Section: CME Category: Practice Management

Coding, Compliance, and Documentation for Foot Care

Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC,

Jeffrey Lehrman, DPM discusses the list of codes for performing shave, punch, and excision biopsies. Dr Lehrman also compares between fine needle aspiration with puncture of a bulla and routine foot care with mycotic nail debridement.

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Goals and Objectives
  1. List the codes for performing shave, punch, and excision biopsies
  2. Compare between fine needle aspiration and puncture of a bulla
  3. Compare between routine foot care and mycotic nail debridement
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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]


    Unidentified Male Speaker 1: All right, let's get into the next one. I know I'm rushing but I started late here and I'm trying to finish on time. Foot care, meaning, toenails and calluses, is the number one service that podiatrists provide by far. Number two isn't anywhere close and it is essential that we are compliant in how we do this. That we code correctly, that we document correctly and we are compliant in doing this.

    The ratio of how much we do this to how terribly we document inappropriately code is way off. We should be way better at this with the volume of it that we are providing. So that's why I wanted to do this here. There are some younger people in the room and I know most people know this, but just to be thorough, Medicare is a national program, but it is administered on a local level by Medicare contractors. There are seven Medicare contractors in the country. Noridian is one of seven, Part B and that's what we care about for these purposes.

    Medicare contractors, if you aren't in any of these States, you fall under Noridian. Everything I'm going to talk about here is Noridian-specific, because I thought most of us would be California here today. If you happen to have come from far away and you're not in any of these States, most of these still applies to you anyway because most of it is carried over. But if you are Noridian, you do have some specific things that are different than the entire rest of the country, and we'll hit on that.

    This is the most important slide of the entire hour that I have with you, maybe other than the 11100 being deleted. When it comes to providing foot care and by foot care, I mean nails and calluses. There are three different policies that you need to be aware of, three different policies.

    [01:59]

    If you cut a toenail or you shave down a callus, the first question is, "Which of the three policies applies to this visit?" That's the very first question that you should ask yourself. We are going to go through each of these three policies in depth. And my goal is that 25 minutes from now, you have this perfect and you never mess this up for the rest of your career. Because like I said, way too many of us are getting this wrong. Three different policies.

    When it comes to nail cutting, there are two different policies that are unrelated, separate and have nothing to do with each other. And this is so often messed up, where people pull one from the other and overlap the two, and maybe they pull some components from one and some components from the other in an attempt to qualify the patient. And in doing so, don't qualify them at all, and then they lose their audit.

    So there was a third one, which doesn't deal with nails. When cutting toenails, there are two completely separate unrelated policies. We don't like to use the word "routine foot care" because we are saving patient's limbs and lives, and routine is what happens at the mall. Unfortunately, that's the name of the policy. So we got to go with it for these purposes.

    Routine foot care is when somebody qualifies by having an at-risk diagnosis and class findings, at-risk diagnosis and class findings. By the routine foot care pathway, there is no mention of pain, no need for pain and no mention of onychomycosis. I'm going to say it again. I'm repeating it because we have too many people getting his wrong. Routine foot care pathway, at-risk diagnosis, class findings, nothing about pain, nothing about onychomycosis.

    [04:02]

    The completely separate, unrelated and different pathway by which somebody can qualify to get their toenails cut by the podiatrist, is debridement of mycotic nails. This one is in the absence of a qualifying diagnosis and/or class findings. They have onychomycosis and one of three secondary diagnoses. Onychomycosis, plus one of three secondary diagnoses, which will go through – the three are slightly different, whether they're ambulatory or non-ambulatory, and I'm going to do this in more detail when we get to it.

    But the bottom line is because I – if I were sitting there, I would be thinking, "What are the three?" It's pain, limitation of ambulation or secondary infection, but we'll list those out on a slide. So two different pathways, routine foot care, at-risk diagnosis plus class findings. No need for pain, no need for onychomycosis.

    The other pathway, onychomycosis plus one of three secondary diagnoses. I suggest that the great majority of your foot care patients should qualify via the routine foot care pathway and not the debridement of mycotic nails pathway. Because those secondary diagnoses I think just aren't present that often. Not saying it can't happen, but how often is somebody's mycotic toenail is so bad that it's limiting their ability to ambulate? Certainly six of them when we get to the 11721 code, right? So my opinion is that the majority of the time, they should be qualifying via the routine foot care pathway. We're going to go through both of this.

    [05:58]

    And then the third one, starting with routine foot care. They need to have a qualifying diagnosis. There are only five qualifying diagnoses, they got to have one. These are the first four. The fifth one is on the next slide.

    First one is diabetes. I think options two, three and four really just fancy ways of saying PAD, right? Different types of PAD. So these are the first four. The fifth one is neuropathy, one big bullet there of neuropathy and then all these other types of neuropathy. So the routine foot care pathway, they have to have one of these five qualifying diagnoses. Notice that some have an asterisk. If the qualifying diagnosis that you use has an asterisk, patient needs to have seen the MD or DO for that asterisk problem within the last six months or shortly after your service.

    They don't define shortly after, who knows. To me, it's a couple of weeks, we get to decide that, make it reasonable. Other parts of the country, right? I talked to you about the different Medicare contractors have MD, DO or non-physician practitioner like NP or PA. You guys don't have that in any of the Noridian States. So if your friend in Minnesota says, "Oh, no, it's fine if they see the NP." Not for you. It has to be an MD or DO who treated that asterisk condition in the time period that's listed here. If it does not have an asterisk like the PAD ones, you don't have to worry about this.

    Routine foot care pathway, they have to have qualifying diagnosis and class findings. I think this room know this, right? One A or two Bs or one B plus two Cs , if it's Medicare and they qualify via the routine foot care pathway, you need the appropriate cue modifier which matches up with these class finding to indicate which class findings they had.

    [08:10]

    More people are writing than I expected, which is great. That's why we're here. So I'm slowing down. Normally, I'll blow through this. But that's cool, nothing wrong with that. That's why we're here. And there are younger people who are newer to this. One A or two Bs, or one B and two Cs. What are the A, Bs, Cs? Here they are.

    The A is a non-traumatic amp. They got something cut off for a reason other than trauma. I've been doing this a long time. And for the first time ever, somebody asked me, "How can you have a non-traumatic amputation? Isn't it by definition that procedure sort of traumatic?" So now I'm adding the explanation of what is meant by that. They got something cut off for a reason other than getting ran over by a dump truck, right? Like gangrene or something. That's your A.

    The Bs are below. There are three Bs. One is a non-palpable PT pulse, one is a non-palpable DP pulse. The third B requires the presence of three out of the five bullets that are listed under that third B. So to have one B of advanced trophic changes, you need to have three of those little bullets beneath them. Three of those bullets constitute one B.

    So remember, our Q8 was two Bs. I see this all the time. Patient has non-palpable DP pulse and pale skin with decreased hair growth. Do we have two Bs? No, we do not have two Bs. We got the non-palpable DP pulse. That's one. But then, the other thing that they listed was pale skin and decreased hair growth. We didn't get there. You need three of those to get that second B.

    [10:03]

    And then, the Cs, you see listed as well. I'll say it again, one A or two Bs, or one B plus two Cs by any combination. And this is a very important point now. Again, two pathways. Routine foot care pathway or debridement of mycotic nails pathway. If they qualify via the routine foot care pathway by having at-risk diagnosis and class findings, there are four, not one, four nail cutting codes that should be considered and you should be using all four of this. Too many people do 11721 every single time. That is begging for trouble. That is a major red flag. Four nail cutting codes, you should be using all of them.

    There may certainly be a bell curve, there is for me. But you're going to see all of these patients throughout the year, right? Four different codes, you should be choosing from all of them. The word onychomycosis is nowhere in the description of these codes. Somehow, our profession, many of us think that 1172 says debridement of mycotic nails. It doesn't. There does not need to be onychomycosis present in order to use 11721. So, I'm going to repeat what I said. If they qualify via routine foot care, if they qualify via at-risk diagnosis and class findings, don't need to have pain, don't need to have onychomycosis.

