Section: CME Category: Practice Management

Big Coding Changes for 2019

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 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: Why don't we finish up with our last lecture? I'm going to introduce Dr. Jeffrey Lehrman. He's not quite from Washington as [Gabe] [00:05] had mentioned but he's actually from Fort Collins, Colorado. He was named recently as one of America's Most Influential Podiatrist, Expert Panelist in Codingline. He's a consultant of the APMA Health Policy and Practice Department. He's also an Adviser to the APMA Coding Committee, APMA Macro Task Force. He's also sitting on the board of directors for both the American Professional Wound Care Association and American Society of Podiatric Surgeons.

    And he's also an adjunct clinical professor at the Temple University School of Podiatric Medicine. You know what that means, is he really knows coding and billing, and that's why we have him here. So we're really excited to hear from him. So let's introduce Dr. Lehrman.

    Jeffrey Lehrman: Thank you. Good afternoon. Every year, we get brand-new ICD 10 codes that go into effect October 1st, and brand-new CPT codes that go into effect January 1st. Sometimes we get changes that we don't care about and aren't pertinent to our care as podiatrists. Sometimes we get significant changes that largely impact our practices. This was one of those years. So we have a lot of important changes, additions, deletions, revisions that we need to know in our practices. I have made my slides available. You're going to have them so we're going to go through a lot of codes here. Don't feel like you have to write them all down. You certainly can if you want and taking pictures is welcome, but I did share the slides already. You will have them.

    So we'll go through to the ICD 10 changes first and then we'll get to the CPT changes. So these are brand-new codes that are listed here, something to be aware of. We're now up to 10 States in our country where marijuana is legal so this may become more of a thing. As with any other coding that we do, you only need to code it if it's pertinent to that visit.

    [02:02]

    So the fact that it's there, it doesn't necessarily mean that you need to code it. But if it plays a role in the visit, if it plays a role in decision making, then you should code it. These codes gave us greater specificity when it came to muscular dystrophy. Before, what we had were just generalized muscular dystrophy codes and we did not have specific code for Duchenne muscular dystrophy, specific code for Becker muscular dystrophy, so we now have those if that's something you encounter. Be aware, we now have these more specific codes. This is a brand-new ICT 10 code, which I think we will use as podiatrists. I've used it already and we've only had it for a couple of months, an abnormal finding on a diagnostic x-ray or diagnostic study.

    And the example I give and the way I have used this is maybe you have an x-ray. You see something isn't right but maybe we don't know exactly what it is. And in my case, ordered a different study. So if it's something funny off of the first metatarsal neck medially, not sure what that is, going to order a CT scan to further evaluate. Well now, we can code that, and a code to go along with the fact that we saw something weird, don't have a diagnosis code for it, but we can code the presence of something abnormal on that imaging study.

    These were also codes that I think we will use as podiatrists. Prior to these, we weren't able to really specify a post-operative infection. And now especially I think that second bullet and third bullet, are codes that we will use if we know that it's a post-op infection involving the superficial closure site. And then, the third bullet, post-op infection involving a deeper closure site. And hopefully, we don't encounter this but with that fourth bullet if we have sepsis, following one of our procedures that we are involved in the management of, we now have a code to go with that.

    [04:05]

    The blank means it requires a seventh character. I think everybody gets that by now. These go back to the muscular dystrophy codes. This is really a repeat of what was on that other slide, indicating that this is what we had before. These all now, starting October 1, 2018, require a fifth character to complete the code and I showed those already. I'm sharing this just for completeness. I don't think we're using these. We use the L97 codes for diabetic foot ulcer, stasis, ulcer. Just in case you're using these, they added of skin. Not that we really know what other type of chronic ulcer there is, but just to be thorough, I wanted to include this in case anybody is using these.

