7/21/2012
CODING 101:
HOW TO GET PAID FOR
EVERYTHING YOU DO
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.
Jeffrey Frederick, DPM, FASPS
President, American Academy of Podiatric
Practice Management
John Guiliana, DPM, FASPS
Trustee, AAPPM
Louis J. Geller, DPM, CWS, FACFAS, FASPS,
FAPWCA
PRACTICE MANAGEMENT TIP
Procedure Codes Payable for Podiatrists
HEALTH CARE 2012
1/ 17/ 12 2:17 PM
Illinois, Michigan, Minnesota and Wisconsin Providers
Home
Part B
Resources
Provider Types
Procedure Codes Payable For Podiatrists
Procedure Codes Payable For Podiatrists
Effective 01/01/2011
Below is a list of the procedure codes that have been approved as payable for
podiatrists by the medical director staff.
Th ings you are
missing in your off ice:
If you can't afford a doctor, go to the airport you will get a free x-ray and a breast exam.
If you mention Al Qaeda,
you will also get a free colonoscopy.
10060, 10061, 10120, 10121, 10140, 10160, 10180, 11000, 11001, 11010-11012,
11040-11047, 11055-11057, 11100, 11101, 11200, 11201, 11300-11302, 1130511308, 11400-11404, 11406, 11420-11424, 11426, 11606, 11620-11624, 11626,
11719-11721, 11730, 11732, 11740, 11750, 11752, 11755, 11760, 11762, 11765,
11900, 11901, 12001, 12002, 12004-12007, 12020, 12021, 12041, 12042, 1204412047, 13120, 13121, 13131-13133, 13160, 14040, 14041, 14300, 14302, 14350,
15004, 15005, 15050, 15320, 15321, 15335, 15336, 15340, 15341-15343, 15350,
15351, 15360, 15365, 15366, 15400, 15401, 15420, 15421, 15430, 15574, 15620,
15738, 15851, 15852, 15999, 16000, 16010, 16020, 16035, 16036, 17000, 17003,
17004, 17106-17108, 17110, 17111, 17250, 17270-17274, 17276, 17999, 20000,
20005, 20103, 20200, 20205, 20206, 20220, 20240, 20245, 20500, 20501, 20520,
20525, 20550-20553, 20600, 20605, 20612, 20615, 20650, 20670, 20680, 20690,
20692-20694, 20900, 20902, 20924, 20926, 20950, 20972-20975, 20979, 20999,
27603-27607, 27610, 27612-27615, 27618-27620, 27625, 27626, 27630, 27632,
27634, 27635, 27637, 27638, 27640, 27641, 27645-27648, 27650, 27652, 27654,
27658, 27659, 27664, 27665, 27675, 27676, 27680, 27681, 27685-27687, 2769027692, 27695, 27696, 27698, 27700, 27702-27704, 27760, 27762, 27766-27769,
27786, 27788, 27792, 27808, 27810, 27814, 27816, 27818, 27822-27829, 27840,
27842, 27846, 27848, 27860, 27870, 27871, 27888, 27899, 28001-28003, 28005,
28008, 28010, 28011, 28020, 28022, 28024, 28030, 28035, 28039, 28041, 28041,
28043, 28045, 28046, 28047, 28050, 28052, 28054, 28055, 28060, 28062, 28070,
28072, 28080, 28086, 28088, 28090, 28092, 28100, 28102-28104, 28106-28108,
28110-28114, 28116, 28118-28120, 28122, 28124, 28126, 28130, 28140, 28150,
28153, 28160, 28171, 28173, 28175, 28190, 28192, 28193, 28200, 28202, 28208,
28210, 28220, 28222, 28225, 28226, 28230, 28232, 28234, 28238, 28240, 28250,
28260-28262, 28264, 28270, 28272, 28280, 28285, 28286, 28288-28290, 2829228294, 28296-28300, 28302, 28304-28310, 28312, 28313, 28315, 28320, 28322,
28340, 28341, 28344, 28345, 28360, 28400, 28405, 28406, 28415, 28420, 28430,
28435, 28436, 28445, 28450, 28455, 28456, 28465, 28470, 28475, 28476, 28485,
28490, 28495, 28496, 28505, 28510, 28515, 28525, 28530, 28531, 28540, 28545,
28546, 28555, 28570, 28575, 28576, 28585, 28600, 28605, 28606, 28615, 28630,
28635, 28636, 28645, 28660, 28665, 28666, 28675, 28705, 28715, 28725, 28730,
28735, 28737, 28740, 28750, 28755, 28760, 28800, 28805, 28810, 28820, 28825,
28890, 28899, 29345, 29355, 29405, 29425, 29435, 29440, 29445, 29450, 29505,
