Section: CME Category: Practice Management


Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC,

Jeffrey Lehrman, DPM discusses current guidelines for properly coding E&M and CPT visits with modifiers as well as going through examples to formulate the proper modifier for various clinical scenarios.

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  1. Review current guidelines for properly coding E&M and CPT codes with modifiers
  2. Formulate proper modifiers for various clinical scenarios
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    Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC has disclosed that he is a consultant for Smith & Nephew, AmerX, Molnlycke, Musculoskeletal Transplant Foundation, Wounds, AI, Orpyx Medical Technologies, is a speaker for BSN Medical, Organogenesis and is an officer/director for American Podiatric Medical Association.

  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Male Speaker: For the younger people that are newer to coding, a modifier is something that gets attached to a CPT code that allows you to tell the payer more about what you did with that code. And we are going to go through the list of the most commonly used modifiers in podiatry. I hope everybody in this room knows these. You should.

    Each toe has its own modifier and each foot, of course, has its own modifier. The one that may -- the one question that often gets asked with these is, where, for purposes of modifiers, does the toe end and the foot begin? Meaning, if I do work at that first MPJ, should it be a T modifier or should it be an RT or a LT modifier? And the answer is, if it is at or proximal to the MPJ, then you use RT or LT. If it is distal to the MPJ, then you use a T modifier. And you should be using these whenever you can. It’s always best to give the payer as much information as you possibly can.

    So, if you do a simple PIPJ arthroplasty, right, if it’s a right second toe PIPJ arthroplasty with a 28285, you should be appending a T6 to that to tell them which toe you did it on. If you do a bunionectomy at the first MPJ, that should be RT or LT. If you do a lesser MPJ capsulotomy, that should be RT or LT. So, again, if it’s at or proximal to the MPJ, use RT or LT. If it’s just in the toe, use a T modifier.

    22 modifier is for increased procedural service. Meaning, you did more than what is typically required for that code. You spent more time. There was more difficulty. The severity of the condition warrants this.


    I’m going to go through examples of when you should and when you should not which I think is the best way to illustrate this. It’s when much more considerable more effort and time is necessary to complete that procedure than what is typically necessary for that code.

    So, a good example would be a failed first MPJ implant where you’re going to make an incision, dissect down, remove the implant, and then convert it to a fusion. Well, unfortunately, the only thing we can code for that is first MPJ fusion. Not fair, but that’s the rule. The removal of the implant was performed at the same surgical site through the same incision and same everything else as the fusion. Therefore, you cannot code for the removal of the implant and the fusion. You could only code for the first MPJ fusion. But we know that that is a very different procedure, the one I just described, than is a straight clean primary first MPJ fusion.

    Getting that implant out could be a lot of work, right? Especially if it’s been in there for a long time. That would be a situation where it would be appropriate to code for first MPJ fusion with a 22 modifier. If you do that, you should send in a claim form and the op report and separate from those two items, a narrative describing what you did. And yes, there’s a lot of overlap between that in the op report, but a narrative of what all this extra work was, why it required so much more effort, why there was more time, more risk involved, and why the 22 modifier is appropriate. That’s a legit example.

    One of my former residents who asks me some weird coding questions, recently, I got a text from him and it started with, “So, a patient came in for nail care and they had 11 toes.”


    I knew where this was going. And yes, he asked it and the answer was, “No, that’s not the spirit of the 22 modifier.” It’s not what we’re getting out here. So, I hope those two examples illustrate when it is appropriate and when it is not appropriate.

    25 modifier is for a separately identifiable evaluation and management. And I can do 30 minutes on what is a separately identifiable evaluation and management just on that. But because we’re covering all modifiers, we can’t do that. And simply stated, the definition of a separately identifiable evaluation and management is that you can -- separately identifiable from the procedure, of course, that you can separate the E&M and all of its components from the documentation that goes along with the procedure and from the actions that go along with the procedure. Take every part of the E&M out of that and have it still stand alone as its own separate entity. Again, you should be able to take all of the components of the E&M out of the procedure and have it stand on its own.

