ICD- 10 SPECIALTY TIPS SPECIALTY TIP #17 Podiatry The Basics As with Plastics, Podiatry often has an uphill battle as to whether a procedure will be paid by an insurance carrier. The procedures may have a justifiable medical necessity (as determined by the carriers) or a matter of comfort; it is the age old battle of need versus wants with added emphasis on supporting documentation to illustrate the medical necessity for treatment. According to CMS, the only covered podiatry services are those considered medically necessary and reasonable foot care. This means that any elective or non- medically necessary services might not be covered as reasonable foot care. Some procedures may require pre- certification to determine whether or not the procedures would meet the criteria as determined by a carrier s medical director review. Check with the carrier for procedures that may or may not be covered as each patient s plan has its own guideline for coverage. Procedures For procedure coding, there are a few tips that would be helpful to the coders to make coding for your services more accurate. Identify the specific location of surgery o Specify toes involved o Specify bones involved Always state laterality. o This is especially relevant when treating different conditions and/or performing different procedures for contralateral sides. Often it is difficult to determine if a surgery is for purely cosmetic reasons or could there be a medical condition that may support requesting reimbursement from an insurance carrier. o Example: One carrier considers foot cheilectomy medically necessary for symptomatic relief of either of the following conditions: Painful bony spurs in the earlier stages of an arthritic joint; or Painful hallux rigidus. For all other indications the carrier considers foot cheilectomy experimental and investigational because its effectiveness for indications other than the ones listed above has not been established. o The H&P or consult may be requested for the medical review, those documents are ideal to illustrate the need for treatment. A path report may also be needed support medical necessity in some instances. o Do not forget to include pertinent information and diagnoses in your surgical op report. Often, the supporting diagnosis (breast cancer with mastectomy, contracture from burn scarring, etc.) may be missing from the op reports and the H&P or consult are needed in order to obtain the information thus causing a delay in submitting the claim. Provide adequate history to identify any former surgeries or conditions affecting treatment. o Often it is difficult to differentiate whether the current surgery is the initial procedure or is this surgery: A repeat surgery (- 76 modifier if same surgeon, - 77 modifier by a different surgeon), A planned, staged procedure (- 58 modifier if within the postoperative global period), For a different condition (thereby starting the global clock for a different condition, - 79 modifier), A correction of a defect (different diagnosis noting a complication). An unplanned return to the operating room for a related procedure (- 78 modifier). o For staged procedures, when was the last surgery? Is this within the global period of the previous surgery? o Otherwise, what condition has prompted the current surgery? Your documentation should clearly explain WHY you did a procedure. o Do not just state that you performed a procedure without adequate medical necessity in the form of a codable definitive diagnosis or signs and/or symptoms. A non- codable rule out diagnosis might be useful in a denial situation or should there be a request for additional information from a carrier to illustrate your decision making process. PODIATRY 1 of 5
ICD- 10 SPECIALTY TIPS YOUR documentation should easily clarify the intent of the visit. Keep in mind that Charge Tickets are not a part of a legal medical record. Below you will find some information that might be helpful and a number of documentation tips for just a few of the procedures you address. Procedures Flat Foot Routine Foot Care Mycotic Nails Debridement Lesion Removal Excisions Information and Documentation Requirements Services or devices directed toward the care or correction of such conditions, including the prescription of supportive devices, are rarely, if ever, covered The following are considered routine and not covered by In certain