29515, 29540, 29550, 29580, 29581, 29590, 29700, 29705, 29730, 29740, 29750,
4
http:/ / www.wpsm edicare.com / part_b/ resources/ provider_types/ podiatrist- codes.shtm l
Page 1 of 2
CCI EDITS – CORRECT CODING
INITIATIVE
CODING POP QUIZ
 When billing the following sequence of cpt codes
which is the proper way to bill:
 1) 11730 TA, 59 11721, 59
 2) 11730 59, 11721, 59
 3) 11730 TA 11721, 59
 4) 11730 TA,RT 11721
 5) 11730 RT 11721 59
 6) trick question all are wrong, should not bill
these together
 7) I don’t worry about modifiers that’s my billers
job
5
 Created to stop un -bundling of CPT codes
 If you perform a procedure additional procedures may be
considered part of the first procedures payment;
bunionectomy and associated capsulotomy
 What procedures are bundled together?
 How can you over -ride the CCI edit?
 What should not be bundled – routine foot care/mycotic nails
6
1
7/21/2012
BEGIN WITH THE CORRECT TOOLS
APMACODINGRC.ORG
www.apmacodingrc.org
Recommended by the AAPPM
www. (your medicare carriers website)
7
ADVANCE CODE SEARCH
8
CCI EDIT TABLE
9
DX ASSOCIATED WITH CPT CODE
10
MEDICARE GUIDELINES BY STATE
11
12
2
7/21/2012
DME GUIDELINES BY STATE
WHAT ABOUT ICD 10?
 APMAcodingRC.org has you covered
 Cross Walks and more
13
DIAGNOSIS YOU SHOULD
CONSIDER
Systemic disease is part of your
grading scale
Are you worth the money?
110.1 , 25000, 4439 more than just the
numbers……
15
PART B NATIONAL SUMMARY DATA
 Formerly known as BESS (Part B Extract Summary System)
Data BMAD DATA
 How Medicare tracks the most commonly billed CPT Codes
 Available for all medical specialties
 The most up-to-date data that we currently have is 2011
 Top 25 Billable Codes for Podiatry
14
DX CODES:
T i n e a P e d i s 1 1 0. 40
D i a b e te s M e l l i tu s ( n e e d 5 - d i g i ts f o r
s p e c i f ic it y) 2 5 0 . x x
H a l l u x Va l g u s 7 3 5 . 0 0
D e f o rm it y o f A n k l e a n d Fo o t , A c q u i r ed
H a l l u x Ri g i d us 7 3 5 . 2 0
7 3 6 . 79
Ta i l or's B u n i o n 7 27. 10
U n s p e c if ie d Fo r e i g n B o d y ( g l a s s , e t c . )
H e m a to m a a n d C o n t u s ion 71 9 . 17 &
917. 6
9 24 . 2 0
Fr a c t u re , P h a l a n x , c l o s e d 8 2 6 . 0
H a m m e r to e D e f o r m it y 7 3 5 . 40
Fr a c t u re , M e t a t a r s a l, c l o s e d 8 2 5 . 2 5
H y p e r t r phic B o n e S p u r 7 3 3 . 9
Fr a c t u re , A n k l e , c l o s e d 8 24 . 8
M e t a t a r s al J o i n t D e f o r mit y 735. 5 0
G a n g l i on C y s t 7 27. 4 3
Ve r r u c a Vu l g a ris/ Pla nt a ris 07 8 , 10
M o r ton 's N e u r om a 3 5 5 . 6
A t h e r o sc le rosis O b l it e ran s 4 4 2 /2 0
o n o n eu rit is o f U n s p e c f ie d S i t e 3 5 5 . 79
P e r i ph e ra l Va s c u la r D i s e a s e , N O S 4 4 3 . 9 M
A n k l e S p r a in 8 4 5 . 0 0
O s t e o ar t hros is , m u l t i ple j o i n t s 71 5 . 97 L a t e r a l A n k l e S p r a in 8 4 5 . 0 2
S p r a in o f A n k l e / Foot 8 4 5 . 01
M e d i a l A n k l e S p r a in 8 4 5 . 01
Ru p t u re o f Te n d o n o f Fo o t 7 2 6 . 7 3
Ta r s a l Tu n n e l S y n d r om e 3 5 5 . 5
P l a n t a r Fa s c i a l F i b rom ato sis 7 2 8 . 71
A c h i l le s Te n d o n it is 7 2 6 . 71
A bnormality of Gait 781 .2
A b c e s s o f To e 6 81 . 10
A b c e s s o f A n k l e o r Fo o t 6 8 2 . 70
Musc le Weakness 728.87
U l c e r a t ion o f L e g , N O S 7 07.10
Numbness 782.0
D e c u b i tu s U l c e r o f Fo o t 7 07. 07
Tenosynov itis 727.09
P e r i ost it is w / o O s t e omy e lit is 7 3 0 . 07
O s t e o mye lt is, A c u t e 7 3 0 . 27
