check with your local carrier, so if Medicare's auditors come calling, you can prove your billing was justified.