Podiatry does not often make the mainstream news, but two podiatrists have recently found themselves the recipients of some unwanted public attention. Podiatry coding mistakes are easy to make—don’t let your practice fall prey to improper billing allegations and compliance nightmares because of them.
‘Cheap Pedicures’ Don’t Have a CPT Code
In July, the Associated Press reported that a doctor in Ocala, Fla. faces up to 10 years in prison after pleading guilty to health care fraud. The doctor, the Palm Beach Post reported, “got the attention of federal prosecutors because he claimed nearly half his procedures involved removal of skin and muscle. That placed him in the top 1 percent nationwide for this procedure.” The procedures, the paper said, amounted to a “cheap pedicure.”
The Florida case was preceded by a similar one in Colorado. In June, according to the Denver Post, a podiatrist in Fort Collins was sentenced to six months in jail and a $20,000 fine for Medicare billing fraud. The doctor, it was found, “created medical records that would justify Medicare coverage for nail debridement even though (the doctor) did not properly examine the beneficiary and did not find the reported clinical evidence.”
No to Clipping, But Yes to Debridement
While standard toe nail clipping is not covered by Medicare, nail debridement is.
“Coding for routine foot care still raises blood pressure throughout podiatry,” noted one expert with The Coding Institute (TCI). “Unfortunately, given the multiple Medicare carriers and the policy variations with each carrier, it can get very confusing.”
“Trimming” simply reduces the length of a nail, and this can be done by a podiatrist on either a normal or dystrophic nail. Debridement, meanwhile, is a procedure which removes excess material or curvature from a dystrophic or diseased nail which is both clinically and significantly thickened.
Common miscoding of debridements include improperly reporting depth, billing for additional nail coverage, or misstating the patient diagnosis, notes a healthcare fraud watchdog, which adds, “Debridement codes are typically found under either the Integumentary System or Musculoskeletal system area of the Surgery section of the CPT® book with some exceptions.”
Podiatry CPT Training More Important Than Ever
“[T]here usually needs to be some kind of qualifying systemic condition (depending on the plan) in order for nail debridements to be a covered service,” according to TCI. Misrepresenting a CPT diagnosis in order to get paid will absolutely land you in the crosshairs of the government. Other trouble spots for podiatry coders and billers include bunion codes, services and supplies related to orthotics, appropriate use of the ABN when patients are responsible for payment, and the latest guidelines for dispensing diabetic shoes.
Remember, CMS defines Medicare fraud in general as “making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist,” and it adds a relevant example for coders and billers: “Knowingly billing for services at a level of complexity higher than services actually provided or documented in the file.”
Diagnosis coding for podiatry requires specific training in foot care and what’s required to document and prove medical necessity, as well as local and national coverage determinations. Be sure you’re up on the fundamentals as well as the details for 2018 CPT coding.
