Podiatry Coding & Billing Alert

Question: A patient came into the office for follow-up treatment of an ingrown toenail. The podiatrist found that the patient actually had two ingrown toenails — one on each foot. The podiatrist removed both and also performed silver nitrate cauterizations to keep them from reoccurring. The visit lasted a total of 47 minutes. Should I report 99214-25 for this encounter?

Florida Subscriber

Answer: If you are calculating the office/outpatient evaluation and management (E/M) level based on total time, 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter) would only be correct if the total time of the E/M component of the encounter minus the time taken for the excisions fell within the parameters of total time for the code (30-39 minutes). If it did, then you could select the code that way; if it did not, you would have to select another level of E/M.

That’s because the total time of the visit cannot include the time taken for the two toenail excision procedures if they are coded separately using 11750 (Excision of nail and nail matrix, partial or complete [eg, ingrown or deformed nail], for permanent removal). Per CPT^® office/outpatient E/M guidelines, total E/M time “does not include any time spent in the performance of other separately reported service(s).”

You can still determine an E/M level for this encounter based on total time, however, or you can calculate the E/M level based on medical decision making (MDM). If total E/M time minus procedure time is greater than 10 minutes and less than 19 minutes, you could go ahead and code 99212 (… 10-19 minutes of total time is spent on the date of the encounter); if total E/M time minus procedure time is greater than 20 minutes and less than 29 minutes, you could go ahead and code 99213 (… 20-29 minutes of total time is spent on the date of the encounter). If you decide to go this route, make sure your documentation contains a breakdown of the time your podiatrist spent evaluating the patient, and the time spent on the excision procedures.

But if total time for the E/M does not fall within any of these parameters (i.e., it is less than 10 minutes but not greater than 39 minutes), your other option would be to choose the E/M level based on MDM. Given that the two ingrown toenails represent two self-limited or minor problems, and the excision procedures represent a low risk of morbidity to the patient from or treatment, that would give you a low level of MDM, which translates to a 99213 office/outpatient E/M.

Then, you should report each toenail removal separately: 11750 for the first complete removal and 11750 for the second removal, appending modifier 59 (Distinct procedural service) to the second removal to tell the payer that the podiatrist performed a second ingrown toenail removal on a different toe. You can use anatomic modifiers to emphasize the procedure was performed on two separate nails, such as 11750-T5 (Right foot, great toe) and 11750-59-TA (Left foot, great toe).

Lastly, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99212 to indicate the podiatrist performed a significant, separate E/M service from the single ingrown toenail removal that had originally been planned.