    Too many people start every single, every 62-day note with, diabetic patient presents with painful nails. They're not painful. They're there because it's day 63 and it was time to come get their nails cut.

    [12:00]

    Don't document that they were complaining of pain if they weren't. You're looking for trouble, especially when you don't have to. These are the codes that we have available to us. Trimming is defined as a reduction in length. Debridement is defined as a reduction in bulk, and that's all they give us. It doesn't say you have to use a Dremel. But by some means, you certainly can. By some means, you have to reduce the bulk of the nail. Maybe a turn on the nail, nipper on the side, and hit it on an angle and that reduces the bulk. Someone, you reduced the bulk and document that you reduced the bulk.

    11719 is a trimming of non-dystrophic nails, which means they were totally normal and there was nothing weird about them. G0127 is trimming of dystrophic nails, meaning they didn't need to be debrided but they needed to be trimmed and they were funky, there was something weird about them. They don't delineate what needs to be. They call it dystrophic, in my mind, it's something weird. And then we have our debridement options, nothing about onychomycosis.

    We know we see plenty of big, thick, giant nails that need to be debrided that don't have onychomycosis because they dropped the bowling ball on it six years ago or it's a hygiene thing or whatever. You can combine 11720 with either of the two codes above it. You cannot combine 11721 with anything else on this list. I find in my practice many people require bilateral hallux debridement and the other eight only need to be trimmed. And if that's what you do, that's what you should code.

    So for those that have being doing 11721 every single time, this requires a little more work. Now, you have to count how many were dystrophic, how many were non-dystrophic, how many needed to be trimmed, how many needed to be debrided and you need to document all of that. Which ones were dystrophic? Which ones were not? Which ones were trimmed? Which ones were debrided?

    [14:08]

    You will have – I'm not saying don't ever use 11721. You will have 10 gross nails that all need to be debrided, but keep track of what they had, document what they had and code what you did. One more time. You can combine 11720 with one of the other two above it. You cannot combine 11721. So if you debride six and trim four, it's 11721 only. People always ask, well, if you combine them, which one gets the 59 modifier or X, which we can talk about during Q&A if you want to. The CCI edit tells us when you combine these two, the 59 modifier goes on the G0127 code. So if you debride for example two and you trim eight dystrophic, which is what the majority of my people are, although again, there is a bell curve. This is the appropriate coding with the appropriate Q code to indicate the class finding.

    If they qualify via routine foot care, at-risk diagnosis and class findings, they are also covered for callus debridement. And you can and should pair their calluses and code for that. We are aware of the people that aren't paying the calluses with the nails and all of that business. We could talk about that later if you want. This is the proper way to code for that. So that was the routine foot care pathway. At-risk diagnosis, class findings, no mention of onychomycosis, no mention of pain in my opinion is that should be most of them.

    Now, there is another pathway, unrelated pathway by which people can qualify for nail care. And that is the debridement of Mycotic Nails Policy, which says, they must have onychomycosis and one of three secondary diagnosis with that.

    [16:03]

    If they are ambulatory, the three options are – and these are three things caused by the mycotic nail, which again is a bad toenail we're talking about, right? Or nails, plural. Onychomycosis plus either marked limitation of ambulation due to that nail, pain or secondary infection. That's the list of their ambulatory. If they are non-ambulatory, like maybe somebody laying in a nursing home, they must have onychomycosis and one of three secondary diagnoses. This people's list
    is different by one and that it is pain, or secondary infection, or this toenail is so bad that it is compromising the patient's activities of daily living.

    Now, if they're non-ambulatory, I think that shortens their list of activities of daily living, but they're still doing – they're still brushing their teeth. But again, you see what I mean about, this is a very bad toenail that's going to impact these non-ambulatory patients' activities of daily living. If they qualify via this pathway with onychomycosis and one of the secondaries, what's the name of the whole policy? Debridement of mycotic nails, which means if they qualify via this pathway with onychomycosis and one of the three secondaries, we can only use the debridement codes. The two that are listed here. It's debridement of mycotic nails is the name of the policy, we can only code debridement.

