We received a nice thank-you note from a member who had some challenges with CPT® codes 11720 and 11721. Their office is now able to obtain appropriate financial reimbursement without frustration.

We want to share what we were able to pass on to our members thanks to the guidance of Jeffrey D. Lehrman, DPM, Certified Professional Coder, and Certified Professional Medical Auditor.

For Medicare Part B beneficiaries in Pennsylvania, Novitas has two different policies that govern covered foot care (below). 

• These are separate policies with no overlap between the two. 
• Each time a patient is seen for covered foot care, it is essential to determine and document which policy the patient is covered under without confounding the two. 

The two policies are: 

1.  Routine Foot Care:https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35138&ver=39&name=336*1&UpdatePeriod=828&bc=AAAAEAAAAAAA&

2.  Debridement of Mycotic Nails:https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35013&ver=31&name=331*1&UpdatePeriod=841&bc=AQAAEAAAAAAA&

The Routine Foot Care policy generally covers patients who have both:

1. One of the qualifying systemic diagnoses in the policy

AND 

2. Class findings

This policy makes no mention of onychomycosis or pain, or limited ambulation.

The Debridement of Mycotic Nails policy covers patients who have both: 

1. Onychomycosis

AND

2. One of three secondary diagnoses listed in the policy

This policy makes no mention of a systemic diagnosis or class findings.

• info@apmacodingrc.org

• 301-581-9200

• The APMA Coding Resource Center is a fully integrated, subscription online coding, and reimbursement resource for foot, ankle, and leg-relevant CPT©, ICD-10-CM (Volumes 1, 2—plus ICD-9 to ICD-10 crosswalks), CCI edits, HCPCS Level II codes, state-specific Medicare LCDs, and fee schedules.

The CRC is continuously updated as new information is available, so no need to purchase new books or search for the latest Medicare documents!

• Multi-user pricing is available for additional users within the same practice:

$129 at the member rate per user

$175 per user at the non-member rate

A one-year subscription is $329 for APMA members for a one-user license

$650 for Non-APMA members, one-user license.

Discounted CodinglineSILVERSubscriptions for APMA Members 

• CodinglineSilver = $80 per year for APMA member and $100 standard.

• CodinglineGOLD = $600 per year/no discount.

• EMAIL: info@codingline.com

• CodinglineSILVER Listserv is a daily emailed interactive FORUM specifically for subscribers to ask (post) questions on foot and ankle coding, reimbursements, and/or practice management topics, with ability to comment/respond to submitted questions.

• CodinglineSILVER subscribers can register two email addresses for the daily Q/A email.

• Codingline GOLD subscribers have exclusive access to Codingline expert panelists and so much more!

Novitas has posted the long-awaited finalized LCD and Article for "Surgical Treatment of Nails" effective 1/30/2022.

In summary, as your MPMA CAC representative, I provided in writing numerous recommendations as did I engage the APMA Health Policy and Practice and suggested changes to the policy several months ago (during the draft process).

Additionally, via the Webex CAC Open Meeting for Novitas, I provided verbal testimony about the numerous concerns in the proposed policy. Supportive arguments were provided to justify changes prior to the finalized version. Article - Response to Comments: Surgical Treatment of Nails (A58961) (cms.gov)

The updated policy is not effective until January 30, 2022 f or those that utilize these CPT codes 11730, 11732,11750, and 11765.

All MPMA members should review the LCD and LCA (Billing Article) to better understand the changes.

The most significant change addresses the frequency of performing these procedures. Be aware of an "8-month" period where you can't bill the same T Code (TA-T9).

However, the carrier states that under certain circumstances, exceptions may be considered.

This is from the LCA "For a medically necessary repeat nail excision on the same finger or toe, use modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or modifier 77 (repeat procedure by another physician or other qualified health care professional). The medical record documentation must be specific to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated. Compliance with the use of modifier 76 and modifier 77 may be monitored and addressed through post payment data analysis and subsequent medical review audits."

It is my understanding that APMA will provide additional information since a similar policy is applicable for First Coast (another major Medicare carrier).

The plan is to review this on the next MPMA membership Zoom in January.

The future LCD link is here: LCD - Surgical Treatment of Nails (L34887) (cms.gov)

The future LCA link is here: Article - Billing and Coding: Surgical Treatment of Nails (A52998) (cms.gov)

QUESTION:

Do MDs get paid higher for codes such as 99213 and SX codes such as 28296 than we do?  

