As the calendar turns to 2007, podiatrists should be aware of the changes to reimbursement codes instituted by the Center for Medicare and Medicaid Services (CMS). Starting on January 1, there are a number of changes that will affect Medicare billing. Accordingly, let us take a closer look at key CPT/ICD-9 codes that are more pertinent to podiatry.
There are a number of changes to the CPT codes that practitioners should know. There is no 90-day grace period for deleted codes as there had been in the past. New CPT codes are valid as of January 1, 2007.
CPT 28055. This code is to resect a nerve in the foot (neurectomy, intrinsic musculature of foot). This code is for the excision of a motor nerve, not a sensory nerve. This will replace CPT 28030. One should still use CPT code 28080 for excision of a Morton’s neuroma.
CPT 17110. Use this code for the destruction of benign lesions including verrucae. The code allows for the billing of one to 14 lesions as a group. One can no longer bill lesions individually. If you treat more than 15 lesions, use CPT 17111, which would be billed as a lump sum for more than 15 lesions. It is unclear at this time what the RVS value will be for the new code to allow for the destruction of multiple lesions.
As of January 1, CPT code 28030 has been deleted for 2007 and replaced with CPT 28055.
As of January 1, a few CPT codes will be revised. The skin care substitute codes themselves will not change but the clause that implies that surgical fixation is required for payment has been deleted. Specifically, as far as the 15XXX code series, there is no change in the codes per se but there is a change in the introduction portion, which clarifies the use of these codes. In the past, there was controversy as some skin substitutes did not require fixation per se. A change in the language deletes the term “surgical fixation.”
CPT codes 17000–17004, which had been used to bill for destruction of “benign” lesions, including verrucae and pre-malignant lesions, have been revised to cover only the pre-malignant lesions. CPT 17000 is the code to use for laser, chemocautery, electrosurgery and cryotherapy. Currettement procedures would be best done with this procedure series. CPT 14200 would require surgical closure of the wound.
New ICD-9 codes were valid as of October 1, 2006. There is no longer a 90-day grace period as there has been in the past. The new codes for 2007 are listed below.
277.30 Amyloidosis, unspecified
288.00 Neutropenia, unspecified
288.03 Drug induced neutropenia
288.04 Neutropenia due to infection
288.09 Other neutropenia
288.50 Leukocytopenia, unspecified
288.59 Other decreased WBC count
288.60 Leukocytosis, unspecified
288.61 Lymphocytosis (symptomatic)
288.69 Other elevated WBC count
333.94 Restless leg syndrome
388.0 Central pain syndrome
338.11 Acute pain due to trauma
338.18 Other acute postoperative pain
388.19 Other acute pain
338.21 Chronic pain due to trauma
338.28 Other chronic postoperative pain
338.29 Other chronic pain
338.3 Neoplasm related pain (acute) (chronic)
338.4 Chronic pain syndrome
729.72 Non-traumatic compartment syndrome of the lower extremity
731.3 Major osseous defects
780.96 Generalized pain
958.90 Compartment syndrome, unspecified
958.92 Traumatic compartment syndrome of lower extremity
995.22 Unspecified adverse effects of anesthesia
995.27 Other drug allergy
995.29 Unspecified adverse effect of other drug, medicinal, and biological substance
V58.30 Encounter for change or removal of non-surgical wound dressing
V58.31 Encounter for change or removal of surgical wound dressing
V58.32 Encounter for removal of sutures
These revised ICD-9 codes became valid after October 1, 2006:
285.29 Anemia of other chronic disease
995.92 Severe sepsis
995.93 Systemic inflammatory response syndrome due to non-infectious process without acute organ dysfunction
995.94 Systemic inflammatory response syndrome due to non-infectious process with acute organ dysfunction
These following deleted ICD-9 codes were no longer valid after October 1, 2006:
995.2 Unspecified adverse effect of drug, medicinal, and biological substance
V58.3 Attention to surgical dressings and sutures
There has been a realignment of DME carriers across the country. Check with your local carrier to see if it is still your current DME carrier. The change would have occurred in approximately October 2006. There should be no changes in the regulations for supplying DME. You do not have to reapply to the new carrier. However, you should contact the carrier to make sure any electronic funds transfer paperwork is accurate.
Any claims in process at the time of the transition will be transferred to the new carrier. This also applies to any appeals that are in progress. The new carrier will also have access to old claims if you need to research old claims, EOMBs, etc.
Regarding electronic funds transfers, new CMS regulations dictate that for a new applicant for a CMS license, you must have future reimbursement checks deposited electronically as opposed to using paper checks. If you do not agree to this, your application will be denied. You can still get a paper EOMB that indicates each individual payment per beneficiary. This change mandating electronic funds transfer also applies to existing providers who want to make any change in their current profile, including changing address, telephone number, etc. Eventually, we all may have to switch to electronic funds transfers but there is no timetable for that yet.
