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I just got back an EOB and the insurance denied my E&M when I used I73.89 with E11.40, why?

Yes, I agree that ICD-10 changes take affect on 10/1/24

Doesn’t it start on 10/1/2024 not 1/1/2025?

ICD-10-CM Coding gets updated when?

There has been significant pressure by all organized medical associations representing all stakeholders in this issue. This includes medical associations, wound care manufacturers and patient advocacy groups. It remains to be seen what action the CMS contractors will take. It is likley whatever action is taken it will be uniform as CMS is bent on cutting down on the abuse and escalating costs associated with CTPs. The recent OIG report certainly does not help. At this point the CMS contractors will either drop the entire issue as they have in the past, amend their initial draft policies or enforce their draft policies with no comment.My personal opinion is that they will take the signficant push back provided by medical providers seriously and either amend or drop the whole thing as they have before. They will then quickly adopt a new draft policy for comment. It would be a shame for any policy to throw the baby out with the bath water (as the proposed policy does) simply because of the inappropriate fraud and abuse of a select number of providers. CTP are here to stay and they most certainly have saved limbs.But perhaps the science behind it must be more strictly adhered to by the mfgs and the HCPCS Common Work Group needs to seriously consider revamping its approval of new HCPCS code for new CTP.

It is recommended that you reply to corresponding MAC by June 8th explaining why the policy does not have any evidence to support the number four! Please go to your MAC and look at the Proposed LCD’s. I have referenced them here:Noridian Healthcare Solutions, LLC - DL39764Noridian Healthcare Solutions, LLC - DL39760First Coast Service Options, Inc. - DL36377Novitas Solutions, Inc. - DL35041Palmetto GBA - DL39806National Government Services, Inc. - DL39828Wisconsin Physicians Service Insurance Corporation - DL39865CGS Administrators, LLC - DL39756 Billing Articles:Noridian Healthcare Solutions, LLC - A59628Noridian Healthcare Solutions, LLC - A59626First Coast Service Options, Inc. - A57680Novitas Solutions, Inc. A54117Palmetto GBA - A59691National Government Services, Inc. - A59712Wisconsin Physicians Service Insurance Corporation - A59740CGS Administrators, LLC - A59618

You cannot. Only DMEPOS providers can submit claims to Medicare for processing (be they paid or simply processed as Patient Responsibility). While you can provide a form for the patient to self-submit, Medicare will still not pay this claim and the patient will be forfeiting their opportunity to self-submit reimbursable claims in the future. If you are a non-participating provider under Medicare then you can elect to do the same and enroll as a non-participating DMEPOS provider and simply submit these types of claims with a GY modifier.

1. If the entity is a HIPAA covered entity it should deny using the typical codes we see that start with "CO’ or “N” or “PR” are some that common ones that come to mind right away. Looking on the Carefirst BCBS site and their billing requirements this is what was found: https://provider.carefirst.com/carefirst-resources/provider/pdf/provider-manual-chapter-5-claims-billing-and-payments.pdf 2. Can a private payer make up it’s own coding initiative, we have seen McKesson products over the years which incorporates NCCI but adds more is this that? Reaching out to this doctor, the representative stated they use NCCI to determine the denial! 3. Clearly, the code pair should be billed with a “59” on CPT 11721 as it is a column 2 code to CPT 11056 but are they looking for the “XS”? Hopefully, more information will be gleaned from this issue, stay tuned!

Some have termed this the “Comprehensive Diabetic Foot Exam” and believe that this is a reimbursable event under Medicare.Dr. Freedman is mostly correct in that Medicare does not cover this type of exam.The one exception is for Loss of Protective Senstation (LOPS) exams. Under this coding, Medicare does provide for a LOPS exam every six months. There is a rather big however, as patients are excluded from LOPS coverage if they have seen any health care provider for a foot related issue within the past six months for any reason. This can be as simple as a contusion. Any visit to any health care provider for a foot related diagnosis, excludes the patient from LOPS. This exception to the rule hardly helps the vast majority of diabetic patients seeking the care from a podiatrist. In my almost forty years of practice, I would be hard pressed to think of any Medicare aged patients with diabetes who did not have some pathology related finding(s). One example is xerosis. Even if this is the only finding, is related to autonomic neuropathy (does the patient have a cardiac, renal or opthamology issue)? Do they have Chronic Venous Insuffiiciency or Peripheral Vascular Disease effecting the lower extremity? Is it fungal, allergenic, actinic keratosis, pre cancerous, Sq Cell or related to some other dermatological disease? Even if the only treatment is related to ADL’s (e.g. change of bathing habits, use of OTC moisturizers) this no longer is a non covered screening event but a reimbursable event.The level of CPT will vary based on your findings and Medical Decision Making.The medical necessity for a re-visit will depend on the above.

Podiatry, unlike internal medicine and family practice are able to get reimbursed for annual well exam, podiatry does not get reimbursed for an annual diabetic foot exam. The good news is that most insurance covers an illness, injury, or symptom related to E&M. A common diabetic issue is Type 2 diabetes with polyneuropathy, ICD-10-CM E11.42. They have a chronic illness that affects feet and legs and should be evaluated and medically managed when necessary.

ANSWER: My first recommendation is to know what CMS says, take a look at this link Foot care (routine) | Medicare If all the provider is doing is nail debridement, then they should be billing the nail CPT codes (11720 & 11721) regardless of traditional Medicare rules. If the MA plan has the policy they cover non medically necessary nail care, then if you perform that service, you should bill the most appropriate CPT coding that day.

Can you tell me what is best to do? ANSWER: If the podiatrists/provider reviewed the medical policy on the MA site and it is stated they do not pay, then it is not covered. If performing an E/M at the time then bill E/M. It is alright to create your own code for cosmetic nail care, practices do this and the patient pays. It is fine to call it a “medical pedicure service”, meaning you the medical provider are doing the cosmetic service and I would bet most plans do not cover cosmetic services. Again, each MA plan has rules, see what they say about cosmetic services.