ANSWER:

The answer varies depending on the payor and the contract you have negotiated with the payor. For Medicare, the answer is “no”. There is one fee schedule for your geographic area and every provider type gets paid the same thing for the same service. For non-Medicare payors, the fee schedule is negotiable. If one provider type negotiates a better fee schedule than a different payor type, they will make more money for the same service. There are many providers that just sign the contract offered to them without even attempting to negotiate their fee schedule and this often leads to discrepancies from provider to provider and between specialty types.

Response provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: As we get further into this pandemic, I am seeing more diabetic patients who have had their PCP appointments delayed for longer periods of time. An increasing number are now not seeing their PCP within the six-month time frame required for a Q8 or Q9 modifier as required by CMS for DM footcare coverage, thereby causing them to self-pay due to a situation that is out of their control. Has CMS adjusted to this situation with any sort of waiver during the pandemic?

A: No, no change has been made. When the patient qualifies for footcare via the Routine Foot Care pathway, and their qualifying condition has an asterisk in the policy, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) or NPP for the treatment and/or evaluation of the complicating disease process during the six- month period prior to the rendition of the routine-type service or if the patient had come under a physician’s or NPP’s care shortly after the services were furnished. The PA Novitas policy is here: https://tinyurl.com/ybjdp8vl. 

One thing to take note of given the COVID-related situation you are encountering: Nowhere does it say this visit has to have been face-to-face or in-person. Therefore, a non-face-to-face visit counts. So, if the patient has not “seen” the provider who is caring for their qualifying condition in the last six months, be sure to also check for any non-face-to-face visits that may have occurred with that provider.

Because the policy as-is does not say the date last seen needs to have been an in-person or face-to-face visit, we do not need what follows, but it will make you feel better if you have any hesitation about what I wrote above. 

On April 30, 2020, CMS released, “Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program Interim Final Rule with Comment Period,” which can be found here: https://tinyurl.com/y9m9o4o4.

On page 157, it says, “We finalized on an interim basis that to the extent an NCD or LCD (including articles) would otherwise require a face-to-face or in-person encounter or other implied face-to-face services, those requirements would not apply during the PHE for the COVID-19 pandemic."

Response provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: Can You Submit Both an E/M Code and A Minor Procedure Code for A New Patient?   

A: If both an evaluation and management (E/M) and a minor procedure are performed at the same encounter, you can and should code both if the E/M is significant and separately identifiable from the procedure. 
Whether the patient is new or established has no bearing on this.

Whether the procedure has a 0-, 10-, or 90-day global period has no bearing on this. The E/M needs to be separately identifiable. This means there cannot be any overlap in the work associated with the E/M and the work associated with the procedure.

Here are some examples of when it would be appropriate to code both a new patient E/M and a minor procedure if the documentation supports that a medically necessary, separately identifiable E/M was performed:

• New patient who gets an E/M for Tinea Pedis and a procedure for toenail debridement;
• New patient who gets an E/M for Xerosis and a procedure for at-risk callus debridement;
• New patient with an ingrown toenail who gets an E/M and a partial nail avulsion (CPT 11730) if the documentation supports an E/M that was separately identifiable from the procedure. If the “plan” section of this note only describes the procedure of a partial nail avulsion, there is no E/M there.

However, a separately identifiable E/M would be supported by a robust paragraph explaining the discussion with the patient regarding: his or her diagnosis; potential etiologies; treatment options for this diagnosis; potential risks; potential advantages and disadvantages of different treatment options; how to try to prevent recurrence; the patient’s questions that you answered; and the discussion you had about treatment options. An operative note of the procedure would be expected to follow in this example.

Response provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: Why do the Aetna “Silver” PPO Plans Pay Less than Others and Paid Less Medicare Rates in 2020, but in 2018/2019 Had Paid the original Medicare Rates?     

A: The payer in question here is a private payer. Therefore, the doctor contracts are with that payer to determine their fee schedule. This is very different from the public payer, Medicare, where all providers of all types in the same region are paid based on the same fee schedule. When dealing with a private payer, it is up to the doctor to agree to a fee schedule. This is often addressed in the doctor’s contract with the payer. 

Too many of our members sign those contracts without legal representation or sometimes without even reading them at all. The first step in considering what has been submitted here is to check to see if this plan is in violation of the contract the doctor signed. If the payer is in violation of this contract, this is a legal issue between the doctor and the plan. However, if the payer is not in violation of the contract the doctor signed, they are stuck with whatever they agreed to.   

Unfortunately this is not something PPMA can help with too much because PPMA cannot negotiate on behalf of their members, and is limited in what it can do due to antitrust laws.  