Osteoar thritis A nkle 715.17
I n g r o w ing N a i l 7 0 3 . 0
O ny c h o myc osis 1 1 0 . 1
P a i n i n L i m b 7 29. 5
16
PART B NATIONAL SUMMARY DATATOP 25 BILLABLE PODIATRY CODES
1. 11721
10. 99348
19. 20605
2. 99213
11. 20600
20. 99347
3. 99212
12. 11042
21. 11055
4. 11730
13. J1100
22. 73620
5. 11720
14. Q4106
23. 99307
6. 73630
15. 99202
24. 11719
7. 97597
16. 10060
25. 29580
8. 11056
17. 17110
9. 99203
18. 11732
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7/21/2012
FOOT X-RAYS:
73620 (#22), 73630 (#6), 73650
NAIL PROCEDURE CODES
 73620: 2 views foot
 $21.08
 73630: 3 views foot
 $24.36
 73650: 2 views calcaneus
 $21.84
Some Of The Most Audited Codes In Podiatry
11730 (#4), 11732 (#18), 11750, 11765
11730 (#4), 11732 (#18), 11750, 11765
 1 1730- Avulsion of nail plate, partial or complete, simple;
single
 1 1732- Avulsion of nail plate, partial or complete, simple;
each additional nail plate ( Li st sep a rately i n a d d i tion to c od e f or
 1 1750- Excision of the nail and the nail matrix p e r formed
u nder lo cal ane sthesia requiring separation and removal of
the entire nail plate or a portion of nail plate (including the
entire length of the nail border to and under the eponychium)
followed by destruction or permanent removal of the
associated nail matrix
p ri m ar y p roc ed ure )
 Involves separation and removal of the entire nail plate or a
portion of nail plate (including the entire length of the nail
border to and under the eponychium)
 A nail avulsion usually requires injected local anesthesia except in
instances wherein the digit is devoid of sensation or there are other
extenuating circumstances for which injectable anesthesia is not
required or is medically contraindicated
 Regrowth of the nail and recurrence of ingrowth will require four
months
11730 (#4), 11732 (#18), 11750, 11765
DOCUMENTATION REQUIREMENTS
 The patient’s primary symptoms and previous treatment (if
any) and description of the nail(s) at the time of avulsion
services
 A complete detailed description of the procedure performed
including exact portion of nail removed
 Post-operative instructions and any follow -up care
 such as use of soaks, proper shoes and nail care, to prevent
recurrences, antibiotics and follow -up appointments
 1 1765- Wedge excision of the nail fold hypertrophic
granulation tissue with removal of the offending portion of
the nail
10060 (#16) AND 10061
 1 0 060- Incision and
drainage of abscess (e.g.,
carbuncle, suppurative
hidradenitis, cutaneous or
subcutaneous abscess,
cyst, furuncle, or
paronychia); simple or
single
 1 0 061- Incision and
drainage of abscess (e.g.,
carbuncle, suppurative
hidradenitis, cutaneous or
subcutaneous abscess,
cyst, furuncle, or
paronychia); complicated or
multiple
10061 -T5 681.11
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7/21/2012
26010 AND 26011
29580 (#25) VS. 29581
 26010- Incision and
drainage of finger
abscess; simple or
single ($198.05
 29580- Application
of an UNNA Boot
($39.97)
 29581- Application
of a multi-layer
compression
system; leg (below
knee), including
ankle and foot
($45.62)
 26011- Incision and
drainage of finger
abscess; complicated
or multiple ($297.04
Don’t forget to use your
finger modifiers (FA-F9)
26011
-F2
681.11
WOUND CAUTERY
17250: Chemical
cauterization of
granulation tissue
(proud flesh, sinus
or fistula)
Silver Nitrate
INJECTION CODES
POP QUIZ
 CMS requires doctors to retain their medical records for how
long a period of time?





