With detailed and specific codes, podiatry coding is a specialized process. Any mistake in selecting codes can lead to claim denials and thus reimbursement issues. Podiatry practices must also be up to date with the rapid changes in the coding standards or they may have to face decreased revenue.
Here are some key tips to prevent podiatry coding mistakes.
Choose relevant CPT and ICD-10 codes
Diagnosis as well as procedure coding for podiatry requires coders to undergo specific training in foot care and what’s required to document and prove medical necessity, as well as local and national coverage determinations.
Coders must be careful enough to clearly list and align at-risk conditions and painful conditions with the appropriate ICD-10 codes on the claim form. Practices should make sure to implement changing coding standards. ICD-11 transition is the next big change to happen. This code set was adopted by the World Health Assembly on May 25, 2019 and will go into effect on January 1, 2022. This 11th Revision of ICD is expected to revolutionize the way conditions are classified and coded in the clinical setting.
Billing for a lower level code or down coding to decrease the odds of being audited is also a mistake.
Correct use of modifiers
Using appropriate modifiers will allow all podiatry procedures including bunionectomy procedure to get properly paid. Coders are recommended to check the Correct Coding Initiative (CCI) edits, available at the Centers for Medicare and Medicaid Services (CMS) website or in a podiatry-focused resource such as the American Podiatric Medical Association (APMA) Coding Resource Center.
Selecting the wrong modifier will result in the claim being denied.
- There will be confusion on whether to use a RT or LT modifier compared to the -50 modifier when performing bilateral services. NCCI edits help to determine whether that specific CPT code requires a single line billed with the -50 modifier or whether you need to bill two separate lines with the RT and LT modifier.
- T codes should be used to separate surgery performed on multiple toes. If you only operate on a single toe, then there is no need to use a T modifier. Do not use a TA modifier to report a bunion surgery.
- Specific evaluation and management (E/M) modifiers such as -24, -25 and -57 may create confusion as well. Use these modifiers only with E/M services. The carrier will automatically deny your claim, if it is used for any other service such as a diagnostic study or procedure.
- The -25 modifier is often used incorrectly. This modifier must be used when the E/M service is “significant and separately identifiable” from the procedure a podiatrist is performing on the same day. Do not use this modifier if the treatment wasn’t medically necessary.
Focus on proper unbundling of services
Some services are bundled together under one code which shows that the podiatrist has performed one service as the result of doing another. Unbundling or fragmentation is the billing of multiple procedure codes for a group of procedures normally covered by a single, comprehensive CPT code. There are certain cases where healthcare providers will intentionally manipulate coding to maximize payment. This will be considered as Medicare fraud.
Unbundling may also occur if the coder misunderstands the proper coding process. Updated quarterly, NCCI is designed to ensure that physicians do not inappropriately unbundle CPT codes.
Durable Medical Equipment (DME) Documentation
The proper place of service (POS) must be submitted correctly on the claim form to ensure accurate reimbursement. The HCPCS codes used must be verified with the DME carrier and explanation of various options along with the financial implications for obtaining DME must be provided to patients.
In case of any claim denial, podiatry practices must carefully read the explanation of benefits, which will provide insight about why the claim was denied and thus can get the basis for an appeal. Appeal letter should also address the specific question the carrier has mentioned.
Podiatry practices should have a clear idea on what procedures are covered before providing treatments. For instance, while standard toe nail clipping is not covered by Medicare, nail debridement is covered. Wound care insurance verification is critical to verify patients’ insurance benefits before services are provided, which prevents non-payments that can impact your bottom line.