    So, here’s a good example of one that is not. So, I was recently asked -- patient had an ulcer debridement and they had been using a topical agent and I made the decision to switch what they were using topically. Can I code a separately identifiable E&M for the effort and the thought that went into switching what they were using topically? No, because that does not stand on its own completely separate from the debridement and a simple illustration of that is, the O, right, the exam, that led to your decision to do the debridement, the exam that goes with the debridement is the same as the exam that led to the decision to switch what you’re using topically.


    So, if you pull the exam portion out of the E&M, you’ve left a hole in the debridement part of the visit. It has to stand on its own as its own service. There are no such thing as automatic separately identifiable E&Ms, right?

    And to break, somebody asked me a really good question. On a first-time patient, a new visit, can I do a separately identifiable E&M with the debridement? And the answer was, “Probably and you should be because I’m sure you did it, but the documentation has to support it.” And the example I gave was on this new patient.

    I’m sure we all do a separately identifiable E&M on that new patient with a diabetic foot ulcer. We educate them, and tell them what a diabetic foot ulcer is, and that it’s really bad, and we have to do this kind of offloading, and we talk nutrition and arterial supply, and activity, and all that stuff. But the documentation has to support that a separately identifiable E&M was performed. And in that note, right, if it’s SOAP, and the P section of that new patient visit that got a debridement says, “Plan: Sharp debridement with a 15 blade down the SubQ with force runners, 300 meters of tissue removed.” The M of the E&M is missing, right? There’s no management there and the auditor who’s -- hasn’t met their quota for the month, is going to say, “Where’s the M, where’s the management? All these tells me is that you debrided it,” and we would say, “Well of course I talked to them about that,” but it has to be documented. So that’s a separately identifiable E&M.

    50 modifier is for bilateral procedures if the procedure that was performed has a bilateral indicator.


    This is a mistake a lot of people make and they miss appropriate reimbursement for a procedure performed bilaterally because they didn’t check to see if that code had a bilateral indicator.

    Some do, some do not, there is absolutely no pattern to it, you can’t say this kind has it and these don’t, or forefoot do and mid-foot doesn’t, there’s no such thing, you just have to check. If you do a procedure bilaterally, the first question is, does it have a bilateral indicator?

    If it does, you use the 50 modifier, if it does not, you do not use the 50 modifier. So again, you do a procedure, the same procedure bilaterally, when you go to code it, first question, does it have a bilateral indicator, and whether it does or it does not, dictates the coding.

    If it does, you use the 50, if it does not, you do not, so you need to have a way to very easily answer this question. Hopefully, whatever coding resource you use, answer that question for you, I use the APNA Coding Resource Center.

    I have no relationship with it to disclose, I subscribe to it just like you guys do. So this resource tells you very easily whether it does or does not. So if you look at the code on the bottom, you’ll see that’s a Keller bunionectomy and following across the bottom, it tells you whether it has a global period, whether you can do an assistant feed, the RVUs, and then you see on bottom, Bilat, why.

    That means it does have a bilateral indicator. If you look at the code that’s three down from the top, that’s a condylectomy, so 2A, 288, that does not have a bilateral indicator. So I’ll tell what it looks like both ways.

    So let’s say we do a bilateral Keller, does it have a bilateral indicator? We look up Keller, 28292, it does.


    Because it does, that means you do use the 50 modifier to code it, and when it does have a bilateral indicator, you use one unit on one line with a 50 modifier.

    Putting the 50 tells them you did it twice. So one unit, one line, 50 modifier, no RT or LT because if you did it bilaterally, there’s only two options, they know that you did RT and LT. So don’t put laterality modifiers with 50 modifier, it can lead to the claim getting kicked out.

    And then because you did it twice, you should bill twice what you normally bill. So whatever you submit when you do a Keller, double that on what you charge them, and they should honor the 50 modifier, recognizing that it was done bilaterally.

    Now let’s look at it in another way. We do this procedure bilaterally, does it have a 50 modifier, we look it up, and it does not. So now you do not use the 50 modifier, and when there is not a 50 modifier, the appropriate coding is to list that code twice, one RT and LT and one gets a 59.