circumstances, services ordinarily considered to be routine Medicare: may be covered if they are performed as a necessary and integral part of The cutting or removal of corns and calluses otherwise covered services, such as diagnosis and treatment of ulcers, The trimming, cutting, clipping, or debriding of nails wounds, or infections. Other hygienic and preventive maintenance care, such as The presence of a systemic condition such as metabolic, neurologic, or cleaning and soaking the feet, the use of skin creams to peripheral vascular disease may require scrupulous foot care by a maintain skin tone of either ambulatory or bedfast patients, professional. In these instances, certain foot care procedures that and any other service performed in the absence of localized otherwise are considered routine (e.g., cutting or removing corns and illness, injury, or symptoms involving the foot calluses, or trimming, cutting, clipping, or debriding nails) may pose a hazard when performed by a nonprofessional person on patients with such systemic conditions. The treatment of mycotic nails for an ambulatory patient is In evaluating whether the routine services can be reimbursed, a covered only when the physician attending the patient s presumption of coverage may be made where the evidence available mycotic condition documents that (1) there is clinical discloses certain physical and/or clinical findings consistent with the evidence of mycosis of the toenail, and (2) the patient has diagnosis and indicative of severe peripheral involvement. For purposes marked limitation of ambulation, pain, or secondary infection of applying this presumption the following findings are pertinent: resulting from the thickening and dystrophy of the infected 1. Class A Findings: toenail plate. - Non- traumatic amputation of foot or integral skeletal portion thereof. The treatment of mycotic nails for a non- ambulatory patient 2. Class B Findings: is covered only when the physician attending the patient s - Absent posterior tibial pulse; mycotic condition documents that (1) there is clinical - Advanced trophic changes as: hair growth (decrease or absence) nail evidence of mycosis of the toenail, and (2) the patient suffers changes (thickening) pigmentary changes (discoloration) skin texture from pain or secondary infection resulting from the (thin, shiny) skin color (rubor or redness) (Three required); and thickening and dystrophy of the infected toenail plate. - Absent dorsalis pedis pulse. 3. Class C Findings: - Claudication; - Temperature changes (e.g., cold feet); - Edema; - Paresthesias (abnormal spontaneous sensations in the feet); and - Burning. The presumption of coverage may be applied when the physician rendering the routine foot care has identified: 1. A Class A finding; 2. Two of the Class B findings; or 3. One Class B and two Class C findings. Services ordinarily considered routine might also be covered if they are performed as a necessary and integral part of otherwise covered services, such as diagnosis and treatment of diabetic ulcers, wounds, and infections. Anatomic Location and Laterality Method: Autolytic, Enzymatic, Mechanical, Sharp/Surgical, Biosurgical Depth of Tissue Removed: Skin, Subcutaneous, Muscle Fascia, Muscle, Bone Lesions: Anatomic Location and Laterality Size of Lesion(s): Specify diameter prior to excision plus narrow margin Number of Lesions Surgical Technique: Excision, Shaving, Destruction (indicate the method) Tissue Level of Excised Lesion: Epidermal and/or dermal, Superficial (non- muscle) fascia, Deep fascia, Intramuscular, Wide excision, etc. Closing Technique: Adhesive strip application, Chemical or electrocauterization, Simple repair, Layered closure, Complex repair, etc. Tumor Excision Synovectomy Document depth and extent Specify location - Cutaneous (Benign lesions) - Intertarsal, tarsometatarsal, or metatarsophalangeal - Subcutaneous (<1.5 cm, 1.5 cm) - Tendon sheath, foot, flexor or extensor - Subfascial (<1.5 cm, 1.5 cm) - Radial resection (<3 cm, 3 cm) - Radial resection of cutaneous origin PODIATRY 2 of 5
