Resolved Billing Podiatry

[NatashaP_63838]

Hi everyone. So I work for a MSO and one of the clinics that we have just added Podiatry for patients within the Primary Care practice. The podiatrists are billed with the Primary Care Group and I am lost about the different classes for routine foot care and when to use the modifiers. Can any one help me with resources for correct billing and documentation practices for routine foot care please?

 

[Jesus]

Billing Podiatry Services in the United States​

In the US, the Centers for Medicare and Medicaid Services (CMS) define the regulations regarding which services are covered under health insurance. The centers don’t directly inform insurance agencies, but they influence billing and coding guidelines.

What is covered in the US?​

According to the CMS, only the services which are considered medically necessary and reasonable foot care are covered. There are strict billing and coding regulations that stipulate how often a patient can be treated, the treatment setting and which diagnoses are covered.

Medicare covers:

• Foot care for patients with chronic diseases;
• Wound care treatment;
• Hyperbaric oxygen therapy for hypoxic and diabetic wounds that affect the lower extremities.

For routine care, the podiatry service must be considered Additional, Mandatory, Supplemental, or Optional Supplemental benefits. Other services that treat conditions that are not specific to the foot area (and are therefore not a specialised podiatric service), such as warts, are covered as they would be if the warts were located anywhere else on the body.

What is excluded?​

There are a number of podiatric services that are not covered by Medicare (and may also not be covered under general third-party insurance). In general, any elective or podiatric services that are not medically necessary will not fall under ‘reasonable foot care’ and thus won’t be covered by insurance.

As a US-based podiatrist, if you’re billing for foot care services that fall into the below categories, you’re unlikely to be able to claim from insurance:

• Routine foot care, exceptions include initial care that may result in a diagnosis that is covered by insurance, mycotic nails, the presence of metabolic, neurologic or peripheral vascular diseases, or if the patient has diabetes, chronic thrombophlebitis, or peripheral neuropathies;
• Subluxation of the foot, although there are exceptions where the dislocation was of the ankle joint, or forms part of the care that resulted from the subluxation;
• Flat foot;
• Supportive devices, exceptions include therapeutic shoes for patients with diabetes and orthotic shoes that form part of a leg brace.

How do you bill for podiatry in the US?​

When you submit a claim you need to include:

• diagnosis
• severity
• podiatrist name
• appointment date

To avoid claim denials, you need to utilize codes correctly, follow the coding procedure and avoid over-coding. Also, rather than simply stating the condition, you should keep documented proof that the client would experience negative health effects without your intervention.

Can podiatrists bill 99204?​

Based on the 2021 E/M guidelines, podiatrists now have the ability to bill E/M 99204/99214 as well as E/M 99205/99215. To bill under these codes a medically appropriate history and/or an examination is needed and there’s also a medical decision making or time element. In terms of medical decision making, it’s best to refer to The Level of Medical Decision Making table. For an in-depth understanding of how to approach Level 4 and Level 5 coding, this article can help.

Can some codes be billed together?​

Yes. In podiatry, some codes can be billed together for one patient, while others cannot.
Examples include:

• 11721 and 11056 can be billed together based on the CPT definitions.
• CPT 11719/20 and G0127 cannot be billed together as both include “any number” of trimmed nails.

US Podiatry Billing Cheat Sheet – What Are the Billing Codes?​

In-Clinic Services​

99203 – 99204 Office Visit New Patient Level 3 – Level 4
99213 – 99214 Office Visit Established Level 3 – Level 4
29405 Apply Short Leg Cast (Non-weight Bearing)
Q4038 Short Leg Cast Material
20550 Injection Tendon Sheath/Ligament
J3301 Triamcinolone Acetonide (Typically 1 unit used)
* See above for E/M 99204/99214 and E/M 99205/99215 billing changes in 2021

Nail Care and Nail Procedures​

11720 Toenail Trim (1 Foot)
11721 Toenail Trim (2 Feet)
11730 Toenail Removal
11750 Toenail Removal (Permanent)
97597 Debridement of Open Wound
17110 Wart or Lesion Removal Up to 14 (Benign)

Orthotics​

L3020 Custom Orthotic Materials (OR002)
29799 Casting Impression Fitting (S0395)
97760 Orthotic Management and Training 15 Minutes EachDurable Medical Equipment
L4360 Ottobock Pneumatic Walker (Immobilizing Boot (SS406)
L4396 Foot Night Splint – Treatment for Plantar Fasciitis (SS397)
L1902 Ankle Brace (SS243)

Source: https://www.powerdiary.com/us/blog/podiatry-billing-codes/