Dez Bryant and why where you break your bone matters

If you are a fantasy football person like me, you are always checking your players status. Are they injured? Are they not going to play due to some suspension? Ect...But when of your players has a blatant injury like that of Dez Bryant this past weekend, the speculation monsters come out of the woodwork.  Also, now in the world of instant access and social media, the injured player might Tweet how great they feel right after surgery. (after foot surgery your foot is still pretty numb right after, so keep that in mind)  If there is any one piece of advice I can give you regarding an injured NFL player, take all the information you can take in from the most educated people talking about the player's issue.

If you follow football you are hearing a lot about 5th metatarsal fractures and surgery.  The next 6-8 weeks are going to give Mr. Bryant some time to think and invariable take up more time in my office.  NO HE IS NOT MY PATIENT, but my patients know who he is and they are coming in with more questions than normal.(I am pretty sure they are also fantasy footballers too)

We see several fractures a week in our little practice in Clermont Florida.  When I see patients who have had an injury to the outside of their foot near the 5th metatarsal region, I always thinks to myself, "Please don't let it be a Jones Fracture, let it be an avulsion fracture of the 5th metatarsal instead." An avulsion fracture is a fracture of the part of the 5th metatarsal, if you reach down and touch the outside of your foot just past your heel the boney prominence you feel is what kind of rips off the rest of the bone. A large reason I feel this way for the "normal Joe" is if the fracture is an avulsion they don't necessarily need surgery.  Most patients have jobs, family stuff and just don't want to be laid up anymore than they have to.  Surgery puts them at a new risk factor for several problems: post op infection, non-union, complex regional pain disorder and even DVT.  Many times with a non displaced avulsion fracture, a patient can go into a walking cast, no crutches and continue on with many everyday life activities in a boot for 8-12 weeks. These fractures tend to heal very well even in the worst patients.  The blood supply to this area of the bone is very good and lends itself to normal healing.

It has been reported that Dez Bryant has a Jones Fracture.  This fracture is at the base of the 5th metatarsal but a centimeter or so past the 5th metatarsal tuberosity that we mentioned above that is palpable on the outside of your foot.  This type of fracture is a much different beast due to the fact that the blood supply to this region is far less optimal. There is a high incidence of nonunion(bone not healing in this area due to lack of blood supply). The biggest problem for you if you have Dez Bryant on your fantasy football team, is that you really don't know if he had a Jones or an avulsion fracture.  See even though the the average Joe may not have surgery for an avulsion fracture, a world class athlete is going to have surgery most likely for both of these scenarios.  Their livelihood depends on getting back on the field in optimal shape ASAP.

Either way, the recovery for one, the Jones fracture, is slightly more guarded and could even be 12 weeks or more before the player makes it back to practice.  The avulsion fracture repaired could see him back practicing at 6 weeks.  I don't have Dez Bryant in my line up but if I did I would drop him, 6 weeks is a long time to have someone just sitting on your bench and 12 weeks is even worse.  But once he is fully recovered he should be back to business as usual.  Dr. Henne, the other foot doctor in my office, also my husband and in the same fantasy football league as me says he would keep him because even if he doesn't play for twelve weeks he still may be perfect for the playoffs.

More importantly, why you shouldn't waste too much time or money on ICD-10 minutia!

The answer to why you should not waste too much time or effort on the minutia codes of ICD-10 has a lot to do with how great most EMR's are with the codes.  I was playing around with my EMR as I was seeing an ankle sprain in my office today for an initial visit and this is what I got in a split second after clicking on the diagnosis of ankle sprain:

I have to say, if your EMR is not doing this for you with such ease, you may have more difficulty than it is worth navigating through the ICD-10 changes.

Yes, you should have quick reference for your most common diagnosis and procedures for podiatry.  But don't get lost in all the codes, if your EMR is up to snuff the codes will be there for you when someone walks in with a displaced talar neck fracture.

I recommend playing around with your EMR and making sure it is already set to do this for you, and if not you need to find out why.  This is a process that your EMR should be ready for well before October 1st, 2015.

http://centeranklefootcare.com/catalog/c14_p1.html

Billing Ingrown Nail under the new ICD-10 Codes

It seems as though the ingrown toenail codes that are billable to the highest level of specificity  right now are for the right and left great toenails.  I guess this is not that big of a deal, considering most of the ingrown toenails are usually the big toenails.  The old code for ingrown toenail was 703.0 is now L60.0 there is no laterality with this code but I would use this code with the other ones suggested next.  The old code for paronychia or infected ingrown nail was 681.11.  The new ICD-10 code has laterality but only for the great toes.  Right great toe infected ingrown toe nail is L03.031 and left is L03.032.  So if you are billing a 11730 or a 11750 the modifier for the toe should still be used on the CPT code.