ICD- 10 SPECIALTY TIPS Check that your documentation supports the procedures Examples of covered diagnoses for procedures from one carrier (CAUTION: These covered diagnoses may not be the same for other carriers): E10.51 - E10.59 E11.51 - E11.59 E13.51 - E13.59 L89.890 - L89.899 L97.501 - L97.529 28290 Bunionectomy Document: Approach Additional procedures in detail 28292 28294 28296 28297 28298 28299 28285 28286 Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (e.g., Silver type procedure) Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride or Mayo type procedure Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (e.g., Joplin type procedure) Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (e.g., Mitchell, Chevron or concentric type procedures) Correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus type procedure Correction, hallux valgus (bunion), with or without sesamoidectomy; by phalanx osteotomy Correction, hallux valgus (bunion), with or without sesamoidectomy; by double osteotomy Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy) Correction, cock- up fifth toe, with plastic skin closure (e.g., Ruiz- Mora type procedure) M20.10 - M20.12 M86.071 - M86.079, M86.171 - M86.179 M86.271 - M86.279, M86.371 - M86.379 M86.471 - M86.479, M86.571 - M86.579 M86.9 D21.20 - D21.22 G57.60 - G57.62 M19.071 - M19.079 M19.171 - M19.179 M20.10 - M20.12 M20.5x1 - M20.5x9 M67.00 - M67.02 M71.171 - M71.179 M77.50 - M77.52 M85.671 - M85.679 Q66.89 E64.3 G57.60 - G57.62 L97.501 - L97.529 M12.271 - M12.279 M20.40 - M20.42 M20.5x1 - M20.62 M24.571 - M24.576 M24.671 - M24.676 Hammertoe Deformity M65.871 - M65.879 M67.00 - M67.02 M77.50 - M77.52 M77.9 Q66.7 Q74.2 S92.521x - S92.529x S93.121x - S92.129x Diabetes with circulatory complications [with ulcer and/or infection stemming solely from bunion] Pressure ulcer of other site [toes] [in diabetic members stemming solely from bunion] Non- pressure ulcer of other part of foot [toes] [in diabetic members stemming solely from bunion] Hallux valgus (acquired) Osteomyelitis, periositis, and other infections involving bone [stemming solely from bunion] Benign neoplasm of connective and other soft tissue of lower limb, including hip Lesion of plantar nerve [neuroma secondary to bunion] Primary osteoarthritis ankle and foot Post- traumatic osteoarthritis, ankle and foot Hallux valgus (acquired) Other deformities of toe(s) (acquired) [overriding of great toe or crossover toe deformity] Short Achilles tendon (acquired) Other infective bursitis, ankle and foot [recurrent] Other enthesopathy of foot [recurrent bursitis] Other cyst of bone, ankle and foot Other specified congenital deformities of feet [overriding of great toe or crossover toe deformity] Sequelae of rickets [hammertoe, claw toe, mallet toe] Lesion of plantar nerve [interdigital neuroma] Non- pressure chronic ulcer of other part of foot [of apices] Villonodular synovitis (pigmente), ankle and foot [of MP joint] Other hammer toe(s) (acquired) Other and acquired anomalies of toes [hammer toe, congenital] Contracture of joint, ankle and foot [MP joint] Ankylosis of joint, ankle and foot [ankylosis of proximal interphalangeal joint] Other synovitis and tenosynovitis, ankle and foot [of MP joint] Short Achilles tendon (acquired) Other enthesopathy of foot [adventitious bursitis on the dorsal surface] Enthesopathy, unspecified [synovitis/capsulitis] Congenital pes cavus [claw toe, congenital] Other congenital malformations of lower limb(s), including pelvic girdle [subluxation or dislocation MP joint] Sprain of metatarsophalangeal joint of toe [lateral MP capsular tear] Dislocation of metatarsophalangeal joint PODIATRY 3 of 5
ICD- 10 SPECIALTY TIPS Diagnosis Documentation tells a story enabling a coder to translate into numbers explaining what you did and why. The more detailed and complete the story, the less difficult it is to support and ask for reimbursement. Be sure to designate laterality (right, left, or bilateral). Location, location, location... always be site specific and detail anatomical locations. For musculoskeletal conditions and injuries, state whether the patient is: o In the treatment phase (surgery, Emergency Department, evaluation and treatment by new physician, etc.), o In the healing phase (cast change or removal, medication adjustment, aftercare following treatment), o Or is this a late effect/sequela of an injury? When treating a sequela for an injury you need to gather information on the mechanism of the injury. o Details of the original injury ( closed fracture of the nasal bone with a dislocation of the septal cartilage of the nose ) o When did the original injury occur? (Date) o What happened? ( driver in an