Forever, since they don’t care about the cost of storage
5 years from the date of service
6 years from the date of service
7 years from the date of service
10 years from the date of service if the patient is a Medicare
managed care program
20600 (#11) VS. 20605 (#19)
 20600- Arthrocentesis,
aspiration and/or
injection; small joint or
bursa (e.g., fingers, toes))
 20605- Arthrocentesis,
aspiration and/or
injection; intermediate
joint or bursa (e.g., ankle)
* * *Not u se d f o r p l antar f a scii tis***
5
7/21/2012
20550 VS. 20551
NEUROMA INJECTION
64455: Injection(s),
anesthetic agent
and/or steroid,
plantar common
digital nerve(s) (eg,
Morton's neuroma)
 20550- Injection(s);
s ingle tendon s heath, or
ligament, aponeurosis
(e.g., plantar "fascia”)
 20551- Injection(s);
s ingle tendon
origin/insertion
NEEDLE ASPIRATION – FLUID, GANGLION
10021: Fine Needle
aspiration without
imaging ($112)
10022: Fine Needle
aspiration when
performed with
imaging guidance
64450: injection,
anesthetic agent;
other peripheral
nerve or branch –
not for neuroma
J-CODES
 J1 020- Methylprednisolone acetate 20mg- $ 3 .1 2
 J1 030- Methylprednisolone acetate 40 mg- $ 3 .10
 J1 094- Dexamethasone acetate 1mg - $ 0 .23
 J1 100- Dexamethasone sodium phosphate 1mg- $ 0 .11
 J3 301- Triamcinolone acetonide 10mg- $ 1 .69
 J3 3 03- Triamcinolone hexacetonide per 5mg - $ 1 .68
 J9 0 40- Bleomycin

HOW TO APPROPRIATELY BILL J CODES
BY UNITS
Example#1: J1100-Dexamethasone, 1 mg
Your bottle says 4 mg/ml
If you use 0.25 cc (1 mg) = 1 Unit
If you use 0.5 cc (2 mg) = 2 Units
If you use 0.75 cc (3 mg) = 3 Units
If you use 1.0 cc (4 mg) = 4 Units
Billed out at 15 units- $25.58 per unit ($383.70)
HOW TO APPROPRIATELY BILL J CODES
BY UNITS
Example#2: J1030 Methylprednisolone
Acetate, 40 mg (Depo-Medrol)
Your bottle says 40 mg/ml
If you use 0.25 cc 10 mg = 1 Unit
If you use 0.5 cc 20 mg = 1 Unit
If you use 0.75 cc 30 mg = 1 Unit
If you use 1.0 cc 40 mg = 1 Unit
If you use 2.0 cc 80 mg = 2 Units
6
7/21/2012
HOW TO APPROPRIATELY BILL J CODES
BY UNITS
Example#3: J3301 Triamcinolone Acetonide,
(Kenalog-10, Kenalog-40) per 10 mg
Your bottle says Kenalog 40 =40mg/ml
If you use 0.25 cc 10 mg/40 mg = 1 Unit
If you use 0.5 cc 20 mg/40 mg = 2 Units
If you use 0.75 cc 30 mg/40 mg = 3 Units
If you use 1.0 cc 40 mg/40 mg = 4 Units
10140 AND 10160
HOW TO APPROPRIATELY BILL J CODES
BY UNITS
Example#4: J0702 Betamethasone Acetate
and Betamethasone Phosphate, per 3 mg
(Celestone Soluspan 6 mg/ml)
If you use 0.25 cc 1.5 mg/6 mg = 1 Unit
If you use 0.5 cc 3 mg/6 mg = 1 Unit
If you use 0.75 cc 4.5 mg/6 mg = 1 Unit
If you use 1.0 cc 6 mg/6 mg = 2 Units
BIOPSY
11100: Cutaneous
Biopsies – punch
Single lesion
10140- Incision and
drainage of
hematoma, seroma
or fluid collection
11101: Cutaneous
each additional
biopsy add on code
10160- Puncture
aspiration of
abscess, hematoma,
bulla, or cyst
HAGLUNDS DEFORMITY
28118: Ostectomy,
calcaneus (includes
retrocalcanel bursa
removal and
exposure of achilles
28200: repair,
tendon flexor foot
without free graft (if
other work is done