    No it does not matter which one you put the 59 on, just pick one. So if you do a procedure bilaterally, use the 50 modifier if there’s a bilateral indicator. If there’s not a bilateral indicator, this is how to do it.

    Whatever coding tool you’re using, I suggest too, you should make it very easy for you to answer that question as to whether it does or it does not. The 59 modifier, this room and our profession and is very familiar with. This is a separate, unrelated procedure, so like buinonectomy and tailor bunionectomy, right, one gets a 59.


    We cannot do 1st MPJ capsulotomy and bunionectomy, that would be unbundling. So 59 modifier indicates a second, unrelated procedure, but I want to spend some time on these X modifiers. These were introduced by Medicare a couple of years ago as an alternative to the 59, and when they first came out, the messaging from me and the APMA Coding Committee was, “You don’t have to worry about it, they are not making us do it. The 59 modifier is still fine, don’t waste your time worrying about it unless a payer tells you, you have to.”

    And that’s been our messaging, because why throw something else into the mix and why complicate it, but over the last year or two, starting to think there may be some usefulness to these X modifiers as a substitute for 59 modifier for Medicare only.

    So this is Medicare only. Only Medicare, as of today, I put the question mark there, because somebody else could pick it up tomorrow, but as of today, only Medicare recognizes X modifiers, and you can use an X instead of a 59, and this XS, that applies to a lot of stuff that we do, right, nails and callouses, bunionectomy, tailor bunionectomy.

    The XS is an appropriate substitute, and a lot of people didn’t want to have to worry about it because they didn’t want to do something, or they didn’t want to have to use one where they can only do it for Medicare people, but the reason I’m revisiting it is, there are a lot of audits that deal with the 59 modifier, and there are a lot of payment cuts dealing with the 59 modifier, where they’ll cut a 59 modifier thing in half.

    For a Medicare patient, if the XS is appropriate, it’s not a bad idea to use it instead of 59, and that’s suggesting that this would allow you to do anything inappropriate or that it gets you through if you’re coding nefariously, which of course I’m not suggesting, but if there is some kind of audit or program that they run based on 59, you’re not going to show up, and maybe that saves you the hassle of a letter, or it saves you the headache of having to provide documentation.

    Again, not suggesting in any way that this allows you to get away with anything, but it might save you some aggravation, and it might keep you off the radar for 59 modifier stuff if you’re not using it as much. Just a thought as to where these X modifiers may help you.

    I want to finish up with the modifier options that you have for coding during a global period. For E&M coding during the global, there is only one option, for procedural coding the post-operative global, there are three options, and that is an important distinction, because it’s two very different options that you have for what you can and cannot do during the global, if it’s an E&M versus if it’s a procedure, two very different situations.

    One, E&M modifier and that is the 24 modifier, which says it is an unrelated E&M during the global, unrelated. That’s different from unexpected. Different from – I found a different diagnosis. This is something a lot of our colleagues get wrong and they fail audits based upon unrelated E&Ms.

    So an example would be somebody who’s post-op bunionectomy, and they’re at their fourth week post-op visit and they say, “You know what? Since I’m here, I’ve been wanting to ask for 20 years why my toenails are yellow.”


    And you do an E&M of dystrophic yellow toenails, totally unrelated to the bunion. That’s a legit unrelated E&M during the global.

    But let’s look at another example. Let’s say, we’ve all been there, you do a transmetatarsal amputation and the patient’s home, and they’re one week post-op. And they think they see redness at the closure site. And they don’t call you, what do they do? They go to the ED. And what happens as soon as the red foot lands in the ED? Admit, they’re in, right? Now they get admitted, now you get consulted. And you don’t have residents. And you drive 20 minutes to the hospital and spend another 10 minutes finding the patient’s room, but they’re not there, because they’re down in radiology. You walk another 10 minutes down to radiology and get there and find them and start to unwrap the bandage and then the radiology tech yells at you and says, “We can’t do that down here, you have to wait until they get back upstairs.” We know this game, right? We’ve all been there. Then you chase him up and do the visit and hunt for the chart for 10 minutes, if your hospital hasn’t converted it to electronic charting yet. And by the time we’re done with this nightmare, it’s two and half hours in and you decide this patient doesn’t need surgery. It’s post-op infection, they need intravenous antibiotic. And that’s it. And maybe it’s dehisced a little, and you pop a suture or two.

