A Closer Look At Practice Management Aspects Of Treating Heel Pain

By Lowell Weil Jr., DPM, MBA
Studies have shown that it is best to treat plantar fasciitis with an “arch support” of some sort. Initially, we utilize an over-the-counter device that we always customize for the patient at the time of initial visit, thereby starting the healing process immediately. There are many devices available on the market that are effective and one can easily customize these in the office by simply grinding the device or adding modifications to the device. When providing this service, you would code it as L3060 for both the left and right foot. While some insurance companies like Medicare do not cover this code, many others will reimburse for this service in the $75 to $150 range. Addressing the tight calf muscle complex is crucial to successfully treating plantar fasciitis. We commonly refer the patient to our physical therapists or prescribe physical therapy to help train patients on proper stretching techniques, and then monitor their compliance over a span of time. Additionally, researchers have found night splints to be effective for treating chronic plantar fasciitis. One would code the night splints with L1930, which is commonly reimbursed by insurance companies. Using antiinflammatory medications is very effective in reducing swelling and pain associated with this condition. Breaking the pain cycle of this problem is key to getting the patient moving toward recovery. In many circumstances, over-the-counter or semi-custom arch supports are not sufficient to properly support and control the patient’s biomechanical problems. In those cases, customized orthotics are very valuable. When it comes to patients with heel pain, we have found that softer, accommodative orthotics have greater success and compliance with our patients than the more typical, plastic, functional devices. The accommodative devices that we utilize for heel pain are produced by The FootCare Depot (footcaredepot@gmail.com). The FootCare Depot’s high medial and lateral phlange (UCB type) offers more support and control of the foot. One would code these devices with L3000, which offers a higher reimbursement than standard orthotics that one would commonly code as L3020. When billing for orthotics, it is important to bill for both the left and right device individually. Pertinent Insights On Coding For Cortisone Injections When these initial treatment options do not successfully control the heel pain, more aggressive alternatives may become necessary. A cortisone injection is a very effective adjunctive treatment to the heel pain treatment regimen. It is my belief that one should only utilize cortisone after initiating proper mechanical control of the foot and addressing the factors that initially caused the problem. At that point, cortisone can be very helpful. However, cortisone injections to the heel have a very traumatic reputation with regard to procedural pain. Many times, I have heard patients state that a cortisone injection to their heel was the most painful experience of their life. To obviate that, I always perform a local anesthetic, medial calcaneal nerve block several minutes prior to the introduction of the cortisone injection. This nerve block significantly reduces the pain associated with the cortisone injection and allows greater ease in performing the cortisone injection. One should bill both the nerve block and the actual cortisone injection in these circumstances. Code the nerve block as CPT 64450 and bill the cortisone injection as CPT 20550. Additionally, in selected cases, if one has a musculoskeletal ultrasound available, you can utilize it to help target the placement of the cortisone injection and help facilitate greater success. This is especially helpful with a fragmented heel spur. One would code this additional tool as CPT 76942. It is unusual for me to utilize more than two cortisone injections for the treatment of plantar fasciitis and I usually do not go beyond a single injection. When the aforementioned treatment regimen fails over a period of four to six months, it is necessary to consider more aggressive treatment alternatives. It has been my experience that most people will respond to the above treatment.

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