Orthopedic Coding Alert

Remember, surgery is a last option.

Patients reporting to the orthopedist with symptoms of plantar fasciitis could be subject to a wide range of treatments, both to confirm the condition and to alleviate it.

There’s an order of treatment options as well, and your provider needs to follow the hierarchy of options in the proper order, or the payer might just deny your claim.

Check out the ins and outs of coding for plantar fasciitis.

E/M Typically Tests for PF

A physician will usually diagnose plantar fasciitis during a routine evaluation and management (E/M) service, explains Kristin Drummelsmith, medical biller at Foot & Ankle Associates of Michigan In Shelby Township.

These E/Ms will likely take place in your practice’s office setting; so, if your provider diagnoses plantar fasciitis during an office E/M, you’ll report a code from the 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …) code set.

The provider would diagnose plantar fasciitis during (or after) a physical exam and medical history review. “The location of the patient’s pain would tell the doctor if it was plantar fasciitis or not,” Drummelsmith says.

More specifically, the provider will typically test the patient’s heel pain while walking, especially when first getting up after sitting, says  Denise Paige, CPC, COSC, of PIH Health in Whittier, California.

Plantar fasciitis symptoms are often relieved by rest.

Once you’ve a confirmed diagnosis of plantar fasciitis, you should assign the patient M72.2 (Plantar fascial fibromatosis) to represent the condition.

Take Conservative Route for Initial Treatment

According to experts, initial treatment for plantar fasciitis should not be surgery; the provider should attempt more conservative means to alleviate the condition first.

Some of the more conservative treatments for plantar fasciitis include:

• Rest,
• Ice,
• Foot stretching,
• Nonsteroidal anti-inflammatory drugs (NSAIDS),
• Physical therapy,
• Shoe inserts, and
• Use of stretching boots.

Give Injections a Shot, too

The above treatment options might just do the trick for your plantar fasciitis patient. If the provider decides that those means aren’t going to work, however, they might also choose to perform an injection, confirms Bill Mallon, MD, former medical director of Triangle Orthopedic Associates in Durham, N.C.

There are a few injection options to treat plantar fasciitis, Paige explains. The most used are 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)) and 20551 (Injection(s); single tendon origin/insertion).

Some injections go directly into the tendon [20550]; others go in the area where the tendon attaches to the bone [20551],” says Paige.

According to Mallon, the injections are typically corticosteroid — but not necessarily. Be sure to check the drug supply on your 20550 and 20551 claims to ensure you’re coding for the right drug.

Clinical Scenario Sets Coding Straight

Paige gifted us with this real-world example involving a patient who began with pain in the heel and ended up getting an injection for plantar fasciitis:

Patient complains of ongoing right heel pain, especially when first getting up from a sitting position or from bed in the morning, and usually gets worse with prolonged walking.  Symptoms came on gradually and are now worse.  Physical exam of the right foot notes point tenderness at insertion of plantar tendon at the right heel.  X-rays of the right heel reveal a calcaneal bone spur at the area of the plantar tendon insertion.  Cortisone injection to the right heel in the area of the bone spur/tendon insertion is recommended.

For this encounter, you’d report:

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …) for the E/M.
• 73620 (Radiologic examination, foot; 2 views) for the X-ray.
• Modifier RT (Right side) appended to 73620 to indicate laterality, if the payer requires it.
• 20551 (Injection(s); single tendon origin/insertion) for the injection.
• Modifier RT (Right side) appended to 20551 to indicate laterality, if the payer requires it.
• J1030  (Injection, methylprednisolone acetate, 40 mg) for the drug supply.
• M72.2 (Plantar fascial fibromatosis) and M77.31 (Calcaneal spur, right foot) appended to 99203, 73620, and 20551 to represent the patient’s conditions.

Check Out These Surgical Options

If the conservative treatment options can’t cut it on the patient’s plantar fasciitis, surgery is the next option. “Surgery is usually a release of the of the origin of the plantar fascia through a medial plantar incision,” according to Mallon.

Your orthopedist might opt for one of these surgeries to treat the patient:

• 28060 (Fasciectomy, plantar fascia; partial (separate procedure))
• 28062 (… radical (separate procedure))
• 28250 (Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure))
• 28008 (Fasciotomy, foot and/or toe)
• 28119 (Ostectomy, calcaneus; for spur, with or without plantar fascial release) (which includes ostectomy for bone spur)
• 28890 (Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia)
• 29893 (Endoscopic plantar fasciotomy).

Note: This is not an exhaustive (or exclusive) list of surgical treatment options. Be sure to choose the surgical code that most closely reflects the surgeon’s actions.