    So those are the ICT 10 changes. CPT changes, much more impactful to our practices. And this is probably the biggest one because podiatrists use this code a lot. The code that we have been using for punch biopsy for all of our careers, is gone. It was deleted. It no longer exists. If you have an old CPT book on your desk, you need to make a change. You should be using a live resource that updates everyday but I know not everybody is, and if you have a 2011 CPT book on your desk, and I know there are people in the room that do, you need to make this change.

    This code does not exist. This is not just one State. This is not just Medicare. This is CPT. The code is gone. It doesn't exist. Get out of your book and never use it again. The code is gone. It was replaced by brand-new biopsy codes. These are brand-new codes that went into effect January 1. You must know these codes because we're doing this, especially the punches.

    [06:02]

    So we have a new set of codes for a tangential biopsy. That's a shave in our language. We have a new set of codes for a punch biopsy and a new set of codes for incisional biopsy. An incisional biopsy is when there's a larger growth and we cut a smaller piece out of it. I think a good example of that is cutting any lips out of what is a larger lesion, a larger growth. We cut any lips out, put a suture to in it depending on the size. That's in incisional biopsy.

    So starting with our shave. These are our brand-new codes for a shave biopsy. If you do lighter with that B and raise a wheel, and take a 15 blade, or a 10 blade, and turn it on its side tangentially and scoop out that lesion, performing a shave, these are your codes. Or that cool bendy shave blade that we can use to kind of scoop under that, create a concavity, these are our new codes. If you perform one shave biopsy, the code is 11102. There is an add-on code for each additional. So if you do more than one shave biopsy, now there's an add-on code to indicate each additional shave that you do.

    Hopefully this room already knows add-on codes, by definition, should never have a 59, a 51 or an X-modifier. So they only come into play when you do multiples. If you do multiple shaves, 11102 for the first one, and then 11103, the number of which should reflect how many additional shaves were done beyond the first. It does not matter if it was foot and leg. It doesn't matter if it was two spots on the same foot, left foot, right foot, it doesn't matter.

    [08:02]

    If you do more than one shave, 11102 for the first one, and then the add-on code for each additional. Also, brand-new codes for punch biopsies, and this is the one we're probably going to use the most. 11104 for the first and again, an add-on code for each additional. So let's give an example, just to make sure we're clear on how these add-on codes work. Let's say you do three punch biopsies. And again, it doesn't matter if it's two on one foot, one on the other, maybe there's one big giant growth on the right calf and you do three punches from the same growth. If you make three holes, you did three punches, regardless of where those punches were performed.

    And if you perform three punch biopsies, the appropriate coding would be 11104 on the first line, one unit. Line two, 11105, two units, because we did two additional, and a lot of people are shaking their heads, which is great. That means you get it. People mess this up and we have people that ask, "I did three, I coded 11105, three units and it didn't work. Why not?" Well, you need the first one. You always need the first one. And then, you add for each additional beyond the first one. So a total of three means one for the first and two for the add-on, two units.

    And then finally, incisional biopsy. Again, means cutting a full thickness. This is a real deal full thickness incision, right? Cutting a smaller piece away from what is a larger growth, one for the first one, add-on code for each additional. So some people walked in after we took a short break and I'm going to say it again, 11100 and its add-on code, do not exist. Delete them. Get them out of whatever book, super bill, whatever you have on your office and replace them with the new one.

    [10:07]

    We also have brand-new fine needle aspiration codes. A bunch of brand-new fine needle aspiration codes, which I'm going to go through and I'm going to share with you. However, before we do that, it's important to define, what is a fine needle aspiration and what is not a fine needle aspiration? Because we have a lot of podiatrists incorrectly using this fine needle aspiration code. We can perform fine needle aspirations. I'm not about to say podiatrists should never code fine needle aspiration. That is not the message.