MVA, slip and fall in home, hit by a baseball, etc.) Is this a complication from a previous surgery? Coding rules dictate that when coding for multiple conditions, the more severe or acute code is sequenced first with chronic conditions as secondary. Be sure to qualify the severity of the condition. Diagnostic sequencing depends on severity (acute over chronic, etc.). State acute or chronic, old injury, any descriptive wording that help to illustrate the condition. Document related, secondary or causal illness whenever appropriate. Include comorbid and relevant conditions that impact decision making or complicate surgery. If a patient is pregnant, always include trimester and number of weeks regardless of the setting. o The only time pregnancy is considered incidental is when it is documented as such. Otherwise it is coded as Pregnancy complicated by... Social factors influencing diagnoses o Note tobacco use, abuse, dependence, past history, or exposure with type of tobacco product (cigarette, chewing, etc.). Document medical necessity in the op report as well as the H&P. Some most often used diagnosis Description ICD- 10 Atherosclerosis of autologous vein bypass graft(s) of the left leg w/ulceration of other part of foot Atherosclerosis of autologous vein bypass graft(s) of the right leg w/ulceration of other part of foot Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot Atherosclerosis of native arteries of left leg w/ulceration of other part of foot Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot Atherosclerosis of native arteries of right leg w/ulceration of other part of foot Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot Atherosclerosis of nonautologous biological bypass graft(s) of the left leg w/ulceration of other part of foot Atherosclerosis of nonautologous biological bypass graft(s) of the right leg w/ulceration of other part of foot Atherosclerosis of nonbiological bypass graft(s) of the left leg w/ulceration of other part of foot Atherosclerosis of nonbiological bypass graft(s) of the right leg w/ulceration of other part of foot Atherosclerosis of other type of bypass graft(s) of the left leg w/ulceration of other part of foot Atherosclerosis of other type of bypass graft(s) of the right leg w/ulceration of other part of foot ICD- 10 I70.445 I70.435 I70.434 I70.245 I70.244 I70.235 I70.234 I70.545 I70.535 I70.645 I70.635 I70.745 I70.735 Atherosclerosis of unspecified type of bypass graft(s) of the left leg w/ulceration of other part of foot Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and midfoot Atherosclerosis of unspecified type of bypass graft(s) of the right leg w/ulceration of other part of foot Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and midfoot Calcaneal spur, left foot Calcaneal spur, right foot Calcaneal spur, unspecified foot Cellulitis of left toe Cellulitis of right toe Cellulitis of unspecified toe Corns and callosities Enthesopathy unspecified Flat foot (acquired) Flat foot (congenital) Foot drop Hallux valgus (acquired) left foot Hallux valgus (acquired) right foot Hallux valgus (acquired) unspecified foot In growing nail Lesion of plantar nerve, left lower limb Lesion of plantar nerve, right lower limb Lesion of plantar nerve, unspecified lower limb I70.345 I70.344 I70.335 I70.334 M77.32 M77.31 M77.30 L03.032 L03.031 L03.039 L84 M77.9 M21.4 Q66.5 M21.37 M20.12 M20.11 M20.10 L60.0 G57.62 G57.61 G57.60 PODIATRY 4 of 5
ICD- 10 SPECIALTY TIPS Non- pressure chronic ulcer of left heel and midfoot limited to breakdown of skin Non- pressure chronic ulcer of left heel and midfoot with fat layer exposed Non- pressure chronic ulcer of left heel and midfoot with necrosis of bone Non- pressure chronic ulcer of left heel and midfoot with necrosis of muscle Non- pressure chronic ulcer of left heel and midfoot with unspecified severity Non- pressure chronic ulcer of other part of left foot limited to breakdown of skin Non- pressure chronic ulcer of other part of left foot w/fat layer exposed Non- pressure chronic ulcer of other part of left foot w/necrosis of bone Non- pressure chronic ulcer of other part of left foot w/necrosis of muscle Non- pressure chronic ulcer of other part of left foot w/unspecified severity Non- pressure chronic ulcer of other part of right foot limited to breakdown of skin Non- pressure chronic ulcer of other part of right foot w/fat layer exposed