    People make the mistake and rightfully so, we think we should get paid for that, right? I want to get paid for that. I know everybody here does also. But people make the mistake of finding a different diagnosis, like, post-op infection or wound dehiscence or stitch abscess or something. And thinking that it’s appropriate to code an E&M with a 24 modifier because they found a different diagnosis.


    But that’s not what it says, it says unrelated. The tinea pedis is – or, sorry, the onychomycosis, the yellow toenails, that’s unrelated to the bunion. But the post-op infection, the dehiscence, the stitch abscess, whatever other creative diagnosis you could find, is related to that TMA. So there are occasions where it’s appropriate and certainly those where it’s not appropriate. So that’s the only E&M option available during the global.

    We have three procedural options. So the 79 modifier is sort of the 24 modifier equivalent for a procedure and that is in unrelated procedure. So post-op bunion person that needs a 11730 portion, that avulsion because they had an ingrown, unrelated procedure. Totally legit, you could do those procedures, you should get paid for those procedures, 79 modifier, unrelated procedure. Notice, it makes no mention of the location, 79 unrelated, does not say anything about the place of service or where that procedure was performed, unrelated procedure anywhere, including an ingrown in the office.

    78 modifier is a related procedure if it’s done in the hospital or operating room, hospital or – sorry, operating or procedure room. So 79 was unrelated, you could do it anywhere. 78 is a related procedure if it’s in the operating or procedure room. So 10-day post-op bunionectomy person that has a hematoma that needs to be incised and drained, that’s related.


    If you do it in the office, you cannot use the 78 modifier. If you do it in the operating or procedure room, you can use a 78 modifier.

    Two-week or let say one month post-op TMA person at the wound care center, where there’s got a little bit of dehiscence and you debrided at the wound center, can’t code for it with a 78 modifier. It has to be in the operating or procedure room. What is a procedure room? That’s a room in your office that is set aside and dedicated for procedures. If it’s a room that somebody got their toenails cut in five minutes ago, that’s not a procedure room.

    So there is some ambiguity there, it’s not exactly clear what is and what’s not. What I tell people when they ask is, “If an auditor shows up and says you coded a 78 in the office, I want to see your procedure room.” When you show it to them, they need to be able to without any questions say, “Oh, I get it. I see what you mean, that’s totally a procedure room.” If you show it to them and they’re like, “There’s toenails on the ground or I see an orthotic grinder in here,” that’s not a procedure room. It needs to legitimately be a procedure room in order for you to use this in the office setting.

    58 is the third option we have during the global. This is for a staged procedure. This was staged and planned, you knew the second procedure was coming and it is important that you document your expectation that a staged second procedure was coming.

    So good example, let’s say today, there’s a gross gas gangrene that we do on open guillotine TMA on. And we know we’re going back in a couple of days to clean it up, debride more approximately, maybe close, whatever, to fit and revamp.


    That second procedure, you’re going to be able to use the 58 modifier on because it was staged. You knew it was coming, like, taking off an Ilizarov external fixator, six weeks after putting it on. That was staged. You knew that was coming. But in order to buy the ticket, to use the 58 modifier on the second procedure, you must document your intent to use it when the first procedure is performed. So with that, guillotine TMA.

    In today’s op-note, you should dictate, “This was left open. We are going to need to return for more work as part of these staged multiple procedure effort,” and I would suggest you say, “Why?” right, to salvage this patient’s limb, or to save as much as we can, or whatever. Important that you document the plan to use the 58 subsequently, that then allows you to use the 58 modifier subsequently.

    And then when you do use it, you should again document this is a staged procedure as planned from the get go. So then, some people say, “Why didn’t you just say that on all of them, then I can use the 58 if I need it later, right?” If you do an amputation today, and you document clean, healthy, clean margins, adequate bleeding, primary closure performed, you can’t then use the 58 three weeks later when it dehisces, it’s one or the other, right? So you need to document your intent to use it subsequently.

    Any procedure that has a 90-day global, if it has a 90-day global, only 90s, if it has 90-day global, that global period extends to 24 hours before the procedure.


