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Under the split-shared rules, the provider who sees the patient for a majority (>50%) of the time is the one who is entitled to bill for the visit.

I see a patient in the hospital along with the nurse practitioner who has also seen the patient. Who is entitled to bill for the services?

You are correct in that Medicare’s LCD and PA most often do not cover devices to offload ulcers other than diabetic shoes or crow boots. This seems archaic to cover nothing between a $300 pair of shoes with inserts and a $2,000 Crow boot. But this is the policy. CAM boots (e.g. L4361/L4387) if used to treat and stabilize a foot deformity ( e.g. Charcot) or fracture (often associated with Charcot) no doubt would qualify for coverage. So might a plantarflexed metatarsal, but you would need to be able to establish medical necessity for whatever you are providing.

My CTP LCD stipulates that I must offload a DFU, yet the DME policy does not recognize offloading as a covered diagnosis. What should I do?

Wastage is a big issue for CMS and its contractors. Technically most of the LCD and PA stipulate that providers should attempt to use a CTP that comes as close as possible to the recipient site. Blatant disregard to this will likely get you into some trouble. In any case, one should be very specific in choosing any specific CTP and document the rationale the specific CTP and size was chosen.

The sales representative from a specific company is telling me that I can only buy one size of a specific graft because that is the only available size. They tell me I can bill whatever is not used as wastage. Is this correct?

If you feel very comfortable answering their questions, by spoon feeding them exactly where the information is in your medical record stating they must have overlooked the information then you’re detailing the answers only helps to win. If you do not feel comfortable answering, do not take it into your own hands, hire a professional who handles appeals.

I received a CERT audit, and they are requesting items which are part of my medical record, what should I do?

Total Contact casting (CPT 29445) would be amended with a 59 as the first modifier (as the payment and distinct separate service). It would then have LT as the secondary modifier. The ICD10 would then need to be the appropriate LT for depth and site. For the right side the appropriate depth CPT code (e.g. 11042) would be billed and modified with RT modifier again using the correct ICD10 signaling the correct depth and site of that ulcer. The rationale here is that the cast (29445) is according to the Correct Coding Initiative a component of the 11042 and thus not separately payable. Use of the 59 on the LT and and the site modifier on both claim lines would signal to the carrier that because of the separate site, there is an exception to the CCI and thus both are payable.

Yes, TCC CPT code 29445 would have a left foot and leg ICD-10-CM diagnosis. Because of bundling concerns, two modifiers would be needed, Modifier 59 and LT appended to the procedure, 29445-LT-59. For the right foot ulcer debridement, it is necessary to show a diagnosis the right foot only, ie: L97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed and that diagnosis is only paired with CPT 11042.

Can I get reimbursed for a total contact cast (TCC) on the left foot and leg that is unrelated to the ulcer debridement on right foot?

No. In light of the initial procedure, L3000, not being a covered service, the billing of CPT 97763 would not be paid. Additionally, if the patient did in fact meet the criteria for the use of custom functional foot orthotics, L3000, the dispensing and education on the use of the devices would be included in the billing of L3000.