    Then we come to the third policy. And then the question is always, it came up in the prior talk, do we have to send specimen? For Noridian States, the answer is no definitely, no question.

    [18:00]

    If you're in any of the Noridian States that we listed, including Part B, including California, you do not have to send specimen that says, "Clinical evidence." You have to document that onychomycosis and you should have a good, healthy description of it, right? Thickness, color, subungual debris, odor, whatever you do to document the presence of that onychomycosis. Your friends in other States, in other parts of the country via that pathway, do have to send. I have to send in Colorado. You do not in California. If you want to diagnose what they have because you want to consider treatment, by all means, do it. We're just saying, just to qualify them by that pathway, you don't have to send.

    Then, this third policy, which is unique to Noridian, the Noridian States are the only ones in the country that have this. So when you have a friend in New York that says, "You can only trim a callus if they have diabetes" or whatever they say. It's different for you and it is a good thing. This is cool that you guys have this. This deals with pairing of systemic hyperkeratosis, which in our language, at least for me is corns and calluses. Just unique to Noridian, they do not need to have an at-risk condition via this pathway. They need to have a corn or a callus and it must be symptomatic. They have to be complaining of symptoms. There's got to be something there, not just, "Can you remove that thick thing on my baby toe? It's got to hurt." Right? Or it makes it difficult to walk or limit shoe gear.

    The presence of a hyperkeratosis with documented symptoms, you can take care of that callus, interesting little thing in your policy if you take care of that callus by debriding it. That's the word that I use, but we agree, you take scalpel and get rid of it.

    [20:02]

    I'm having a hard time not using the word shave, because that's part of my vocabulary, and part of my documentation but that's a very important point here. If you pair a callus by this pathway, it says right in the LCD, this is not for shaving, excision or destruction. Because in their mind, those are different codes. We call it – I shaved down a callus sub 1 on that patient. Don't do that in your documentation because they are not covered under this policy for callus care if you shave it. It has to be pairing or cutting. It's not my language when taking care of calluses, but it should be yours when documenting this via this policy to get them covered for their symptomatic calluses.

    In order for them to be covered under this policy, you need to have two things. One of the lists on the left and one of the lists on the right, which is pretty simple. That's a long list on the left, there's 19 of them there, but there's two really important ones for our purposes. One is calluses, LA4.0 and the other is keratomas because that's when we're doing this, right? QA2.8.

    So, this is the patient who, right, like the healthy, 45-year-old person that wears tight shoes, that has a painful corn on their dorsal right fifth PIPJ. Rest of the country can't get paid for that, you guys can, right? Because they have one of the lists on the left and one of the lists on the right and the easy ones there are pain. So systemic hyperkeratosis, that's the third pathway. Again, three different pathways. If you cut somebody's toenails and/or shave a callus, you have to ask yourself, which of these three pathways do they qualify under?

    [22:03]

    Code it properly and document it properly. Do you guys have something else before people ran out? Is there like a raffle or something? Can I take two minutes of questions because I feel like there are some? Doctor?

    Unidentified Male Speaker 2: [Off-Mic].

    Unidentified Male Speaker 1: Okay. So Doctor said, "What if you use the word reduction of calluses via that third pathway?" I think it is acceptable. My suggestion to you is use their words. They gave you two, that's very much what the auditor is looking for. And when an auditor shows up, this is probably going to be on their piece of paper. I wouldn't leave it up to them to trust them to interpret it. Now, most auditors are somewhat reasonable and you could say, "Come on. What do you think I meant by reduction?" But why chance it? I would use their words in their face and they know – you know, this doc knows what's up. Please?

    Unidentified Female Speaker 1: [Off-Mic].

    Unidentified Male Speaker 1: I didn't hear you. The 11719?

    Unidentified Female Speaker 1: [Off-Mic]

    Unidentified Male Speaker 1: Okay. So the question was, 11719 is trimming of a non-dystrophic toenail via the routine foot care pathway, which diagnosis should be pointing to that? It is the diagnosis that qualify them. So we showed the list of the five potential qualifying diagnoses. One of those five should be the one pointing to the 11719. I do a secondary of L60.8 for hypertrophy of nail, you don't have to. There were some – doctor?

