However, she notes that if the total surface area of allograft application is 100 cm2 or greater, this requires different codes for the first 100 cm2. For example, Dr. Aung advises reporting the application of 170 cm2 of allograft to both feet with two codes: 15277 and +15278.
What are useful modifiers for wound care practice?
Modifier -58 is for a staged or related procedure, such as a serial OR debridement when one knows that more than one surgical setting is required, according to Dr. Aung.
Modifier -58 is probably the most used modifier in the wound care setting, asserts Dr. Suzuki, who notes that DPMs often must “stage” a wound closure for complex wounds. Citing the example of a grossly infected foot wound, he notes he may have to perform a partial foot amputation, use VAC therapy (KCI) and subsequently take the patient back to the OR for a definitive wound closure. Since a foot amputation carries a global period of 90 days, Dr. Suzuki says one would need to use -58 to allow for reimbursement of the second procedure (wound closure).
Dr. Suzuki says one would use modifier -78 (return to the OR) for treatment of a complication or an unplanned surgical procedure. He cites the example of an evacuation of a hematoma after an elective procedure such as a bunionectomy. For modifier -78, Dr. Aung cites the example of a deep incision and drainage/debridement for a partial foot amputation followed a few days later by a second surgery after one discovers infection of the amputation site.
Modifier -79 (an unrelated procedure in the post-op period) protects the second procedure from receiving less payment, notes Dr. Suzuki. For example, Dr. Aung says one may perform a deep I&D/debridement on the right foot and on the follow-up visit, the patient develops an ulcer on the left foot that needs debridement.
When using this modifier, Dr. Suzuki says one should indicate that the post-op period of the first procedure was unrelated to the second procedure. He rarely uses this code, preferring to let the patient heal completely before doing any other elective surgical procedure.
Do you have any advice regarding coding and billing to the current residents who will be in practice in a few years?
“If you haven’t learned how to code, start now,” advises Dr. Suzuki. “I believe learning how to code your procedures appropriately is the best way to maximize your income, unless you know that you are going to be a lifetime salaried physician, which is very unlikely.”
Dr. Aung agrees. She advises residents to learn how to use the CPT and ICD 9 or ICD 10 codes as well as the HCPCS codes when it comes time for practice.
“Whether you work for a hospital organization, a specialty group and/or enter private practice, you are ultimately responsible for what gets billed out for services you have performed,” says Dr. Aung.
Dr. Aung suggests starting a study group with fellow residents of any specialty to learn about billing and coding or having the residency program add billing and coding as part of a journal club or online learning through PRESENT Podiatry. Although it is not necessary to memorize the codes, she says one should know how to look up the codes and/or how to talk to coders and billers when they have queries before they bill out for your services.
Dr. Suzuki cautions that there is a plenty of “gamesmanship” one must learn involving surgical coding. When physicians perform a complex procedure, there may be three different ways to code the procedure and the reimbursement will be drastically different, according to Dr. Suzuki.
For example, he says for a diabetic foot ulcer with osteomyelitis, one can debride the wound and the bone, then fashion the skin flap and close the wound. In this case, Dr. Suzuki notes one could code it as a bone debridement, an ostectomy or a complex wound closure. Those procedures may be exclusive to each other (one cannot bill them together) and he says they get reimbursements at different amounts.