on achilles other
than exposure –
debridement of
necrotic tissue
Add this code
POP QUIZ
When performing a
Subtalar
Arthroereisis (Screw
thingy) which would
be the correct way to
code for this
procedure:
28725 Subtalar
arthrodesis
28585 open
treatment of
talotarsal joint
dislocation
28899 unlisted
S2117 Temporary
code
7
7/21/2012
SMOKING CESSATION- 99406
SMOKING CESSATION- 99406
 9 9 406: Smoking and tobacco use cessation counseling visit;
intermediate, greater than 3 minutes up to 10 minutes
 https://cissecure.nci.nih.gov
/ncipubs/detail.aspx?prodid
=P133
 “I adv ised t he p at ient to sto p sm oking as to b acco/nicotine use
can cau se de lays in sk in he aling, wo und he aling, su r gical
he aling, te ndon and lig ament he aling, b o ne he aling, can cause
sk in g r af t/skin g r aft su b stitute failure and can cau se
p r o blems wit h his/her cir culation. T he p at ient r e lates t hat
he /she u nderstands all t hat was discu ssed .”
 Diagnosis codes
V15.82: History of tobacco use
305.1: Tobacco use disorder
 $10.28/$8.77
 Can bill this 2 times/year
CARE PLAN OVERSIGHT (CPO):
HOW MUCH MONEY ARE YOU LEAVING ON THE
TABLE?
 G01 80- Ce r tification: Physician services for initial
certification of home health services, billable, once for a
patient’s home health certification period
 This code will be utilized when the patient has not received
Medicare-covered home health services for at least 60 days
 G0179- Re - Certification: Physician services for re -certification
of home health services, billable once for a patient’s home
health certification period
 This code will be utilized after a patient has received home
health services for at least 60 days (or one certification
period) when the physician signs the certification after the
initial certification period
E&M ADD-ON CODES- BILLED IN ADDITION TO
YOUR E&M CODES
 9 9 050: Services provided in the office at time other than
regularly scheduled office hours or when the office is usually
closed beyond 9 to 5 (in addition to the basic service )~ $ 25.00
 9 9 051: Services provided in the office during regularly
scheduled evening, weekend, or holiday hours (in addition to
the basic service)- ~ $ 25.00
ORTHOTICS CODES TO CONSIDER
 L3 0 00 Foot insert, removable, molded to patient model,
UCB type, Berkeley shell, each
 L3000 RT……….$x
 L3000 LT………..$x
 L3 0 20 Foot insert, removable, molded to patient model,
longitudinal/metatarsal support, each
 2 9799: Casting -LT
$75 - $100
 2 9799: Casting -RT
$75 - $100
 S 0 395: (A etna/Cigna): Impression casting of a foot
performed by a practitioner other than manufacturer of the
orthotic
 9 9 002: Handling, mailing, packaging
$10
 A 4 580: Material plaster
As of June 11, 2012, a Coding
Clarification was made by
Jurisdiction B DME in regards to
Toe Fillers and Diabetic Shoe
Inserts
$40
8
7/21/2012
TOE FILLERS AND DIABETIC SHOE INSERTS
– CODING CLARIFICATION
 Questions have arisen about the correct coding for shoe
inserts used to accommodate missing digits (toes) on feet for
beneficiaries with and without diabetes.