    However, the message is only do it if you do it, and what this goes to is aspirating a ganglion. If there's a ganglion cyst and it is aspirated, the question is often asked, which of these two codes do we use? So it depends on your technique. It depends on what you do. I think most of us, I think, do the following, ganglion cyst, little, local, right? V-block, maybe just a wheel under it. Stick a needle in it. That's attached to a syringe. Pull out the juice. Send it for path, which you should. That's good risk management. Maybe make a couple of holes in it to pop it. That's aspirating the ganglion.

    And then, the question is, which code should we use? Is that a fine needle aspiration? Well, you have to choose from one of the two codes that's listed here, and the guidance in coding is to pick the code that most accurately reflects the procedure that was performed. Well, look at the second one. We can leave out the and/or injection. Just pretend you didn't do an injection when you were done. It says, aspiration of a ganglion cyst. If your note says, patient had a ganglion on their dorsal midfoot, and I aspirated it, that sounds like the right code.

    [12:03]

    But let's look at fine needle aspiration just to be thorough. And what you can see is the first bullet kind of sounds like what we're doing, but look at the second one. It very clearly says, fine needle aspiration should only be used if what you did cannot otherwise be achieved by standard diagnostic technique. So does what I describe, sticking a needle that's on a syringe into a ganglion, and pulling the stuff out, qualify as a standard diagnostic technique? I think so. If you care, the consensus opinion of the APMA coding committee is the same, that if you do what I described, if you do it by that technique, that is not a fine needle aspiration.

    When you look at fine needle aspiration in the literature, this is what you see. All of this stuff, and just to hammer home the point to really sell it, if you go on PubMed, and yes I did this, and you search fine needle aspiration and go through the first 1,000 results, there are zero mentions of ganglions. What you see is all of this. You know, not that that dictates coding, but that to me gives a really good clue here.

    So to go back, if you aspirate a ganglion, you're probably using the second one there, depending on what you did. Now, I've done the same thing and heard a week later, "Lehrman said podiatrists can't do fine needle aspirations." That's not the message. The message is pick the right code and we can do fine needle aspirations, and I think a good example is something on maybe the plantar foot that looks like a plantar fibroma, and you're not sure that's what it is and you want to be sure. And maybe numb it up, hard to get stuff out of that, but sometimes if you inject a little bit of the formalin in there and then pull out some cells, you can send that.

    [14:05]

    That's probably a fine needle aspiration if you've met the description of the code. So we can do it. Just don't over utilize it. A lot of podiatrists are improperly using that code when really what they're doing is aspirating a ganglion. And we have a more specific code that describes that. So if you do perform fine needle aspiration, now we can give you the new codes for fine needle aspiration. There's one set of codes if you perform fine needle aspiration without imaging guidance, and another set of codes if you perform fine needle aspiration with imaging guidance. So what's here is if you perform fine needle aspiration without imaging guidance.

    If you have that thing that looks like a plantar fibroma that I described, and you're going to stick a needle in it and pull stuff out to send for cytology with no imaging guidance, because you don't need it with what I described. We can see it. One code for the first one. If you do more than one, there's an add-on code for each additional with the same lesson regarding how to use add-on codes that I said previously. So this is fine needle aspiration without imaging guidance. And then, we have four brand-new sets of codes. Two for each because of the add-on deal for fine needle aspiration with imaging guidance.

    I'll go through this quickly. You have the slides. Fine needle aspiration with ultrasound guidance for the first one. If you do more than one, we have the add-on code for each additional. This applies to anything that you do with ultrasound guidance. When you do it and you ask yourself, "Can I code both? Can I code for the procedure and the ultrasound code?" The answer comes from going back and looking at, is there a code that describes that procedure with imaging guidance?

    [16:04]

    And if there is, you can only do that one code. If there is not one single code that describes that service with imaging guidance, then you get to do both. Then, you can code for the service and the ultrasound separately if there is not one code that includes both. This of course includes both. So if you do this one, code. So fine needle aspiration with ultrasound guidance, there's also a fine needle aspiration with fluoroscopic guidance. I think we're getting into stuff most of us aren't doing now. One for the first, add-on for each additional. Two more sets, fine needle aspiration with CT guidance, first, each additional, fine needle aspiration with MR guidance, first one, and then each additional. So those are the brand-new fine needle aspiration codes.