Other CMS changes indicate that all claims must be submitted electronically. There is an exception provision that this requirement does not apply if a practice has under 10 employees. However, you should notify your carrier that you are requesting this exemption. Recently, I have seen some denials of payment based upon the carrier not receiving appropriate paperwork attesting to this exemption. Such claims have not been denied but have simply been returned to the provider as non-processable.
Two contractors for CMS may ask for a single chart to audit. This is part of CMS’s program safeguard process (the Comprehensive Error Testing Rate (CERT) program and Recovery Audit Contractors (RAC)), and not specifically an audit of the practitioner. These agencies will audit the carrier’s correct processing of your claims. The claims may deal with a specific code but the patient charts themselves are selected at random.
If you do not respond to the audit, the claim will be designated as paid in error. This will affect the overall “error rate” for the processing of that claim. Based upon the eventual  error rate, policies may be instituted to address that perceived problem. Submit chart notes and any other supporting documentation to the agency requesting the information, not the carrier. Furthermore, you will need to return any monies paid. You must respond to the request for records.
If you are asked to return money, you may appeal that decision but do so to your local carrier, not the CERT or RAC companies.
Medicare is looking into cost savings measures and one area of focus is the cost of processing claims. One area of concern is a significant number of duplicate billings of claims.
Once a claim has been denied, you cannot “correct” and resubmit it. This resubmitted claim, even if it is corrected, will be denied as a duplicate. Keep in mind that the appeal time for a claim starts with the initial date of determination, which is the date when the claim was initially processed. Therefore, repeated resubmission of a denied claim will be in vain with regard to payment but, more importantly, you may miss the 120-day window when you eventually decide to submit a formal appeal.
You cannot appeal claims that are denied as non-processable. Since they are not valid claims, no appeal rights are extended to these claims. Rather, one should resubmit these claims as new claims once you or your staff have corrected the problems.
According to NHIC, the top ten claims submissions errors are as follows:
1. Duplicate claims
2. The need for this service was not supported on this claim
3. Medicare eligibility not in effect when services were rendered
4. Service denied/reduced because this service is not payable separately
5. Medicare is secondary payer on this claim
6. This service is part of another service performed on the same day
7. Not payable, service part of another service performed on the same day
8. Service not considered, requested information not received
9. This item or service is not covered by Medicare
10. This charge is included in the surgical fee
A new year brings the usual controversy regarding the new fee schedule allowance. There had been a proposed fee reduction for 2007 of 5 percent. However, in December, Congress averted the proposed fee reduction.
Similarly, the RVS values for each service are reviewed annually. Any changes in the RVS unit allowance for the various services were unknown as this issue went to press.
There is a new CMS (HCFA)-1500 form change. The revision to the CMS-1500 form was slated to be effective Oct. 1, 2006 (but will not be mandated until Feb. 1, 2007). The form will allow for the use of the new NPI number.
To learn more about the new form changes, see:
For a complete description, see: http://www.cms.hhs.gov/transmittals/downloads/R899CP.pdf 
You will need to apply for a NPI number from the National Plan and Provider Enumeration System (NPPES). This will be a universal number that all insurance companies are to use. It will follow you regardless of change in job or location. You will only be assigned one number per provider as will each group. In order to get the application process started, see the link below:
The implementation of the NPI number will continue to be phased in over time. However, if you have not yet applied for a NPI number, you may want to do soon. According to CMS, one must use the NPI on standard transactions with health plans, other than small health plans, no later than May 23, 2007.
However, CMS notes that health care providers should not begin using the NPI in standard transactions on or before the compliance dates until health plans have issued specific instructions on accepting the NPI.
Medicare’s implementation involving the acceptance and processing of transactions with the NPI has occurred in separate stages previously.
Between May 23, 2005 and January 2, 2006, CMS claims processing systems would accept an existing legacy Medicare number and reject as non-processable any claim that included only an NPI.
From January 3, 2006, to October 1, 2006, CMS systems accepted an existing legacy Medicare number or an NPI as long as it was accompanied by an existing legacy Medicare number.
From October 2, 2006 through May 22, 2007, CMS systems will accept an existing legacy Medicare number and/or an NPI. This will allow for six to seven months of provider testing before only an NPI will be accepted by the Medicare program on May 23, 2007.
Dr. Poggio is a California Podiatric Medicine Association Liaison to the National Heritage Insurance Company and a medical consultant to Health-Net Insurance Company. Dr. Poggio is a member of the American College of Podiatric Medical Reviewers and is board-certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics.
Editor’s note: For related articles, see “A Clear View Of The Intricacies Of Coding” in the February 2002 issue of Podiatry Today, “Key Coding Insights For Skin Conditions And Wounds” in the October 2004 issue, or “Maximize Your Reimbursement: A Guide To Billing In Diabetic Care” in the March 2003 issue.