 These items fall under two separate benefit categories and
use two distinct Healthcare Common Procedure Coding
System (HCPCS) codes, L5000 and A5513.
BENEFICIARIES WITHOUT DIABETES
 Shoe inserts for beneficiaries with missing toes or partial foot
amputations who are not diabetic are considered for coverage
under the prosthetic benefit. C o de L 5 000 is described by:
 L 5 000 - Partial foot, shoe insert with longitudinal arch, toe
filler
L5000
L5000
 Code L5 0 00 describes a shoe insert with a rigid longitudinal
arch support that also incorporates material accommodating
the void left by the missing digit(s) or forefoot.
 Additional soft material is added where contact is made with
the residual limb/toes. For beneficiaries missing digits,
particularly the hallux (great toe), or the forefoot, L5 000
inserts are designed to provide standing balance and toe off
support for improved gait. The biomechanical control required
of L5 000 differs from the foot -protective function provided by
inserts used as part of diabetes management.
 For beneficiaries who require accommodation of missing foot
digit(s) or forefoot, su p plier s m u st o nly b ill co de L 5 0 00.
 Codes A 5 512 and A 5 513 describe inserts used with
therapeutic shoes provided to persons with diabetes and must
not be billed for non-diabetic beneficiaries.
BENEFICIARIES WITH DIABETES
BENEFICIARIES WITH DIABETES
 A separate benefit category allows Medicare coverage of
therapeutic shoes and inserts for persons with diabetes.
Shoe inserts for persons with diabetes are described by
the codes below:
 A551 2 - For diabetics only, multiple density insert , direct
formed, molded to foot after external heat source of 230
degrees Fahrenheit or higher, total contact with patient’s
foot, including arch, base layer minimum of 1/4 inch
material of shore a 35 durometer or 3/16 inch material of
shore a 40 durometer (or higher), prefabricated, each
 A5513 - For diabetics only, multiple density insert, custom
molded from model of patient’s foot, total contact with
patient’s foot, including arch, base layer minimum of 3/16
inch material of shore a 35 durometer or higher), includes
arch filler and other shaping material, custom fabricated,
each
 For a beneficiar y with diabetes missing digit(s) or a forefoot,
supplier s have two options for billing inser ts:
 O ption 1 : For diabetic beneficiaries who do no t require the
rigidity and suppor t af forded by code L5000 (e.g., beneficiaries
missing digits excluding the hallux), supplier s must bill code
A5513 for an inser t appropriately custom -fabricated to
accommodate the missing digit(s). Codes L5 000 or A5512 may
not be billed in addition to code A5513.
 O ption 2 : For beneficiaries missing the hallux or a forefoot that
require rigidity and suppor t for ef fective gait, supplier s must
bill L5 000 for an inser t appropriately custom -fabricated to
accommodate the missing digit(s) or forefoot as well as
providing the foot -protective functions required for a per son
with diabetes. Codes A5512 or A5513 may not be billed in
addition to code L5 000.
9
7/21/2012
MATH PROBLEM
DEBRIDEMENT CODES
John has 32 candy bars, He eats
28, what does he have now?
N ot I ncluding S ubq
 97597 de bridement no t i ncluding subq <20 sq ( firest 2 0 sq)
 97598 de bridement no t i ncluding subq >20 sq (each additional)
Yo u c an bill t hese to gether 97597 & 97598
Diabetes
Including Subq
 1 1042 de bridement i ncludes subq < 2 0 sq
1 1045 added i f > 2 0 sq
 1 1043 i ncludes subq/muscle/fascia < 20 sq
1 1046 added i f > 2 0 sq
 1 1044 i ncludes subq/muscle/bone < 20 sq
1 1047 added i f > 2 0 sq
POP QUIZ
 A Medicare patient fails to show for their scheduled
appointment, knowing that there is a cost associated with the
time left blank by the patient not showing, which is true:
JUST AS IMPORTANT AS
THE CODES…
MODIFIERS AND OTHER BILLING
INDICATORS
 Billing Medicare for the no show would be inappropriate
 Medicare does not allow billing the patient for the no show
 Medicare requires billing for the no show and after a rejection
will allow the patient to be billed
 Medicare doesn’t run our office or pay the overhead, so we bill
what we deem correct
 Medicare allows billing the patient for the no show
WHAT ARE MODIFIERS FOR?