    If it has a 90-day global, the global actually started 90 days prior to the procedure. So if we go in today to the hospital, and there’s a gross abscess that we’re going to I&D tomorrow, the I&D that we’re doing tomorrow has a 90-day global that extends into today, and eats today’s E&M. But we have the option for a 57 modifier on an E&M that is done 24 hours preceding a procedure that has a 90-day global where the decision for surgery was made. So if we go in today and do that consult on the gross abscess and say I’m going to do an I&D tomorrow, you can put a 57 modifier on today’s E&M because the decision for surgery was made today.

    If, on the other hand, where you have a patient at the hospital that were rounding on and on Friday, you write, “We’re going to take this patient to the operating room on Monday for, let’s say, primary closure of something,” right? That’s not a good example because it’ll be in a global. We’re going to take this patient in the OR on Monday for an amputation. Friday’s fine because they’re not in the global, right? Monday’s 90-day global amp, that global extends to Sundays, you can cover Friday, you can code for Saturday. But if Sunday’s note says, vital stable, all questions answered, patient to the OR tomorrow, the decision for surgery wasn’t made, it was made on Friday. You cannot use the 57 modifier there, only when the decision for surgery was made.

    If you’re doing skin subs in your office, hopefully you know these, the FTA does not want us to call them skin subs anymore. They are now supposed to be referred to as CTPs, Cellular and/or Tissue-based Products for wounds.


    And if you think that some of these newer, fancy, amniotic options, they’re not really skin subs, right, they’re not substitutes for skin, that’s why the change. So we’re supposed to be calling skin subs CTPs that hasn’t really caught on. Most of us are still saying skin subs, but we’ll say it right for the rest of our time here.

    If you’re putting a CTP on in your office, you code for the application, that 1527, whatever, right? And then you code for the product. If you’re putting one of these on in your office, it has a cue code. All of these CTP options that you would be using in your office, they have cue codes. We have always had to document how much we used and how much we wasted. We now need to code how much we used and how much we wasted. You have to code how much you used and how much you wasted. You do that with what was a brand new modifier, January 1, 2017. And that modifier is the JW modifier. So the appropriate way to code this, if you put one of this in your office, it’s the first line should be the application code, 15275 if it’s foot under a certain size, right?

    Then line two should be the cue code for that product with the number of units you used with the JC modifier. The third line should be that same cue code again with the number of units wasted with a JW modifier. When you add together the number of units used and the number of units wasted, it should equal to total number of units that came out of the box. They are paying both.

    Today, my own conspiracy theory, which is based on nothing, is that they’re making us do this for a reason. And if I was the one right in the checks at Medicare, I would not be wanting to pay for 44 square centimeters of product to cover a sub one four-square centimeter ulcer.


    I think they’re making us do this for a reason. So think about that when you decide which products to use and which size products to use. They are paying for both now, but my own opinion is they’re making us do this for a reason. They want to know how much is getting wasted.

    If you are using plain film x-ray in your office, starting January 1, 2017, you need to attach a modifier to your x-ray codes. If you’re doing plain film in your office, for Medicare only, this is only for Medicare, you need an FX modifier on your x-ray codes. If you haven’t been doing it and you’re going getting paid, it’s because nobody’s come to look at your x-ray machine yet. They can and they have, and that’s – could be a problem.

    For Medicare only, if you’re using plain film x-ray, put an FX modifier on your x-ray codes, and now, just using digital isn’t enough. You need to know for Medicare which type of digital x-ray you’re using. You need to ask, “Is my digital x-ray unit CR or DR?” If you don’t know, look at what’s written on the machine, or call the manufacturer and ask, “Is my digital x-ray CR or is it DR?” If it is a CR digital x-ray, you need an FY modifier on your x-ray codes. This started 11-18.

    So, for Medicare, if you’re using plain film, you need an FX modifier. If you’re using CR digital radiography, you need an FY modifier. If you’re using DR digital x-ray, you don’t need any modifier.


    Thanks so much for your attention. Enjoy the rest of the morning or afternoon.

    TAPE ENDS – [30:11]