Don't Trip Up Your Foot and Ankle Claims

Be aware of some of the more common foot procedures your family physician might face if you want to get the rightful reimbursements for your foot and ankle claims.

You need to be aware of some of the more common foot procedures your family physician might face if you want to get the rightful reimbursements for your foot and ankle claims.

You should have sound basic knowledge

Sudden impact or simple wear-and-tear can cause toe, foot and ankle problems. As such you need to be aware of the differences between these diagnoses or you may miss a subtle difference and report the wrong code.

One thing to bear in mind is that you might require modifiers to help differentiate work on different areas of the feet or for that matter toes. These modifiers include LT and RT, TA-T9 and sometimes 59 depending on the service your physician provides. These modifiers become all the more important if the FP carries out the same procedure on more than one foot or toe.

Be aware of the difference between Bunions and Hallux Valgus

A bunion is an enlargement of bone or tissue around the metatarsophalangeal (MTP) joint of the great toe. It's often caused by patients wearing shoes that are too narrow around the toe box and can cause pain and deformity of the toes.

Remember: A common mistaken belief is that "hallux valgus" and "bunion" refer to the same thing. Even though CPT code lists bunion procedure codes like 28290 as "hallux valgus corrections," doctors who carry out these are not necessarily correcting a hallux valgus, according to ICD-9 terminology. If you look up 735.0, the definition reads, "Angled displacement of the great toe, causing it to ride over or under other toes."

As such, you should not report 735.0 unless the patient has an angular deformity of the great toe. As per this definition, a person could have a bunion but not necessarily a hallux valgus deformity; however experts say that the above definition is not actually followed. Hallux valgus is simply a valgus deformity of the distal great toe and does not have to overlap for a physician to call it hallux valgus.

If the patient's great toe is not overlapping or impinging upon the second toe, but he still has an obvious bunion, take a look at 727.1; this code specifically says 'bunion' and the ICD-9 definition is "enlarged first metatarsal head due to inflamed bursa; results in laterally displaced great toe."

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Settle On Which Primary Code This Case Suggests: +33225

Start by analyzing the report excerpt An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was geared up with extensive dissection. Three different guidewires were advanced into the left subclavian vein using the Seldinger technique across the open pocket.

The middle of these wires were then used to further a coronary sinus sheath for placement of the left ventricular lead. With some complexity, we were in the end able to advance the coronary sinus sheath in the mid coronary sinus and an angiogram was obtained. After this a left ventricular lead was advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was done at three separate locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV. After this, the bipolar right ventricular defibrillator active fixation lead was advanced to the right ventricle, various areas were checked and the lead was lastly fixated along the RV. Next the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was in the end fixated along the RV septum and tested. Post this, a bipolar screw in type right atrial lead was advanced to the right atrium and the lead was fixated to the right atrial wall. Then the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead. All three leads were then sutured to the pectoral fascia over the Silastic sleeves; the pocket was then irrigated. Pretty soon the leads were attached to the ICD/BiV device.

Then the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. Pocket was then sutured closed. The patient was given propofol and the following establishment of adequate general anesthesia. Ventricular fibrillation was induced; the advice analyzed and delivered three different DC counter shocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was awakened from sedation minus obvious side effects. Find your first stop at an add-on code The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant. While making your way through the first two paragraphs, you should train eyes on the terms describing placement of the left ventricular lead through the coronary sinus. The proper code for this portion is +33225. Documentation tip: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.

Add the primary code for that add-on code The next few paragraphs of the documentation describe lead fixation for the right ventricle (RV) and the right atrium (RA). Also the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. All of this is covered by one code: 33249. Add-on note: CPT code lists 33249 as a proper primary code for add-on code +33225. Remember that ‘add-on' codes are always carried out in addition to the primary service or procedure and must never be reported as a stand-alone code.

Defib testing earns the final code The last paragraph of the case study excerpt describes 93641. With defib testing, you want to see impedance in the documentation. Generally physicians will state something like ‘Ventricular fibrillation was induced. The device analyzed and delivered 3 separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. The high-voltage impedance was 45 ohms. Term tip: The defibrillation threshold (DFT) is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart reliably. Knowing the patient's DFT aids the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a surprise to defibrillate the patient's heart.

Ensure your practice hits these points In a situation like this, the doctor would typically use fluoroscopy, as well; however, it is not documented in this case. No documentation of fluoroscopy means you should not bill fluoroscopy. When fluoroscopy is documented, you should go for 71090-26. ICD-9: What's more, the case study does not mention indications for you to select ICD-9 diagnosis codes. Minus a VT [ventricular tachycardia] diagnosis or information relating to primary prevention criteria, this cannot be coded. Either you have to have a payable diagnosis for the ICD or data to support adding a Q0 modifier to 33249. What's more, check your local requirements for diagnosis codes that support medical necessity for 33225.