    This is a really good one, I think, because traditionally for us, if we've put graph in, in the operating room along with their procedure that we're doing, we've really only been able to code for it if it's autographed. And if we took something off the shell of out of a box and put it in there, we couldn't separately code for it. Well now, there are situations where we can, which is great, because I think we should be able to code for that. That involves work sometimes, right? Getting that piece out, remodeling it, sometimes changing the shape of it to make it fit. But read the whole description of the code here, allograft, and it must be osteoarticular. So there has to be some joint surface there.

    Allograft that involves joint surface, we can do it, and look right in the description of the code, in addition to the code for the primary procedure. I think that's great. So I thought of first med head resurfacing maybe, probably more likely talar dome stuff, right? If you drill out a talar dome and have an allograft that has osteoarticular, got to have joint surface to meet the description of the code, and stuff it in that talar dome defect, we can code for that now, which I think is great.

    [18:14]

    Probably not as common here the next two. This one is allograft which has to be hemicortical intercalary and the last one, same deal allograft, but it has to be intercalary complete. So I will probably not use in number two and number three there, but that first one, if it's osteoarticular, that's fantastic. This is a big change. This was in some of our country's LCDs but now is in the CPT book. We cannot use the skins of application codes anymore anywhere if we are using any of these forms of that skin substitute product.

    So some of these skin subs come in a flowable form, right? Like the powder that's in the syringe, and then you get another syringe with the saline and mix it up, and it's flowable, and we can squirt it under tunneling ulcers. It does not qualify for the 1527 codes anymore, nor do the powder form. So the flowable, the powders, any of these alternative forms that are listed, we cannot use that and then code for skin sub application. So that's an important point for many of us. Our skin sub people are telling us, "This is great, it's flowable." Squirting in a tunneling wound, that's super don't do that, and then code 1527 whatever, right, depending on foot or leg. 15275 is what we're doing most of the time for foot. So that's a big change for us. Very few people were using this and chances are excellent. Nobody in the room was using this code.

    [20:00]

    But just in case you were, 20005 no longer exists. Do not mistake this with 28005, which we do use a lot. That's IND of bone. 20005 has been deleted just like the 11100. Delete it. Get it out of book. It doesn't exist anymore. Never use it again. Small change here to home, E&M services, it used to be a private residents only. Now, no wonder what occasion you would be doing this, but just in case, you're providing E&M services in hotels, camp grounds, hostels or cruise ships, that now counts as a home E&M. So be aware. Take your doctor bag on a cruise ship with you.

    This is a great change for us. How many times do you have an ED doc call and say, "Hey, can you log in to the PAC System, look at this x-ray, and then tell me what to do with this thing, and we do it for free?" We can now code for that if, there's an if here, some people are stopping there and not going further. There's more that has to be done. So this is phone or online, HIPAA-compliant online, or via the EHR, providing a consultation to another doc, and this is the important part, and providing a written report. So that situation I described about the ED doc, we're normally not writing notes when that happens. We should be. Our risk management carrier wants us to, right?

    If something bad happens and the ED doc said, "Well, I called him and he said to do whatever," and we didn't document, that could be bad. So you could argue. You should be documenting those conversations with the ED doc or it doesn't have to be ED. I'm just using that as an example anyway, but if you do, get the patient's info.

    [22:04]

    Get the face sheet from the emergency department or whoever else is calling you, and code for it. That's a service we're providing and now we can code for it, which is awesome. So there's one for five minutes. There's one if you go over 30. So five to 29 minutes, one code, 30 minutes or more of time spent doing that. That's a lot of time, but if you do, there's a code for that.

