Podiatry Coding & Billing Alert

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

You may be an expert at podiatry codes but you could still be mystified when it comes coding and billing peripheral nerve surgeries for conditions such as tarsal tunnel and diabetic neuropathy. Different coding guidelines that payers use for these procedures add to the confusion.

Avoid these five common mistakes to come out unscathed from the minefield of nerve surgery coding.

Mistake #1: You Overlook the Latest CCI Edits and Local Guidelines

You may be missing out on major dollars and also putting yourself on the way to rejection if you’re billing codes that the Correct Coding Initiative (CCI) bundles together. You may have compounded the mistake if you have not justified the unbundling with your documentation and appropriate op notes.

For all practical purposes, you will most probably choose one or more codes when you encounter a neuroplasty:

• 64702 — Neuroplasty; digital, 1 or both, same digit

• 64704 — Neuroplasty; nerve of hand or foot

• 64708 — Neuroplasty, major peripheral nerve, arm or leg, open; other than specified

• 64722 — Decompression; unspecified nerve(s) (specify)

• 64726 — Decompression; plantar digital nerve

• +64727 — Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)

For example, a Medicare patient is involved in a car accident and injures his foot. Your podiatrist performs peripheral nerve surgery to correct the damage the injury caused. You decide to report the codes 28035 (Release, tarsal tunnel [posterior tibial nerve decompression]), 64712 (Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve), 64704, +64727, and 64708.

However, you are surely heading for denial territory as code 64704 is bundled by CCI into 28035. You should report 64704 separately only if your physician separately mentions the procedure and provides detailed notes for it. Even after that, don’t forget to append modifier 59 (Distinct procedural service) to the code.

Caution: “Ensure that you are not arbitrarily unbundling a CCI edit with modifier 59 just because documentation supports a separate site, incision, or patient encounter,” cautions Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. “You can append modifier 59 only after verifying the modifier indicator for the bundled code pair,” he adds. 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.

You should also be wary of reporting code 64712 as podiatrists don’t normally report this code because the sciatic nerve is not something a podiatrist normally works on. Double check whether the insurance carrier will pay the podiatrist for this procedure because of the anatomic location of the nerve.

Mistake #2: The Diagnosis Codes Don’t Match Procedure Codes

You may have selected the right procedure codes but not cross matching them with the right diagnosis codes may lay all your previous efforts to waste. 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. Some accepted ICD-9 codes for justifying the neuropathy are 250.60-250.63 (Diabetes with neurological manifestations…), 357.2 (Polyneuropathy in diabetes), and from among 354.0-355.9 (Mononeuritis…).

Under ICD-10, similarly possible codes may be E11.40-E11.9 (Type 2 diabetes mellitus with neurological complications), E08.42 (Diabetes mellitus due to underlying condition with diabetic polyneuropathy), E09.42 (Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy), E10.42 (Type 1 diabetes mellitus with diabetic polyneuropathy), E11.42 (Type 2 diabetes mellitus with diabetic polyneuropathy), E13.42 (Other specified diabetes mellitus with diabetic polyneuropathy), and the G57 (Mononeuropathies of lower limb) code range G5700-G5792.

Mistake #3: Order of Codes Reported is Skewed

Order plays an important part while submitting a claim. You should always code the highest relative value unit (RVU) procedure first. Under multiple surgery rules, the subsequent procedure codes will only be reimbursed half of the normal payment. Therefore, you could be losing valuable dollars by listing lesser paid procedures at the top of the bill. In the example above, you should not list 64708 first because it only has 14.34 non facility RVUs (You will get paid 14.34 multiplied with the 2015 conversion factor of 35.7547,

i.e., $512.72). You should list code 28035, if eligible, as the first billed item because it has 15.24 non-facility RVUs (you will get paid 15.24 × 35.7547 = 544.90).

Mistake #4: Legal Parameters for Workers’ Comp Claims are Unclear

You could miss out on the workers’ comp claims if you are not extra careful with 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 a Colorado 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.

Mistake #5: Incorrect Modifiers are Used for Multiple Procedure Claims

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.