Podiatry Coding & Billing Alert

Hint: Make sure your primary diagnosis matches the procedure codes.

If you're just plodding though nerve surgery claims, you could be stepping over a great deal of well-earned reimbursement.

Coding and billing peripheral nerve surgeries for conditions such as tarsal tunnel and diabetic neuropathy can involve a frazzling number of codes. And podiatry coders often struggle to navigate the various coding guidelines that payers use for these procedures. Use these five tips to maximize payment for your podiatrist's hard work on nerve surgeries:

Tip #1: Check CCI edits and your local Medicare guidelines. If you're billing codes that the Correct Coding Initiative bundles together -- and your documentation and diagnosis codes can't justify breaking the bundle -- you're not going to see one extra cent for that bundled procedure code.

Example: A California Medicare patient injures his foot when he falls off a ladder and requires peripheral nerve surgery to correct the damage the injury caused. The podiatrist performs the following:

• 28035 -- Release, tarsal tunnel (posterior tibial nerve decompression)
• 64712 -- Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve
• 64704 -- Neuroplasty; nerve of hand or foot
• +64727 -- Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)
• 64708 -- Neuroplasty, major peripheral nerve, arm or leg, open; other than specified.

If you report all these codes, you're bound to get a denial on 64704 -- this is one of the codes the Correct Coding Initiative (CCI) bundles into 28035. Unless you can justify billing 64704 separately (and if that's the case, append modifier 59, Distinct procedural service, to the code), you shouldn't list it all.

Unbundling is not automatic: Be aware that you can't automatically override a CCI edit with modifier 59 just because documentation supports a separate site, incision, or patient encounter, says Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas.

Here's why: Before appending modifier 59, check the modifier indicator for the bundled code pair. You'll find the modifier indicator in Column F of the CCI Excel spreadsheet, which you can download from www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.

A modifier indicator of "0" means that you may not unbundle the edit combination under any circumstances. Alternately, a "1" indicator opens the possibility for you to override an edit using a modifier if your documentation supports that the procedures are distinct from one another and meets the criteria described in the definition of modifier 59.

Better way: You can check on two codes' bundled status by entering them into the CCI Tool on https://www.aapc.com/codes/.

Reporting 64712 could also raise some eyebrows with the insurance carrier. Podiatrists don't normally report this code because the sciatic nerve is not something a podiatrist normally works on. Use caution when reporting this code because of the anatomic location of the nerve it refers to, and check first whether the carrier will pay the podiatrist for this procedure.

Tip #2: Make sure diagnosis codes match procedure codes. For example, you might be tempted to report 355.71 (Causalgia of lower limb) on a workers' compensation claim to show that the patient's problem is the result of a traumatic injury, and therefore justifies reporting 28035. But if the only accepted primary diagnosis for the surgery is 355.5 (Tarsal tunnel syndrome), carriers will reject your claim.

Tip #3: Code the highest RVU procedure first. Order does make a difference. You should always code first the procedure with the highest value because under multiple surgery rules, the subsequent procedure codes will only merit half of the normal reimbursement. In the example above, you should not list 64708 first because it only has 14.12 nonfacility RVUs. Code 28035 has 14.84 non-facility RVUs, and therefore should be the first code you report.

Tip #4: Work out jurisdiction and fee schedule for workers' comp claims. If you're not paying attention, you could lose out big with your workers' comp patients. Workers' comp has its own set of rules, and deviating from them can lead to numerous denials.

When billing workers' comp claims, you need to look out for a number of things:

• Does the documentation support the billing? If the podiatrist bills for working on the sciatic nerve, does the documentation state how and why he worked on this nerve?
• Are you billing the correct jurisdiction for the payment? If the patient is aColorado resident but sustained the injury working in California, you need to follow the fee schedule of the state in which the patient's first WC claim was filed.
• Are you billing with the correct year CPT® manual? Not all WC carriers use the current fee schedule, so if you're using new codes that aren't in the WC fee schedule, you won't get paid.
• Are all of the procedures WC-related and authorized? If a patient decided to have a bunionectomy performed at the same time as the peripheral nerve surgery, WC won't pay for it if the bunionectomy is not related to the work injury.

Tip #5: Append modifiers if multiple surgery rules apply. This can be especially important if you are performing the same procedure multiple times on the same foot.

Example: A typical tarsal tunnel case on the right foot would be 28035-RT (Right side) linked to diagnosis code 355.5, along with 64704-RT, 64704-RT-59, and 64704-RT-59. One of the difficulties in coding peripheral nerve surgery is that CPT® lacks a code to describe a three- or four-nerve release. Code 64704 is a possible fit when the podiatrist performs a release of the nerve that is past the tarsal tunnel. So before coding in this manner, ask the carrier for its guidelines in this situation.

If the carrier will allow 64704 for a release of the nerve past the tarsal tunnel, you should report 64704 three times -- once for the medial nerve, once for the lateral plantar nerve, and once for the calcaneal nerve that are all on the same foot, Larson says. Modifiers RT and 59 help indicate the podiatrist is performing the procedure on distinct parts of the same foot.