 They provide more information on your claim and increase
your chance for reimbursement
PLACE OF SERVICE CODES








11 – Office
1 2 – Home (Be sure to use for CMS DME !!)
21 - Inpatient Hospital
22 – Outpatient Hospital
23 – Emergency Room Hospital
24 – ASC
31- Skilled Nursing Facility
32 – Nursing Facility
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TOE MODIFIERS, IF YOU DO IT TO A TOE
YOU NEED A TOE MODIFIER!
WHY POS MATTERS
 Using the wrong place-of-service code triggers
overpayments because Medicare Part B pays more
for certain physician services when they are provided
at offices or freestanding clinics rather than at
hospital departments, including provider -based
entities. The reason: professional fees include
overhead when services are provided at practices
and freestanding clinics. But Medicare Part B
reduces professional fees when physicians treat
patients in outpatient departments,
EVALUATION AND MANAGEMENT MODIFIERS
 Toes, Toes,
TA = 1 st left
T1 = 2 nd left
T2 = 3 rd left
T3 = 4 th left
T4 = 5 th left
LT = Left
Toes
T5 =
T6 =
T7 =
T8 =
T9 =
1 st right
2 nd right
3 rd right
4 th right
5 th right
RT = Right
\
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 24 Unrelated E/M Service During a post operative visit
During a post operative visit (within the global period), the
patient presents with an acute onset of heel pain
99213 -24
These Modifiers are only used on E/M codes: 99xxx
25
SURGICAL MODIFIERS
Significant, separately identifiable Evaluation
and Management service by the same physician
on the same day as the procedure or other
service
 25
During a visit for heel pain which requires an injection, the patient
also presents with an ingrown nail
99213 -25 (703.0)(728.71)
20550 (728.71) RT
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59
procedure or service that was distinct or
independent from other services performed on
the same day
 59 A
During a first metatarsal head osteotomy, the surgeon also
corrects a hammer toe deformity
28296 (735.0) RT
28285 (735.4) –RT, 59
ADVANCED BENEFICIARY NOTICES
79
 79 Unrelated surgery during postop period
At the first post operative visit following a bunion surgery, the
patient presents with an ingrown nail requiring an I/D
99213 (703.0)(681 .10) - 24
10060 (681 .10) – 79 TA
GA
 GA Waiver of liability statement on file – Use to indicate that the
physician’s office has a signed advance notice retained in the
patient’s medical record. The notice is for services that may be
denied by Medicare.
A patient presents for at risk foot care sooner than what is
normally allowed
GY
GET PAID FOR YOUR HOSPICE PATIENTS!
 GY Waiver of liability statement NOT on file – Use to indicate
when an item or service is statutorily excluded or does not meet
the definition of any Medicare benefit.
A patient presents for foot care without qualifying findings
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7/21/2012
HOSPICE
DME RELATED MODIFIERS
 GW or GV
 GV- Attending physician not employed or paid under agreement
by the patient’s hospice provider.
 GW - Service not related to the hospice patient’s terminal
condition.
KX
A FREQUENTLY “MISSED” OPPORTUNIT Y
MODIFIER 76
 The KX modifier is added to claims for equipment that require
a certificate of medical necessity (CMN) or that currently
require a written order prior to delivery (WOPD).
 76 Repeat procedure by same physician – The physician may
need to indicate that a procedure or service was repeated
subsequent to the original procedure or service
Repeat xray for manipulation of dislocation
Return to OR same day, implant dislocation
ROUTINE FOOT CARE –
AT RISK FOOT CARE
NOTHING STAYS THE SAME
Even if you’re on the right track,
you’ll get run over if you just sit there.
Will Rogers
ICD 10 in 2014
Up Next
How to bill correctly AT RISK FOOT
CARE
Jfrederick@aappm.org
Coding and Billing seminar
November 30, 2012 Arizona
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