    These are the codes of Dr. [Castleman] [22:29] mentioned, which deal with remote monitoring of physiologic parameters. So when can we do this? There's no list of devices that count but we can do it if the device which is providing the information that we're monitoring is approved by the FDA as a medical device. It has to be a medical device. So if there's a manufacturer that's saying, "Here, use this. You can use the remote monitoring codes." The question is, is that considered to be a medical device by the FDA? And if it is, then we can do it, and I totally agree with what Dr. Castleman said, now we have this fancy inserts that go in shoes that send back signals about pressure or temperature, or steps, or whatever we're monitoring.

    If that has FDA approval as a medical device, we can code for that, which is super, because a lot of them do. They're on the market right now and we can be doing this. I think this is a nice practice management add. So if you employ those devices, there's one code, first one that's listed there, again, these are brand-new, for the initial setup and educating the patient, which you can only do once per episode. Then, there's another code for when you actually dispense it and give it to them once per episode.

    [24:02]

    And then, once you've educated them and they have it, and they're rolling with it, now it's providing feedback every month that you or your trained staff spent 20 minutes or more monitoring what's coming back, and have at least one live communication with the patient regarding that feedback, you can submit this code. So again, they have the medical device. It's providing feedback that you can monitor somehow. It's getting beamed into your EHR or it's sending a report, whatever, right? Different toys have different ways that they work, and you spend 20 minutes or more in that month monitoring, and at least one story in a month have an interactive communication that can be in a HIPAA-compliant texting or phone call, or whatever, you can code for this.

    So think about you get 20 patients or more rolling with this and now you're doing this every single month, month after month after month, I think that's a nice add. So this is very new. I'm sure none of us are doing this yet but when you encounter that technology, or maybe you seek it out after knowing this as an option, nice to know these new codes exist. We also have a brand-new code for ESWT for wound care. This is becoming a much bigger thing in the wound care world. There's literature supporting the use of ESWT for wound care. There's a code for this.

    If you use ESWT for wound care, brand-new code. For the first wound treated and then another one for each additional, and that's another add-on code. With the addition of the ESWT for wound care code, they went back to the one that we've typically been using for muscular skeletal purposes and just added not for integumentary procedures because we have a new one for ESWT, for integumentary procedures.

    [26:06]

    "Is there a code for subtalar arthrodesis?" Something we get asked all the time. The answer is, yes. Do not use the other code. Don't use arthrodesis, which a lot of people do, because they think, "Oh, it's close enough." That will fail an audit every single time. There is a code for subtalar arthrodesis. It's a category three code but it exists, which means we're supposed to use it. This is our code for subtalar arthrodesis. You can see the description changed a bit and then we got brand-new codes that went into effect 26 days ago.

    One code for taking one of those out and then there's another code if you take one out and put another one in, one code removal and replacement, one code. So maybe it's a kid that gets older and the thing gets loose and it needs to be removed and replaced, one code that brand-new category three code. What happened with the E&M thing, right? I'm getting asked this a lot. Whatever happened with that? So let's talk about what was proposed and what was finalized, which are two very different things. So what they proposed was to take new two through five and consolidate the payment for any of those codes to one number, and take established two through five, and consolidate the payment for any of those to one number, except for podiatrists.

    And they proposed to take us only out of that and give us our own E&M codes that would have reimburse less. That is not happening. We won, right?

    [28:00]

    There was a tremendous effort by many, many, many parties and organizations, and people, and mostly us because we wrote the letters and clicked the button that our society send out to submit those letters and we won. This is not a temporary delay. I've seen this incorrectly reported and written that it's a temporary thing. It might come back. This is a final rule. This is not happening.

    If you read the final rule, they almost went so far as to apologize to us, right? It says in there, I don't have it memorized, something to the effect of, we do not intend to make it look as though the services podiatrists provided are less than or something like that. It's not happening. It's a final rule. It's in the Federal register. It's not a temporary delay. So what is happening? This is referred to earlier and I'm going to get to what's on the slide here. I'm not speaking to this yet. What is happening is January 1, 2021, not next year, January 1, 2021, if you submit a 99212, 213, or 214, it's going to pay the same number. If you submit a 99202, 03, or 04, it's going to pay the same number.

