Podiatry Coding & Billing Alert

Also: Got ulcer care, Dermagraft, and VAC questions? Read on for our expert wound care answers.

Incorrectly coding wound care claims can cause a breakdown in your bottom line. Study these wound care questions and answers to determine if your wound coding knowledge means a speedy reimbursement or needs immediate treatment.

Question #1: If our podiatrist sees a patient in the ED for a hunting gunshot wound to the foot that includes broken metatarsal bones that the podiatrist must repair in the operating room, should we report the tissue or bone injury and repair as the primary diagnosis and procedure?

Answer: A gunshot wound to the foot is a high-velocity wound that tends to have fractures and requires an aggressive washing and cleaning of the wound because of contamination from sock and shoe material and dirt.

Based on the situation you describe, you're also going to have to do multiple debridements.

The rules say you list things in order with the procedure that uses the most time and skill for that required service first. In this case, the debridement of the open compound fracture would take precedence, because it's a bigger code in terms of RVUs.

So, you would code the wound as 1101x (Debridement including removal of foreign material at the site of an open fracture[s] and/or dislocation[s]...) linked to diagnosis code 892.1 (Open wound of foot except toe[s] alone; complicated), and 28485 (Open treatment of metatarsal fracture, includes internal fixation, when performed, each) linked to 825.30 (Fracture of unspecified bone[s] of foot [except toes]; open).

Watch out: "Reporting a debridement is now a highly scrutinized service," warns Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA. "Documentation should mention contamination or devitalization of tissues when present and the surgeon must state the depth of tissue debrided."

Don't miss: This was an accident, so you should also include E code E922.2 (Accident caused by hunting rifle).

Question #2: What codes should we report for compression therapy for patients with venous stasis ulcers?

Answer: There's no one code for compression therapy for venous stasis ulcers as there is for statin therapy. Podiatrists treat venous stasis ulcers with a number of modalities,

depending on the situation. Examples include the Unna boot, for which you may only report the application of the boot (29580, Strapping; Unna boot), but not the boot itself.

Other modalities include Ace wraps with compression markers (HCPCS code A6449, Light compression bandage, elastic, knitted/woven, width greater than or equal to 3 in. and less than 5 in., per yard) and Profore, a multi-layer compression bandage system.

Report Profore with 29580, and consider appending modifier 22 (Increased procedural services) to account for the multiple layers that the podiatrist must apply. You should link the CPT® code to ICD-9 code 454.0 (Varicose veins of lower extremities; with ulcer).

Venous stasis wounds result when the veins in the lower leg don't work so well and you get leakage of venous blood and swelling of the legs. The ulcers are a result of the poor blood exchange and the swelling.

Question #3: What diagnosis code should we use for an ulcer that is both neuropathic and ischemic?

Answer: You should use the same code that you use for all non-decubitus ulcers: 707.1x (Ulcer of lower limbs, except decubitus). ICD-9 does not now have diagnosis codes that differentiate between neuropathic ulcers and ischemic ulcers, so an ulcer that is a combination of the two poses no special diagnosis coding problem.

"Mixed" ulcers may be identified by their combination of neuropathic and ischemic characteristics, reduced to nonpalpable pulses, cool skin temperature, sparse hair growth, and a slightly viable ulcer base.

Question #4: How should I report the treatment of a wound of less than 50 sq cm that requires both the application of Dermagraft and wound VAC within the global period?

Answer: You would code the wound treatment as follows: For the wound preparation, select 15002 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues], or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children); for the Dermagraft application, report G0440 (Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less) and G0441 (... each additional 25 sq cm). For the final step, the wound VAC application, report 97605 (Negative pressure wound therapy [e.g., vacuum-assisted drainage collection], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session; total wound[s] surface area less than or equal to 50 square centimeters).