To answer the two questions that were handwritten on that form [PPMA’s Peer Review Committee Form], these private plans do not have to pay Medicare rates, and they can adjust their rates to whatever they want as long as the contract the doctor signed allows them to. 

Medicare Advantage plans are required by law to provide the same coverage as original Medicare. This is often a mistake to say they have to provide the same payment, and that is not true. Coverage and payment are two different things. They do not have to pay the same as original Medicare.

The summary is, because this is a private plan, they can do whatever the doctor allows them to do based on the contract they signed. This can all be negotiated and too many of our members just sign these agreements without legal expertise or negotiation.

Response provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: I know for MIPS we must do a minimum of 3 vitals in reporting for each patient. Must it be blood pressure? OR may we switch that out and do temperatures instead? We’ve always taken height/weight/BP.   

A: There is no component of MIPS that requires vital signs. You may be thinking of the Meaningful Use program, which was retired at the end of 2016. If you want to learn more about MIPS, everything you need to know is at apma.org/mips2020.

And, hopefully you already saw this, but in case you missed it, last month CMS announced the option for a COVID-related MIPS exception for all of 2020. If that is of interest to you, you can learn about that here (including the link to apply): 
https://www.apma.org/PracticingDPMs/content.cfm?ItemNumber=%2040089

Answers provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: What CPT code should I use for initial nursing home
encounters? Can podiatrists use CPT 99304?


A: CPT codes 99304–99306 describe initial nursing facility care. Yes,
podiatrists can absolutely submit initial nursing facility evaluation and
management (E/M) codes for Medicare patients.

Medicare does not recognize consultation codes. When Medicare stopped
recognizing consultation codes on January 1, 2010, it then instructed specialists,
including podiatrists, to use the initial nursing facility CPT codes when
seeing a nursing facility patient for the first time during that patient’s
admission.

Podiatrists should use initial nursing facility codes for Medicare patients if
that encounter qualified for what the facility would consider a “consult,” even
if the specialist was not the admitting/primary doctor. Since there are now
multiple doctors using those initial encounter codes, the admitting/primary
doctor must use an “AI” modifier on the initial E/M encounter.

This change did not alter the fact that in order to submit any E/M code, one
must meet the thresholds of complexity for that code. Complexity refers to
the key elements of E/M coding (history, exam, decision-making) in what
you performed; what you documented; and what was medically necessary for
that level. If counseling and coordinating dominate the visit, time may be
used to select the appropriate level.

These thresholds and time requirements are relatively high for the lowest
level initial nursing facility E/M (CPT 99304). Therefore, CMS clarified that
it is appropriate for specialists to use the subsequent nursing facility E/M
codes for initial encounters that do not meet the complexity thresholds for
CPT 99304. This is an important point. Even though podiatrists can use
initial nursing facility E/M codes for Medicare patients, every initial encounter
does not automatically qualify for the use of an initial encounter E/M.
For Non-Medicare payers that still recognize consultation codes, podiatrists
should still use consultation codes for nursing home consults.
 

Answers provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC   

Q: Are “observation” patients, Inpatients?

A: No. Medicare considers observation services to be outpatient services.  Even though this is counterintuitive, we cannot assume that a patient who is in a hospital bed is in fact “admitted” to the hospital. In other words, a patient who is physically in the hospital is not necessarily a hospital inpatient. We must know if the patient is in the hospital under observation status or inpatient status because this affects the codes we should be using when seeing these patients.    
With observation services being considered outpatient services, when one is performing a consult for a hospital observation patient, the “Office or Other Outpatient Consultations” codes (CPT® 99241 – 99245) apply.

The exception to this is for payers such as Part B Medicare and United Healthcare that do not recognize consult codes. For these payers, one would code the initial visit for a hospital observation patient with an “Initial Observation Care” code (CPT® 99218 – 99220) and subsequent visits with “Subsequent Observation Care” codes (CPT® 99224-99226).

As always, clinicians must meet the thresholds of performance, documentation, and medical necessity for the given code level they select. When providing observation services, the place of service should be “22: On Campus - Outpatient Hospital.”

Observation status is not limited to stays of 24-hours or less. It can even last multiple days, so we cannot rely on length of stay in making this determination. Some facilities have observation units, but we cannot rely on that either because sometimes hospitals place patients in different beds or units based on hospital volume or other criteria. Accordingly, we cannot make the determination based on duration of stay or location in the hospital. 

It is important to confirm patient status with an administrator or staff person at the hospital who understands the difference, and has access to determine the patient’s official status.