Tick removal; nail trimming for a diabetic patient; ECG prior to a stress test
Answers to your questions about . . .
Q: I removed an embedded tick from a patient's upper arm, then checked for signs and symptoms of Lyme disease and Rocky Mountain spotted fever. How should I report the visit and removal?
A: Most visits for tick removal are quick and uncomplicated. For the office visit you describe, include the removal in the appropriate-level E&M code, such as 99211-99215, based on the level of history, evaluation, and medical decision-making.
You may be tempted to look for a way to report the tick removal separately, using a foreign-body removal code such as 24200 (removal of foreign body, upper arm or elbow area; subcutaneous), but removal codes require incision, and tick removal normally does not.
Q:A Medicare diabetic patient presents for nail trimming of onychopathic nails. Would the procedure be considered routine foot care? Which codes should I use to ensure coverage?
A: Medicare considers trimming nails routine foot care and limits coverage to patients who have complicated systemic diseases with severe peripheral involvement that make nonprofessional treatment hazardous. For you to receive reimbursement, the claim would have to contain an accepted diabetes mellitus diagnosis and the appropriate number of class findings.
To find out if the patient has a covered diagnosis, check your carrier's local medical review policy (LMRP). For instance, National Heritage Insurance, the Medicare Part B carrier for much of New England, covers routine foot care for claims that contain diagnosis codes for diabetes mellitus with renal, ophthalmic, or neurologic complications or peripheral circulatory disorders. To get paid, you must document that the patient has a combination of signs and symptoms that fall into three classes.
Class A, which is nontraumatic amputation of foot or integral skeletal portion.
Class B, which includes absent posterior tibial pulse, absent dorsalis pedis pulse, and advanced trophic changes. (Three trophic changes are required to meet one class finding.)
Class C, which includes claudication, temperature changes, edema, paresthesia, and burning.
If documentation supports Medicare coverage of the nail trimming, report 11719 (trimming of nondystrophic nails, any number) or G0127 (trimming of dystrophic nails, any number). Append the procedural code with the modifier that indicates the proper number of findings: Q7 (one class-A finding), Q8 (two class-B findings), or Q9 (one class-B and two class-C findings). Link the procedure to the diabetes diagnosis, and put 703.8 (diseases of nail; other specified diseases of nail) in the secondary position.
Q:I did an ECG before giving the patient a stress test. Should I report the ECG as well as the stress test?
A: Most payers will cover an ECG (93000) when it's used as a diagnostic tool before a stress test (93015). For example, you want to confirm a diagnosis of coronary artery disease, such as 414.9 (chronic ischemic heart disease, unspecified). You rely on the patient's history, an ECG, and symptoms of chest pain.
Some physicians inappropriately bill for ECGs during the stress test. In that case, the National Correct Coding Initiative bundles the ECG into the stress test. To properly indicate an ECG performed prior to a stress test as a diagnostic procedure, append modifier 59 (distinct procedural service) to the ECG.
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Coding Consult: Answers to your questions about. . .. Medical Economics Oct. 24, 2003;80:15.