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28010 multiple toes (Medicare patient)

  1. #11
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    Quote Originally Posted by martn View Post
    I say 28011 x2 for bilateral?
    I would say no, the description of the procedure is for multiple tendons, so my thought process would be it doesnt matter if its 1 or all 10. BUT..I've put a message out on the ortho list serve to see if anyone has anything in writing on this...I will follow up when I hear back.
    Mary, CPC, CANPC, COSC

  2. #12
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    Here is one response:




    This is from the PPRVU
    bilat surg=0

    0=150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100% of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

    The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

    (credit to Laura P)
    Last edited by mbort; 10-12-2009 at 02:52 PM.
    Mary, CPC, CANPC, COSC

  3. #13
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    here is another response:

    I have an old MEDICARE CORRECT CODING GUIDE 2005 by Ingenix (which I don't really use any more)but it states in the code 28011 that the 50 modifier rule does NOT apply - meaning that you should not use that modifier...

    (credit to Anne H)
    Mary, CPC, CANPC, COSC

  4. #14
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    I agree Mary. 28011 has a bilateral payment indicator of Zero ( 0) on the Medicare fee schedule.

    0=Bilateral Surgery (50) 0 = 150% payment adjustment for bilateral procedures does not apply. Do not use -50 modifier.

  5. #15
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    thanks Rebecca..You must have seen the post elsewhere too!!...lol

    Here is another:

    Code 28011 has a zero indicator regarding bilateral. Here is what what the Medicare Physician Fee Schedule Database says.

    MEDICARE PHYSICIAN FEE SCHEDULE DATA BASE (MPFSDB)

    Indicators listed in this data base are assigned by the U.S. Government, Department of Health and Human Services, Centers for Medicare and Medicaid Services. Changes may be made on a quarterly basis.
    Indicators show if a specific modifier can be used with a CPT code and how the modifier affects payment.

    BILATERAL SURGERY (Modifier 50)

    0 150% payment adjustment for bilateral procedures does not apply.
    If procedure is
    reported with modifier 50 or with modifiers RT and LT, base payment for the two sides
    on the lower of the total charge for both sides or 100% of the fee schedule amount for a
    single code.The bilateral adjustment is inappropriate for codes in this category
    because of physiology or anatomy or because the code description states that it is a
    unilateral procedure and there is no existing code for a bilateral procedure.
    1 150% payment adjustment for bilateral procedure applies. If
    code is billed with a
    bilateral modifier (50) or is reported twice on the same day by any other means (eg with
    the RT and LT modifiers or with 2 in the units field) base payment for these procedures
    when reported as bilateral procedures on the lower of the total actual charge for both
    sides or 150% of the fee schedule for a single code.If code is reported as a bilateral
    procedure and is reported with other procedure codes on the same day, apply the
    bilateral adjustment before applying any applicable multiple surgery rules.
    2 150% payment adjustment for bilateral procedures does not apply.
    RVUs are based
    on the procedure being performed as a bilateral procedure. If procedure is reported
    with modifier 50 or is reported twice on the same day by any other means (eg with the
    RT and LT modifiers or with 2 in the units field) base payment for both sides on the
    lower of the total actual charge for both sides or 100% of the fee schedule for a single
    code.
    3 The usual payment adjustment for bilateral procedures does not
    apply. If procedure is
    reported with modifier 50 or is reported for both sides on the same day by any other
    means (eg with the RT and LT modifiers or with 2 in the units
    field) base payment for
    each side or organ or site of a paired organ on the lower of the total actual charge for
    each side or 100% of the fee schedule for each side.If procedure is reported as a
    bilateral procedure and with other procedure codes on the same day, determine the fee
    schedule amount for a bilateral procedure before applying any applicable multiple
    procedures rules. Services in this category are generally radiology procedures or other
    diagnostic tests, which are not subject to the special payment rules for other bilateral
    procedures.
    9 Concept does not apply.

    (credit to Faye P)
    Mary, CPC, CANPC, COSC

  6. #16
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    Howdy Mary...

    In case someone needs a "hard copy" reference to the payment status indicators...I like Medtronics handy list.

    http://www.medtronicsofamordanek.com...indicators.pdf

  7. Default
    Thanks so much!!!!!

  8. #18
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    While I agree with what you all have said and references posted, shouldn't you be able to bill -RT and -LT or even mayber -59 for the opposite foot (if both feet are done). Sometimes the rules and guidelines simply don't seem logical.
    Lisa Bledsoe, CPC, CPMA

  9. #19
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    These are toes and not feet, and the code is for multiple toes which means any number 2 thru 10, toes do not have laterality, they are each separate or as in this code all together.

    Debra A. Mitchell, MSPH, CPC-H

  10. #20
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    Greeley, Colorado
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    Put that way it makes sense...
    Lisa Bledsoe, CPC, CPMA

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