Welcome 11/19/ Recommended by the AAPPM. Begin with the correct tools APC. www. (your medicare carriers website)

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1 Welcome We are glad you re Here!! The opinions given are not necessarily the opinion of the AAPPM and are subject to interpretation by each individual. It is not a substitute for professional legal, financial, or medical advice---coding rules and payment policies can differ from carrier to carrier. 1 Jeffrey Frederick, DPM, FASPS President, American Academy of Podiatric Practice Management Chairman Ins Committee, Michigan Podiatric Medical Association Jon Moore, DPM, MS Trustee, AAPPM Neal Frankel, DPM, FASPS, WLMM Co-Chairman, Illinois Ins Committee President, Advanced Foot and Ankle Group, 80 Doctor IPA 2 Begin with the correct tools Recommended by the AAPPM www. (your medicare carriers website) 3 4 APC All codes and reimbursement are LCD dependent Coding: Ultrasound Guided Injection: approx. $ : Tissue Graft Harvest: approx. $ Unlisted Procedure: 28899:? 5 1

2 ENFD: CPT Reimbursement = $85.00 ($ ) = $30.00 ($25-36) Diagnosis: 356.8, 356.4, Biological Alternative Tissue PRODUCT CODE CODE DESCRIPTOR Misc. Q4100 n/a SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED Apligraf Q4101 J 7340 SKIN SUBSTITUTE, APLIGRAF, PER SQ CM Oasis Wound Q4102 J 7341 SKIN SUBSTITUTE, OASIS WOUND MATRIX, PER SQ CM Oasis Burn Q4103 J 7341 SKIN SUBSTITUTE, OASIS BURN MATRIX, PER SQUARE CENTIMETER Integra Wound Q4104 J 7347 SKIN SUBSTITUTE, INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), Integra DRT Q4105 n/a SKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), DERMAGRAFT Q4106 J 7342 SKIN SUBSTITUTE, DERMAGRAFT, PER SQ CM Graft Jacket Q4107 J 7344 SKIN SUBSTITUTE, GRAFTJACKET, PER SQ CM Integra Q4108 J 7347 SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQ CM Tissuemend Q4109 J 7348 SKIN SUBSTITUTE, TISSUEMEND, PER SQ CM Primatrix Q4110 J 7349 SKIN SUBSTITUTE, GRAFTJACKET, PER SQ CM Gammagraft Q4111 J 3590 SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQ CM Three Lines of Treatment for Fall Prevention (OTC)Peromax AFO: Light weight, easy to fit into shoes, but no ankle stability, no somatosensory feedback L1951 Reimbursement 700+ Treatment Options for Balance Bledsoe Axiom or the Ossur Rebound L1971 Reimbursement: $400+ The Custom Option The MBB MBB 2

3 Reimbursement Arizona With Dorsi Assist MBB cost: $ bilateral/pair ($ per limb) The MBB is designed to be worn as a pair to optimize balance and stability, improve postrual sway, and reduce in the incidence of falls Medicare ceiling for codes: L1940, L2330, L2820 is $1, ($2, for the pair) Arizona AFO Dorsi Assist ARTICULATED AFO: L-1970, 2280, 2820, 2210 (x 2) L2275 (if extrinsic post was added) Test your Coding knowledge L3010 (if partial foot custom fabricated insole is added to the AFO) L3020 (if full length custom fabricated insole is added to the AFO) L5000 (if filler is added to orthosis) Potential Reimbursement: L1971 $626.50, L2280 $511.16, L2820 $72.52, L2210 $56.91 X 2 = $1,324 During a post-op period (1 week following an I&D abscess) you are examining the patient and you encounter a skin rash, after working up the rash you write a scrip for topical anti-fungal, What if anything would you be able to bill for? Charge the Patient CASH Bill an E/M code and add a modifier You would not be able to bill anything since there is a global period for the I&D which precludes billing during this time Have your partner see the patient instead 16 Modifier 24 Test your coding knowledge Modifier 24: Unrelated evaluation and management (E/M) service by the same physician* during a postoperative period Append modifier 24 to the E/M procedure code. Apply modifier 24 to an unrelated E/M services during the post-operative period beginning the day after a procedure, when the E/M is performed by the same physician* during the post- operative period of procedure code with a 10 or 90 day global period. A patient is on the operating room table and has a reaction that the anesthesiologist is concerned about and advises you to cancel the surgery You cannot bill the surgery You should send a bill to the patient You should ignore the advise and do the surgery and get paid You should bill the surgery but add a modifier