    Unidentified Male Speaker 3: [Off-Mic].

    [24:01]

    Unidentified Male Speaker 1: Yeah.

    Unidentified Male Speaker 3: [Off-Mic].

    Unidentified Male Speaker 1: Doctor asked, if somebody has really thick painful nails, and that's their only thing, is that there's pain and the nails are mycotic?

    Unidentified Male Speaker 4: No, dystrophic.

    Unidentified Male Speaker 1: Okay. So this is a good one, right? So thick, crazy nails that require debridement, they don't have onychomycosis. Maybe you sent specimen and it came back negative. They don't have class findings. They don't have a qualifying at-risk diagnosis. Even though they're really, really, really thick, and even though they're painful, in the absence of mycosis, and class findings, and at-risk diagnosis, is that covered? It's not covered, right? Two different pathways. One is class findings plus qualifying diagnosis. The other is onychomycosis plus one of the three secondaries.

    If they're really awful and they require debridement and they're painful, but there's no onychomycosis, it's not covered. Is that fair? No, it's crazy because they can't do it themselves and I wouldn't want the person at the nail salon doing it for those thick, crazy nails. But if it's not mycotic, it's not covered. That is further complicated by the fact that we get, and the labs tells us this, a lot of false negatives. So send good specimens. Too often, that stump doesn't grow, it comes back negative. Now, they're not covered. That is a cash service. In my line, that works. Always blame it on them, right? Don't say, "I can't do it. We can't do it." I say, "The rules are crazy. The rules are terrible but given what you have here, they don't cover it. I have little kids. My wife is going to be mad if I go to prison. We follow the rules and I want to do this for you. I think you should have it done. But if you do it here, they make you pay cash for it."

    [26:06]

    They, of course it's me, but that's my line. I find that it works. It normally gets a smile and I've had no problems with it. Now, when they say, "But the person I was going to for the last five years did it." Well, sure, they weren't making up class findings over there or something, right? I'd say, "I can't speak for what they were doing down the road. I know the rules really well. I follow them and that's how we roll here." And if they don't like that, you don't want them anyway. Let them go somewhere else.

    Unidentified Male Speaker 5: [Off-Mic].

    Unidentified Male Speaker 1: Okay. The question was about mycotic versus dystrophic. There are two different pathways. One is routine foot care, one is mycotic nail debridement. If they qualify via routine foot care, dystrophic is fine, right? We talked about all the different definitions.

    Unidentified Male Speaker 5: [Off-Mic].

    Unidentified Male Speaker 1: Let me finish that thought. If they qualify via the mycotic nail debridement pathway, they must have onychomycosis. Dystrophy gets you nothing via the mycotic nail debridement pathway.

    Unidentified Male Speaker 5: [Off-Mic].

    Unidentified Male Speaker 1: Okay. So Doctor asked, we said that via the mycotic nail debridement pathway, you needed to have clinical evidence of onychomycosis. Is dystrophy clinical evidence of onychomycosis? Dystrophy alone, no. They're looking for color, odor, debris, thickness.

    Unidentified Male Speaker 5: How about thickness and discoloration?

    Unidentified Male Speaker 1: All right. So Doctor said, what about thickness and discoloration? I think an auditor would buy it. But why cheat it, right? If it's mycotic, it's mycotic. Document them. Why do two if you could do five, right? Yellow discoloration, subungual debris, crumbling on debridement, characteristic of smell consistent with onychomycosis. Make it very clear to them that you're doing what needs to be done. Please?

    [28:12]

    Unidentified Male Speaker 6: [Off-Mic].

    Unidentified Male Speaker 1: Yeah.

    Unidentified Male Speaker 6: [Off-Mic].

    Unidentified Male Speaker 1: Yeah.

    Unidentified Male Speaker 6: [Off-Mic].

    Unidentified Male Speaker 1: Yeah.

    Unidentified Male Speaker 6: So how would you feel like you can't separate?

