When coding podiatry procedures one of the most valuable tools you have is an anatomy chart. Understanding exactly where the provider is, what bones, ligaments and tendons are involved, will help you select your CPT and diagnosis codes. At times finding CPT codes thru an encoder can be challenging. Don’t be afraid to crack open the ol’ CPT book and peruse the related section of codes. There are great instructional notes, full code descriptors, pictures and modifier recommendations that can assist you. If your provider is placing an implant and you are not sure what its purpose is, even if you are unclear on how it’s placed, you may be able to find information online. There are videos available at assorted manufacturer sites that are very descriptive which can help you picture what is being performed. Knowledge is power! The more you understand the easier podiatry surgical coding becomes.
Routine foot care in a Podiatry office can include things such as the paring of corns and calli, dystrophic nail trimming and debridement. When coding wound debridement it is especially important to pay attention to the type of procedure being performed (i.e. non-selective, excisional), the depth of tissue being addressed and the location. If it is unclear, query, query, query! It is impossible to assign a CPT code without specific documentation from our providers. If we don’t have it, we need to ask. Providers may not realize what details we need. Asking for clarification not only helps us as coding professionals but also alerts providers to what documentation we are looking for.
In the surgical setting there is a variety of procedures that are performed including hammertoe and hallux valgus corrections, arthrodesis and various tendon repairs. When coding tendon procedures you will want to look for documentation of which tendon (i.e. extensor, flexor) and at what level the provider is surgically located. This information will determine if you are choosing a code from the CPT section containing procedures on the “Foot and Toes” or the “Leg and Ankle.” When in doubt, anatomy chart for the win!
Last but not least, don’t forget to append those modifiers! Before choosing your modifier take note of what part of the foot was involved in your procedure. When you are coding procedures performed on the phalanges you will want to add a toe modifier from TA-T9. An easy way to remember is T for toes. When you are coding a procedure performed on the bones of the foot, think metatarsals and tarsals (cuneiform bones, navicular, cuboid, calcaneus), you will want to use modifiers RT (right) and LT (left) instead of a toe modifier.
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