4 Modifier 53 Billing and Audits Modifier 53: Indicates the physician elected to terminate a surgical or diagnostic procedure due to the patient s well-being. Appropriate Usage: A discontinued procedure after induction of anesthesia Which statement is correct: One shouldn t bill more than one service per claim or visit this will increase chances of an audit Down Coding my Office visits will put me under the auditors radar (bill instead of 99213) Helping all my elderly patients by waiving their co-pays will protect me from complaints to Medicare Once I have billed a new patient visit to Medicare, I can never bill this patient again as a new patient service 99202/4 If I see one of my partners patients, I can code the visit as a new patient visit Being an AAPPM member is the best investment for my future The amount of time Medicare requires you to keep your chart records is 3 yrs, 5 yrs, 6 yrs & 3 months, 7 yrs (from time of payment or is it from the time of billing?) Test your coding Test Your Coding You are seeing a Medicare pt for an injury to the ankle, you determine that a cam walker would be appropriate, before dispensing the item the patient mentions that she needs to get home because her home health nurse is meeting her to examine an ucler on her arm. If you bill the cam walker to the DME carrier would you get paid? You make a visit to an assisted living home and treat a patient for an ingrown nail. While there you notice a folder from Good Angels Hospice care on the table with todays date filled out by the hospice nurse. You should demand cash from the patient You should consider this your good deed for the week and write off the visit You should bill the patients family for the visit You should bill the appropriate CPT code and add a modifier You should look through the patients dresser for cash or items for trade for the service Modifier GV Hospice GV or GW- Attending physician not employed or paid under agreement by the patient's hospice provider. Test your Coding knowledge Which of the following situations qualify for billing a consult? A patient is sent to your office from the family doctor s office next door for a severely ingrown nail A patient comes to your office after going to the ER with a severely sprained ankle, after the ER Doc told the patient to seek out care with their Podiatrist A patient comes to your office with a slip from their doctor that reads painful toe please treat appropriately

5 Answer Test your coding knowledge None of the above, ALL consultation codes have been eliminated for 2010 What to bill: Nursing homes 99304/5 initial /8 subseq Hospital 99251/5 initial /3 subseq Domiciliary, Rest Home /7 initial /6 subseq When using the modifier 59 which is true If billing 2 procedures during a visit, always put modifier 59 on each procedure always put modifier 59 on the most expensive procedure (generally) always put modifier 59 on the least expensive procedure (generally) never use modifier 59, it triggers an audit modifier 59 is for the weak minded Billing and Audits Which statement is correct: Billing an office visit along with a procedure will trigger an audit Coding Untapped Revenue Codes you should consider.. Down coding my Office visits to a lower level will put me under the auditors radar Helping all my elderly patients by waiving their co-pays will protect me from complaints to Medicare Once I have billed a new patient visit to Medicare, I can never bill this patient again as a new patient service 99202/4 If I see one of my partners patients, I can code the visit as NP Being an AAPPM member is the best investment for my future Orthotics L3000 (or L3030) RT $200 L3000 LT $200 S0395 impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic $75 A4580 material $ : handling/mailing transport orthotics outside lab to be fitted by physician The amount of time Medicare requires you to keep your chart records is 3 yrs, 5 yrs, 6 yrs & 3 months, 7 yrs (from time of payment or is it from the time of billing?) Coding Untapped Revenue Vs cautery of wound $ Treatment of Burns Jcodes - injectables reimbursement varies J1094 dexamethasone acetate J1020 methylpred acetate 20mg J1030 methylpred acetate 40 mg J1710 hydrocortisone Naphos J1100 dexamethasone NaPhos J3303 triamcinalone hex J3301 triamcinalone acetonide $40 Strapping; Unna boot $72 Dx 1) venous insuff 2) ulcer Application of multi-layer venous wound compression system, below knee Multi-Layer High Compression Bandaging System Wound Contact Layer (WCL) A6207..$7 Padding Bandage Layer #1 A Conforming Bandage Layer #2 A Light Compression Bandage Layer #3 A6449..$1.84 Self-Adherent Bandage Layer #4 A

6 Coding Untapped Revenue Hammertoe Repair Home Health Care: G0180 Certification of Home Health Care ($80) G0179 Recertification of Home Health Care includes any procedure done on the same digit except nail procedures does not include a MTPJ release if performing a flexor plate release common diagnoses Hammertoe Claw toe Joint Contracture POS place of service Nail Procedures 11 = office 12 = home 13 = assisted living/domiciliary, rest home, day care 21 = In pt hospital 24 = Sx center 31 = skilled nursing facility 32 = nursing facility 33- = custodial care matricectomy matricectomy with subungual exostectomy nail avulsion (partial or complete) each additional nail avulsion evacuate subungual hematoma common diagnoses ingrown nail dystrophic nail WART TX Codes , to report the destruction of premalignant lesions only Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions or more lesions Excision of Neuroma any intermetatarsal neuroma common diagnoses neuralgia, plantar nerve neuroma mononeuritis, nerve compression

