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Focus on What’s Necessary at Year’s End
The holiday season can throw some employees off track, draining their levels of engagement and enthusiasm for their jobs at the end of a long year....
Many ASC coders will tell you that they find podiatry surgery to be one of the most challenging specialties to code. One podiatry procedure in particular — Haglund's deformity resection — is definitely a challenge to code. When auditing ASC podiatry cases, I usually find that the Haglund's deformity resection has been miscoded, and during coding training sessions with ASC coders, I find that many are unclear about the clinical aspects of both the deformity and the surgical procedure.
'Pump bump'
Haglund's deformity (haglundsdeformity.net), also known as pump bump or Bauer bump, is a condition where a bony enlargement on the back of the heel forms, leading to retrocalcaneal bursitis, which can become quite painful and irritated if the area rubs up against any type of footwear. It's called "pump bump" because the condition often occurs due to the pump-style shoes that many women wear. The rigid backs of the shoes create the pressure that irritates that area of the heel, and women who wear pumps are the most common sufferers of this condition. The first Haglund's deformity symptoms begin with the enlargement of the bony prominence on the heel's back. It is usually seen in that very area, where the Achilles tendon attaches to the heel. As a rule, the bump is very painful, especially when a person wears tight shoes. It becomes swollen or red, and may form a bursa that later becomes inflamed.
Surgical care focuses mainly on the lateral/posterior heel's bump resection. There can be severe cases of the deformity that require a calcaneus wedge resection, which results in calcaneus shortening. The calcaneus shortening procedure is a separate procedure that is performed in addition to the posterior heel partial resection.
Haglund's Deformity Resection Case Study
A: 28118-LT: Resection of Haglund's deformity, left lateral calcaneus
Observed a prominent bony prominence on the patient's left posterior superior lateral calcaneus. Created an incision just anterior to the Achilles tendon about 5cm in length centered over the large bony protuberance. Dissection was carried to the levels of the subcutaneous tissues, where the lateral calcaneal nerve branch of the sural nerve was identified. It was reflected superiorly and isolated and protected. Dissection was carried down to the levels of the periosteum of the calcaneus where a large bony protuberance was noted along the posterior superior lateral aspect of the calcaneus. At this time, a periosteal incision was created within the confines of the original skin incision. The periosteum was reflected both medially and laterally thus exposing the hypertrophic prominence to the calcaneus. The Achilles tendon was identified. It was reflected posteriorly. Then, utilizing a Hall sagittal saw, the prominence was osteotomized obliquely from inferior to superior. This piece of bone was exited in toto from the surgical site. Next, the superior trailing edge of the calcaneus was also osteotomized utilizing a Hall sagittal saw, and this piece of bone was removed from the surgical site. Next, utilizing a rasp, the area was smoothed to a more normal anatomical contour. Upon palpation, the bony prominence was totally removed.
Official coding guidelines
In the May 2011 CPT Assistant newsletter, the American Medical Association provided the following coding guidelines:
Haglund's deformity and retrocalcaneal bursa removal with osteotome is coded as 28118:
28118 Ostectomy, calcaneus;
If additional work other than for exposure is also performed on the Achilles tendon, such as debridement of necrotic tissue, then also assign code 28200:
28200 Repair, tendon, flexor, foot; primary or
secondary, without free graft, each tendon
If there is a spur on the bottom of the foot and a plantar fascial release is also performed, assign code 28119 (with or without 28118):
28119 Ostectomy, calcaneus; for spur, with or without plantar fascial release.
Reimbursement Roundup
How Should You Report PSTIM and $436.70 Less for Lithotripsy?
' How to report the PSTIM device? There's been considerable confusion about how to report Pulse Stimulation Treatment (PSTIM), a tiny, battery-powered device that you install behind a patient's ear to treat chronic, acute or post-operative pain. Should you report CPT code 64555 (percutaneous implantation of neurostimulator electrodes; peripheral nerve [excludes sacral nerve]), HCPCS code S8930 (electrical stimulation of auricular acupuncture points), the unlisted CPT code 64999 or a code(s) from the 99XXX acupuncture series of codes? While CPT 64555 appears to describe the PSTIM procedure, the American Medical Association says CPT 64555 is not appropriate for the PSTIM procedure. Rather, the AMA says you should use CPT 64999 (unlisted procedure, nervous system) to report the procedure.
Some commercial carriers have compared the PSTIM procedure to acupuncture procedures with carrier directives ranging from the unlisted code 64999 to reporting of codes from the acupuncture code series. Other carriers consider the procedure investigational and recommend the reporting of unlisted code 64999.
Let the patient's diagnosis determine the coding for PSTIM, says James Carpenter, managing partner of Eagle Advancement Institute, a distributor of the PSTIM. "It's up to the [facility] what to choose based on the operative report," he says.
Katie Fitzgerald, the medical coder at the Dearborn (Mich.) Surgery Center, says the physicians' usual admit diagnosis for PSTIM patients is chronic pain 33829 (other chronic pain). She'll often add the site of pain as a secondary code; for example, 71946 (pain in joint, lower leg) if the patient has knee or hip degenerative arthritis. She'll use 64555 to bill PSTIM on the facility and professional side. "With Blue Cross and Medicare, we haven't had any issues," says anesthesiologist Ricardo Borrego, MD, Dearborn's medical director. Ms. Fitzgerald notes that her claims will be rejected if she doesn't note the site of service (left or right ear); you must place the implant on alternate ear sites every week for 9 weeks. Ms. Fitzgerald says you can't report the same ear every 10 days. Also, some payors don't reimburse for post-op pain. The Medicare allowable reimbursement for the 15-minute procedure is $3,539. The implant costs about $2,550, says Ms. Fitzgerald.
' ' '
$436.70 less for lithotripsy. The reimbursement rate for lithotripsy just dropped by about 21% thanks to Medicare's correction of an erroneous payment rate. CPT code 50590 (fragmenting of kidney stone) was set at a national average of $2,102.29 upon its November 2011 release. On April 24, however, CMS adjusted the payment rate to $1,665.59, a reduction of $436.70 or 20.77%. The rate is retroactive to January 1, 2012. According to the ASC Association, "Medicare contractors are not supposed to automatically reprocess previously paid claims."
— Dan O'Connor
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