    Unidentified Male Speaker 1: Oh, okay. I have a 30-minute lecture on this, which I'm not going to do right now. The question was, brand-new patient gets their toenails cut but they also get a 99203. If the only diagnosis pointing to the nail care is the qualifying diagnosis, because it was 11719, what do you point to the 99203?

    Unidentified Male Speaker 6: You repeated the question.

    Unidentified Male Speaker 1: I know, I repeated it so everybody else could hear. For new and established patients, let me change my emphasis. For established and new patients, you cannot code an E&M along with the procedure unless that E&M is separately identifiable from the procedure, established and new. Which means, there is no such thing as an automatic E&M along with the nail care just because they were new.

    Now, I have had zero visits in my career of 17 years where I have a new nail patient that didn't get an E&M, but you have to follow the rules. Just because they're new, it doesn't automatically mean they get an E&M. There must be a separately identifiable E&M. Like I said, I have another 28 minutes to define that.

    [29:57]

    But briefly stated, separately identifiable means, you can pull all of the components of the E&M out of that note and separate them from the procedure components and put it somewhere else, and you would still have a full E&M over here and a full procedure over here with no overlap. And the great majority of the time, in order to have that, you have to have a different diagnosis and your note needs to support that.

    If the plan, SOAP, if the P of your SOAP note on this new patient visit is, patient has class finding and is at risk for pedal pathology, therefore I trim toenails one through ten and they should come in ever 61 days for that. That's a procedure note. There's no M. To have the E&M, you need the M, you need to manage something. So, maybe it is onychomycosis. The first time, you can certainly manage that. Potential ideologies, treatment options, risk and benefits of these treatment options, considerations for treatment. I do a lot of xerosis, hyperhidrosis, tinea pedis, crooked toes, so all kinds of stuff.

    If you get done with all the nail stuff and nothing has come up and you say – and don't cringe because this is good care. And you say, "Is there anything else you've always wanted to ask about, about your feet or lower legs?" Are they going to say something? Heck yeah, they are. So there's your separately identifiable E&M.

    Or even a little crooked toe, right? I see your baby toe is crooked, how's that – and they go, "No, no, no, I don't want – I just want my nails cut." "Okay, cool. Just so you know, that's a hammered toe. If it ever bugs you, you could do wider shoes, put a pad on it. If it's ever a problem, let me know. There are options." You just managed a hammer toe.

    Unidentified Male Speaker 7: [Off-Mic].

    Unidentified Male Speaker 1: Doctor asked, "Would you put a 25 modifier on the separately identifiable E&M?"

    [32:00]

    For the most part, and now this is a CCI edit lecture, for the most part, only if they are established and you don't need to do it if they're new. There are some exceptions to that but the real answer comes in looking at the CCI edits. Established, yes, most of the time. Most of the time for new, you don't have to. Let's do one more. Please?

    Unidentified Female Speaker 2: [Off-Mic].

    Unidentified Male Speaker 1: Yeah. Right.

    Unidentified Female Speaker 2: [Off-Mic].

    Unidentified Male Speaker 1: Okay. Doctor asked, "We only – the LCD, your LCD only lists five qualifying diagnosis. Does mean we shouldn't be using others?" They must have one of those five diagnosis, and you have to document the presence of one of those five. The four that were on the first page and then one of that long list of different types of neuropathy.

    Unidentified Female Speaker 2: [Off-Mic].

    Unidentified Male Speaker 1: Right.

    Unidentified Female Speaker 2: [Off-Mic].

    Unidentified Male Speaker 1: Right. Doctor said, "But I've seen online really, really long lists of qualifying diagnoses." Which is why my very first slide was to talk about the fact that there are different carriers in the country, seven of them. New Jersey has a really, really, really long list. Minnesota has a different list. You, your list in all of those Noridian States, I put them up there, California, Nevada, Arizona, whatever it was, five options.

    National articles that list long things can't cover all the different regions because there's seven of them, so your patients need to have one of those five. Thanks for your attention, guys.


    TAPE ENDS - [34:09]