Non- pressure chronic ulcer of other part of right foot w/necrosis of bone Non- pressure chronic ulcer of other part of right foot w/necrosis of muscle Non- pressure chronic ulcer of other part of right foot w/unspecified severity Non- pressure chronic ulcer of other part of unspecified foot limited to breakdown of skin Non- pressure chronic ulcer of other part of unspecified foot w/fat layer exposed Non- pressure chronic ulcer of other part of unspecified foot w/necrosis of bone Non- pressure chronic ulcer of other part of unspecified foot w/necrosis of muscle Non- pressure chronic ulcer of other part of unspecified foot w/unspecified severity Non- pressure chronic ulcer of right heel and midfoot limited to breakdown of skin Non- pressure chronic ulcer of right heel and midfoot with fat layer exposed Non- pressure chronic ulcer of right heel and midfoot with necrosis of bone Non- pressure chronic ulcer of right heel and midfoot with necrosis of muscle Non- pressure chronic ulcer of right heel and midfoot with unspecified severity Non- pressure chronic ulcer of unspecified heel and midfoot limited to breakdown of skin Non- pressure chronic ulcer of unspecified heel and midfoot with fat layer exposed Non- pressure chronic ulcer of unspecified heel and midfoot with necrosis of bone Non- pressure chronic ulcer of unspecified heel and midfoot with necrosis of muscle Non- pressure chronic ulcer of unspecified heel and midfoot with unspecified severity Other enthesopathy of left foot L97.421 L97.422 L97.424 L97.423 L97.429 L97.521 L97.522 L97.524 L97.523 L97.529 L97.511 L97.512 L97.514 L97.513 L97.519 L97.501 L97.502 L97.504 L97.503 L97.509 L97.411 L97.412 L97.414 L97.413 L97.419 L97.401 L97.402 L97.404 L97.403 Other enthesopathy of right foot Other enthesopathy of unspecified foot Other hammer toes (acquired) left foot Other hammer toes (acquired) right foot Other hammer toes (acquired) unspecified foot Other specified diabetes mellitus with diabetic amyotrophy Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy Other specified diabetes mellitus with diabetic mononeuropathy Other specified diabetes mellitus with diabetic neuropathic arthropathy Other specified diabetes mellitus with diabetic neuropathy, unspecified Other specified diabetes mellitus with diabetic polyneuropathy Other specified diabetes mellitus with other diabetic neurological complication Other specified diabetes mellitus without complications Other specified viral warts Pain in left ankle and joints of left foot Pain in left foot Pain in left toe(s) Pain in right ankle and joints of right foot Pain in right foot Pain in right toe(s) Pain in unspecified ankle and joints of unspecified foot Pain in unspecified foot Pain in unspecified toe(s) Peripheral vascular disease, unspecified Peroneal tendinitis, left leg Peroneal tendinitis, right leg Peroneal tendinitis, unspecified leg Plantar fascial fibromatosis Plantar wart Tinea unguium Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy M77.51 M77.50 M20.42 M20.41 M20.40 E13.44 E13.43 Type 1 diabetes mellitus with diabetic mononeuropathy Type 1 diabetes mellitus with diabetic neuropathic arthropathy Type 1 diabetes mellitus with diabetic neuropathy, unspecified Type 1 diabetes mellitus with diabetic polyneuropathy Type 1 diabetes mellitus with other diabetic neurological complication Type 1 diabetes mellitus without complications Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.41 E10.610 E10.40 E10.42 E10.49 Type 2 diabetes mellitus with diabetic mononeuropathy Type 2 diabetes mellitus with diabetic neuropathic arthropathy Type 2 diabetes mellitus with diabetic neuropathy, unspecified Type 2 diabetes mellitus with diabetic polyneuropathy Type 2 diabetes mellitus with other diabetic neurological complication Type 2 diabetes mellitus without complications Valgus (acquired), left ankle Valgus (acquired), right ankle Valgus (acquired), unspecified ankle Valgus (congenital) Varus (congenital) E11.41 E11.610 E11.40 E11.42 E11.49 E13.41 E13.610 E13.40 E13.42 E13.49 E13.9 B07.8 M25.572 M79.672 M79.675 M25.571 M79.671 M79.674 M25.579 M79.673 M79.676 I73.9 M76.72 M76.71 M76.70 M72.2 B07.0 B35.1 E10.43 E10.9 E11.43 E11.9 M21.072 M21.071 M21.079 Q66.6 Q66.3 L97.409 M77.52 The information provided is only intended to be a general summary and not intended to take place of either written law or regulations. PODIATRY 5 of 5