7 Injections ligament/tendon sheath, injection soft tissue diagnosis, ex: plantar fascia single tendon origin/insertion 20600, intra articular injection joint, bursa diagnosis diagnosis therapeutic nerve block nerve diagnosis, anesthetic agent; other peripheral nerve or branch destruction of peripheral nerve (sclerosing alcohol injections) injection for neuroma/anesthetic agent/or steroid plantar common digital nerve ex: Morton neuroma always bill for the steroid, if used, with the appropriate J code Incision and Drainage I&D abscess simple I&D abscess complicated or multiple incision and removal of foreign body, subcutaneous tissues; simple Incision and drainage of hematoma, seroma or fluid collection Puncture aspiration of abscess, hematoma, bulla, or cyst common diagnoses paronychia/onychia abscess ankle,682.7-foot, toe or nail Hematoma/Contusion foot Hematoma/Contusion toe(s) Misc Procedures Ulcer Care The Old Codes going, going, gone casting numerous codes total contact cast diagnosis of ulceration with diabetes and/or Charcot foot and ankle strapping diagnoses include injury or fasciitis based on depth and tissue debrided common diagnoses ulcer codes Infections Blister Important Code Changes for 2011 If anything is consistent in medicine, its change...and there are plenty of changes coming. Next year the debridement codes in Current Physician Terminology (2011) are changing. These updated codes were a product of over 4 years of effort by a multispecialty CPT workgroup which included the APMA CPT Panel Advisors and APMA Staff. Also, In 2013 ICD-10 is coming. CHANGES FOR 2011 Codes and have been deleted as of January 1, These two codes will cross reference to the active wound care codes (Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters) (greater than 20 square centimeters) This means that effective January 1, 2011, for any wound debridement that does not include the subcutaneous tissue you would bill or

8 CHANGES CONTINUED SubQ SubQ SubQ SubQ (Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square centimeters or less) (Debridement, subcutaneous tissue (includes epidermis and dermis, if performed, muscle and/or fascia; first 20 square centimeters or less) (Debridement, (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, bone if performed); first 20 square centimeters or less). Next there will be new CPT codes for each additional 20 square centimeters that will appear out-of-sequence. These new codes will immediately follow the primary code and will be used in conjunction with that code. Additional size: (each additional 20 square centimeters, or part thereof) should be listed separately in addition to code (each additional 20 square centimeters, or part thereof) is to be used in addition to (each additional 20 square centimeters, or part thereof) will be used in These add-on codes can be used multiple times based on the overall size of the wound. 44 Debridement Codes Summary debridement not including subq <20 sq debridement not including subq >20 sq debridement includes subq < 20sq added if > 20 sq includes subq/muscle/fascia <20 sq added if > 20 sq includes subq/muscle/bone <20 sq added if > 20 sq In CPT (ultrasound extremity, non-vascular, real time with image documentation)has been deleted and replaced with ultrasound extremity, nonvascular, real time with image documentation, complete ultrasound extremity, nonvascular, real time with image documentation, limited 45 Changes Continued Radiographs DPM s would usually do the limited (for a plantar fascia) but could bill the complete if a full joint (ankle ) was evaluated It requires image documentation which means a picture (printout or digital) of the ultrasound image must be in the chart code includes taking and reading the x-rays which a report must be made -26 modifier if only reading -TC modifier if only taking Type or size of the machine is irrelevant as long as it can produce a printed or digital image. Don t know the RVU s yet for these codes 48 8

9 E/M Services Specific Diagnosis Codes New Patient visits Established Patient visits 99251/5 Inpatient Initial visits 99231/5 Inpatient Subsequent visits New Patient Domiciliary Care Established Pt Domiciliary Care Home visit New Home visit Est abnormal gait joint pain, arthralgia Tinea Pedis calcaneal apophysitis capsulitis dehiscence of post-op wound dyshidrosis Other Specific Diagnosis Codes Other Specific Diagnosis Codes ecchymosis/hematoma of foot ecchymosis/hematoma of toe fissure of skin frostbite haglund s disease unspecified injury to foot or ankle ischemia keloid limb length inequality post-op lymphedema metatarsalgia numbness pain in limb porokeratosis-congenital (vs benign lesion of skin) rash sesmoiditis stiffness of joint Other Specific Diagnosis Codes V-Codes stitch abscess surgical wound non-healing V15.81 noncompliance with medical treatment V45.4 Failed Fusion/Arthrodesis V53.7 fitting/adjustment of orthotic device-brace, cast, shoe V54.01 Aftercare internal/external fixation V54.19 Aftercare for healing traumatic fracture V54.29 Aftercare for healing pathologic fracture V58.30 Removal of non-surgical wound dressing V58.31 Removal of surgical wound dressing V58.32 Removal of sutures V58.61 long term use of anticoagulant V58.69 current use high risk meds V66.7 encounter for palliative care V67.00 F/U after surgery V67.4 F/U after healed fracture

10 HCPCS CODES SPECIFIC L CODES A5500-A5507 diabetic shoes A5512 Heat Molded Diabetic Inserts A5513 Custom Molded Diabetic Inserts E codes DME such as crutches, walkers, bone stimulators J codes injectable drugs Orthotics L3000-L3030 L3000 UCB type orthotic molded to model of foot L3030 orthotic molded to foot L4360 Pneumatic walking splint L4350 Pneumatic ankle control splint L1906 Multiligamentous ankle splint L4386 Non-pneumatic walking splint L4396 Static AFO-PF Night splint WEBPAGES Stop examining what happened yesterday and start preparing for tomorrow Captain Jean-Luc Picard