    The good news for us is that number is going to fall between what would have been the payment of a three and a four, which means for us, our average E&M reimbursement is going to go up by 10%, which is awesome. This is not something we want to crow about. We don't want to rub it in their faces but we'll take it. It's not what we asked for but that's great. That's super. That's tremendous. The other good thing, notice I left out five. Fives will continue to stand on their own. We've typically, not just we, any specialists that focused on one area of the body, had a hard time getting to a level five given the E&M documentation requirements, but that's something else that's changing.

    [30:12]

    January 1, 2021, we will be able to select our E&M level based on medical decision making only if we choose to. And those of us like podiatrists that do focus on one body area, we'll have a much easier time getting to a level five. So good all the way around for us. None of that is coming until January 1, 2021. And those of you that stuck it out until after 3:00 in a Sunday, make sure you get the terminology right. People are saying this wrong. They're saying it's a consolidation of the E&M codes. That's not true.

    It's a consolidation of the payment for some of the E&M codes. So sound like you know what you're talking about. They're not consolidating. It's stupid, why keep two, three and four if they're going to pay the same, and the documentation requirements for them are the same, but they're keeping all the codes as weird as that is? Properly stated, the payment for those codes is being consolidated. The codes are not being consolidated. So a couple of small things did change effective now. Some of these at first sound really good but when you read the whole thing, I think it's actually not that big of a deal, especially if you're using EHR.

    So this is what went into effect now. For established patients, you do not need to rerecord E&M bullets, right? We count up bullets of history or present illness, exam bullets, past medical history, stuff like that. If, this is the part people are missing, if there's evidence that the doc reviewed the previous information and updated it as necessary. So what does evidence mean? How do we show evidence that we reviewed it? Document that you reviewed it.

    [32:08]

    And in my mind, just the way my practice works, if you're using EHR, by the time you document, I reviewed the past medical history and the vascular exam from the visit of two weeks ago and there were no changes. You could have just carried over those components of last time without putting that sentence in there.

    So I think for most of us, this isn't a huge deal and I don't think it's as good as it originally sounds because you need that evidence that the practitioner reviewed what was done before and updated it as necessary. So if you're doing paper notes, then by all means, this is huge. But for those of us that can very easily carry over from last time, I think it's not such a big deal. All the same, good thing to be aware of.

    For new, and this is kind of the same deal here, for new and established patients, if information was entered by the staff or the patient, like maybe you have an EHR where they can answer the review of systems, questions in the waiting room, or even before the visit, we don't have to re-document that if we indicate that we reviewed it and verified that it was correct. So we still have to acknowledge that it was done. We certainly don't need to redo the whole thing. So that might be a nice change again depending on how you are documenting. If you're training residents, this is a really good one.

    Now, your hospital may have a different set of rules, right? Your hospital bylaws may say, if the student or resident writes a note, you have to redo the whole thing. That's a different set of rules, but for Medicare purposes, for E&M coding, if a resident or other member of the medical team, like a PA who might round ahead of you or something like that, writes a note, you no longer need to re-document that stuff. You don't have to make that notation of, I reviewed the above and agreed with whatever you were doing.

    [34:08]

    For coding purposes, you don't need to do that. You can just sign it. So if you're training residents, that's cool. For those of you that are performing home visits, this is a big change. Before they had to be home-bound, this was a whole thing that we need to document that they were home-bound. And if we found out that they were at their orthopedic surgeon two days prior, that would be a big problem for us. If we are providing home visits, we no longer need to demonstrate the fact that they are home-bound in order to perform a home visit. So that's a nice change.

    Thanks for your attention on that one. Can you…

    TAPE ENDS - [34:44]