Podiatry Coding & Billing Alert

This grievance is a top reason for podiatry visits.

Heel pain is a very frequent complaint treated on a daily basis in podiatry offices. Given the multitude of reasons a patient could be experiencing this symptom, it’s a good idea to familiarize yourself with a few of the conditions that can be the source of the pain.

Continue reading to review some of the most common causes of heel pain and how to correctly code their treatment options.

Code Pain From Heel Spurs Confidently

Heel spur defined: Also known as calcaneal spurs, these may be caused by tears in the origin of the plantar fascia at the calcaneus. A tear on the heel bone may occur because of excessive use or microtrauma. If the tear does not heal completely, calcium deposits can form an exostosis, or protrusion, creating a heel spur.

If your podiatrist performs a heel spur excision, with or without a plantar fascial release, you will want to report the procedure using code 28119 (Ostectomy, calcaneus; for spur, with or without plantar fascial release). Use this code regardless of whether the podiatrist makes release incisions on the stressed or irritated plantar fascia.

In another instance, if your podiatrist excises a portion of the patient’s calcaneus during the spur removal, you should report this as 28118 (Ostectomy, calcaneus).

However, if your podiatrist administers an injection that includes both the plantar fascia and the area around the calcaneal spur, you should code this as 20551 (Injection(s); single tendon origin/insertion). Also, report any necessary J codes if your podiatrist uses corticosteroid injections to reduce the inflammation during the procedure.

Determine the Right Diabetic Ulcer Pain Code

Diabetic ulcers defined: A diabetic ulcer of the heel is a common complication of diabetes, resulting from a combination of factors such as poor circulation, nerve damage (neuropathy), and high blood sugar levels. These ulcers can become serious if not treated promptly and properly, as they can lead to infections, gangrene, and, potentially, the need for amputation.

When your podiatrist treats a patient with a diabetic heel ulcer and the additional complication of gangrene, you’ll first need to clarify what type of diabetes the patient has. The ICD-10-CM code book includes four types of specified diabetes groups and an unspecified category, each having their own code sets: E08.- (Diabetes mellitus due to underlying condition), E09.- (Drug or chemical induced diabetes mellitus), E10.- (Type 1 diabetes mellitus), E11.- (Type 2 diabetes mellitus), and E13.- (Other specified diabetes mellitus).

If the provider doesn’t clarify which form of diabetes the patient has in the notes, or you are unable to verify which type even after querying the provider, do not use a code from E13.-. Instead, follow ICD-10-CM guideline I.C.4.a.2, which tells you to use a code from E11.- as the default code. (For the purposes of this scenario, E11.- will also be our default code).

Sequencing is another important factor when coding a patient. Should you code diabetes, the pressure ulcer, or the gangrene first? ICD-10-CM guideline IV.G tells you to “[l]ist first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided” for all outpatient services. For coding this decubitus ulcer, you should use L89.614 (Pressure ulcer of right heel, stage 4) to identify the location, but you should also list E11.622 (Type 2 diabetes mellitus with other skin ulcer) first because L89.614 only identifies the location, not the connection between diabetes and the ulcer. Based on guideline I.C.4.a for diabetes, you should connect diabetes to all conditions listed under “with” in the index.

In the next step, you’ll need to decide the order of the conditions: diabetes, peripheral angiopathy, or gangrene. Coincidentally, there’s a code that encompasses all the conditions in one — E11.52 (Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene).

The primary diagnosis is gangrene, likely influenced by both diabetes and peripheral angiopathy. Peripheral angiopathy hinders blood flow and healing, increasing the risk of gangrene and worsening the decubitus ulcer. Diabetes also raises the risk of gangrene and infection. Incorporating all known factors gives a comprehensive understanding of the patient’s situation.

Listing all the conditions responsible for the visit supports the medical necessity of the provider’s care plan, aiding in payer reimbursement.

Identify Pain Treatments for Plantar Fasciitis

Plantar fasciitis defined: This condition is an inflammation of the thick band of fascia tissue across the bottom of the foot, causing a stabbing type of foot pain.

If a patient presents to your practice complaining of a sharp stabbing pain in their heel when standing or walking, and conservative treatments like rest, ice, and stretching have done nothing, the podiatrist may decide it’s time for a corticosteroid injection.

After reviewing the visit notes, you’ll assign either 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)) or 20551 depending on where the podiatrist injected the patient’s plantar fascia. You’ll assign 20550 if the provider injected the medication directly into the tendon, whereas you’ll use 20551 if the injection occurred where the tendon attaches to the bone.

Remember to report an appropriate HCPCS Level II code to be reimbursed for the drug supply or medication injected into the tendon. Double-check your documentation or query the provider for the specific drug and dosage to assign the correct code.

Lastly, you’ll use diagnosis code M72.2 (Plantar fascial fibromatosis) to report the patient’s plantar fasciitis as the reason for the visit.

Assign the Correct Achilles Tendinitis Code

Achilles tendinitis defined: Achilles tendinitis is a degeneration or injury to the Achilles (calcaneal) tendon. Achilles tendinitis is most often caused by overuse or repetitive stress. The two types of Achilles tendinitis are noninsertional and insertional. When a patient has noninsertional Achilles tendinitis, the fibers in the middle section of the Achilles tendon degenerate, swell, and thicken. Insertional Achilles tendinitis involves the lower part of the patient’s heel where the Achilles tendon attaches to the heel bone.

Nonsurgical treatment options for Achilles tendinitis include resting, icing the tendon, nonsteroidal anti-inflammatory drugs (NSAIDs), stretching, and physical therapy.

There are two main surgical options for Achilles tendinitis: tendon repair and tendon lengthening. You should report code 27650 (Repair, primary, open or percutaneous, ruptured Achilles tendon) for repair and 27685 (Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)) for lengthening.

You should report ICD-10-CM codes M76.61 (Achilles tendinitis, right leg) and M76.62 (… left leg) for Achilles tendinitis.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC