Tips to Maximize Podiatry Practice Reimbursement

Podiatrists specialize in diagnosing and treating conditions and function of the foot and ankle. Podiatry billing and coding is complex as procedures and services related to the foot are very specific because of medical necessity requirements and restrictions on the conditions that can be treated. Moreover, as experienced medical billing and coding companies know, insurance companies have specific and rather rigid coverage regulations with regard to nail debridement, treatment of corns and calluses, flat foot, and bunions, and many other conditions, which make it difficult to get claims approved. To maximize reimbursement, podiatrists need to understand what will be covered, choose the appropriate codes for their services, and ensure clean documentation.

First, it is crucial to stay current with coding changes. In 2017, the AMA introduced several key changes in podiatry codes, which included additions, deletions and revisions.

Podiatry CPT Code Changes effective January 1, 2017

New codes

Two new codes were added:

• 28291 – Hallux rigidus correction with cheilectomy, débridement and capsular release of the first metatarsophalangeal joint; with implant
• 28295 – Correction, hallux valgus (bunionectomy) with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method

Deleted codes

Three bunionectomy codes were deleted effective January 2017, so as to remove all proper names from code descriptions such as Austin, McBride, etc., and correctly describe the services as they are currently performed:

• 28290 Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (eg, Silver-type procedure)
• 28293 Correction, hallux valgus (bunion), with or without sesamoidectomy; resection of joint with implant
• 28294 Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (eg, Joplin-type procedure)

Revised codes

• 28289 – Hallux rigidus repair without implant. Note: This previously read with or without implant but 28291 (see above) was added for the procedure with an implant.
• 28292 – Bunionectomy with sesamoidectomy with resection of proximal phalanx base
• 28296 – Bunionectomy with sesamoidectomy with distal metatarsal osteotomy (new code 28295 is now used for proximal metatarsal osteotomy – see above)
• 28297 – Bunionectomy), with sesamoidectomy with first metatarsal and medial cuneiform joint arthrodesis
• 28298 – Bunionectomy with sesamoidectomy with proximal phalanx osteotomy
• 28299 – Bunionectomy) with sesamoidectomy with double osteotomy
• +77002 – Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). Note: The previous description did not designate this code as an add-on code.

Deleted codes

The following CPT codes were deleted:

• 28290-Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (eg, Silver-type procedure)
• 28293-Correction, hallux valgus (bunion), with or without sesamoidectomy; resection of joint with implant
• 28294-Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (eg, Joplin-type procedure)

Know Coverage Policies

Medicare Part B (Medical Insurance) covers podiatrist services for medically necessary treatment of foot injuries or diseases such as hammer toes, bunion deformities, and heel spurs. Part B generally does not cover

• Treatment of Flat Foot.
• Routine Foot Care, for e.g. cutting or removal of corns and calluses; trimming, cutting, clipping, or debriding of nails, hygienic or other preventive maintenance, including cleaning and soaking the feet
• Supportive Devices for Feet: Medicare will not cover orthopedic shoes and other supportive devices for the feet, unless it is an integral part of a leg brace and its expense is included as part of the cost of the brace. Also, a narrow exception permits coverage of therapeutic shoes and inserts for certain patients with diabetes.

Usually, Medicare pays for 80% of the costs and the remaining 20% is paid by the patient and deductibles apply. In a hospital outpatient setting, patients also pay a copayment for medically necessary treatment.

Exception: Medicare may cover routine foot care when systemic condition(s), such as metabolic, neurologic, or peripheral vascular disease, results in severe circulatory embarrassment or areas of diminished sensation in the patient’s legs or feet.

The following services may also be covered:

• The treatment of warts (including plantar warts) on the foot
• In the absence of a systemic condition, treatment of mycotic nails may be covered. The treatment of mycotic nails for an ambulatory patient/non-ambulatory patient based on the provider’s documentation.

Value-based Reimbursement and Podiatrists

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) aims to integrate value-based reimbursement into the Medicare system. Under MACRA payment reforms, podiatrists, like other providers, can choose between two reimbursement models: the Merit-Based Incentive Payment System (MIPS) or an alternative payment system such as an accountable care organization (ACO), patient-centered medical home or bundled payments. According to an article published in Podiatric Economics in 2016, the answer as to which program is best will differ among podiatrists and in most cases, will be impacted by factors such as a practice’s location, patient population, and EHR set-up (or lack of it)

However, though private insurance companies may still pay based on the fee-for-service policy, experts point out that the emergence of tiered health plans shows that private payers are beginning to factor value into payment. In this changing reimbursement landscape, podiatrists need to take proactive steps to protect their bottom line:

• Steer clear of coding errors: According to a recent report in Becker’s ASC Review, the coding errors commonly seen in podiatry and certain other specialties include:
• Coding from the operative note title rather than reading the operative note body, leading to missing other billable procedures performed during surgery
• Not coding to the highest level of specificity
• Not coding for bilateral procedures
• Not coding for multiple procedures where allowed
• Using wrong or non-specific diagnosis codes
• Unbundling or up-coding
• Failure to append sufficient modifiers
• Not coding for billable supplies or equipment usage
• Not using current/updated code sets

Podiatric practices can stay on top of the game by outsourcing medical coding to an expert. Experienced medical billing and coding companies have teams of expert coders that stay current with changing coding rules and will work with physicians to adhere to best practices to help them maximize reimbursement.

Other steps that podiatrists can take to boost reimbursement include ensuring a mix of payers in the practice and getting into ancillary businesses. Experts recommend that providers should not let any plan be more than one-third in the practice’s reimbursement picture. Podiatrists can also provide diversified services to enhance their revenue. According to the report in Podiatric Economics, there are practices that offer Botox injections and sell orthotics or other lucrative services outside the Medicare system to boost income.