Billing 11730 or 11750

Use the following codes:
L60.0- Ingrown Nail
L03.031- if right hallux  modifier on CPT code T5
L03.032- if left hallux    modifier on CPT code TA
M79.609 which is just pain in limb this is the unspecified pain in limb because there is no pain in limb in foot or toes specific.

This is pretty straightforward information, so far as it looks in the new world of ICD-10.  Again, in our practice, this is a procedure that we perform several times throughout the day.  I suggest knowing what you do every day inside out.  The more common things should be well established in your mind before October 1st, 2015 so this transition is smooth for you.  If you have a good EMR you will be able to look up the specific code translation from ICD9 to ICD10, and there are so many nice resources available on the web for your reference for the "zebras" that walk into your office.  Remember, know your codes for plantar fasciitis/heel pain, diabetic foot care, ingrown nails, and the other most common patients you see a day.  There is a lot of transparency in what we do, but in a good way.  Many people come to us for very simple problems and we have simple answers to help them in usually a very cost effective way.

Michele McGowan, DPM
The Center for Ankle and Foot Care
http://centeranklefootcare.com/catalog/c14_p1.html

The top 4 foot and ankle injuries we see in our youth soccer players

Top 4 foot and ankle injuries we see in our youth soccer players:

Week one of our youth soccer season is done in the Central Florida area and we have already seen several young athletes for these top 4 foot and ankle injuries in our office the Center for Ankle and Foot Care.  Our daughter is very excited to be back into the swing of things with her soccer team.  She maybe playing with even more heart than ever before after this past summer's USA Women's National Team win of the World Cup!  

With great coaching and a good supportive team, many injuries can be avoided.  Coaches and parents who focus on conditioning the children before the season really starts can help the children stay injury free.  But sometimes many injuries can happen even with the best preseason preparation.  

Shin Splints

First of all, you might be asking yourself "Self, what is a shin splint?" I will explain.  The most common type of shin splint is inflammation on the front of the lower leg.  The culprit is usually from the repetitive micro-trauma that occurs when one is running on a consistent basis. The anterior tibialis muscle belly becomes strained and starts to pull on the tibia bone causing the most common anterior shin splint.  The inflammation occurs on the bone and on the attachment of the muscle to the bone.  The repeated stress, can over time lead to stress fracture of the tibia if ignored and not addressed. 

How you get shin splints becomes an important question as well. If you want to treat and avoid getting this problem again, you have to understand the root cause.  Some people get shin splints from a very simple culprit, shoe gear. If you have ever played soccer, you may know that soccer cleats are notorious for being a flat insole with very little support. This may be a by product of many cultures playing this sport with out shoes on growing up, once we put the cleat on we still want "touch" on the ball. We tend to see this injury the most when kids are practicing on harder than normal surfaces or as the weather gets cooler and the ground gets harder.

Ankle Sprain  

It is a common scenario in soccer, you cut one way but your ankle didn't get the memo and you feel it, your foot and ankle turn in a way it shouldn't! Within seconds your outer ankle starts to swell, get red, and very painful.  If you stand up and can walk, I still would recommend you see your foot and ankle specialist.  It is absolutely best to see a specialist that can take an X-ray of your foot and ankle to make sure you have not broken anything.  Your specialist can give you advice on what you need to do to get better, write for a medicine if necessary and offer you devices that may help in the aid or care of your foot or ankle injury.    The reason I stress that you should see your foot and ankle specialist is because there are 8 plus different bones you could possible break with this type of injury. Also, a well thought plan of care is going to be better than your own self diagnosis and treatment. Just "googling" your child's symptoms, more often than not results in sub-optimal results in their outcome, and taking your neighbors advice on your child's foot problems yields pretty terrible results!

So you see your doctor and X-ray shows no fracture, SWEET, right? Well, though I think breaking a bone is not ideal, soft tissue injuries can take some time to get better, and some people struggle for an extended duration.  Convalescence of a foot or ankle injury is very important.  If you do not treat it right, it will not treat you right! It can take much longer for your little athlete to get back on the field with out proper care.

Ingrown Nails


If you do not know what an ingrown toenail is be thankful.  If you "think" you know what an ingrown toenail is you probably do not.  People who have had an ingrown nail know the difference.  If it hurts, bleeds, smells and ruins you white socks, you probably have an ingrown nail! 

Why is your little soccer player more susceptible for an ingrown nail?  The repetitive little micro trauma that occurs while playing soccer is the culprit!  Stopping and starting and quit pivoting motion that is required to fake out your opponent really does a number on your big toes and specifically your big toe nail!    

This can be a very painful problem but can be solved in just one office visit to a podiatrist.  Some kids will not show their parents their ingrown nail until it is very bad. If your child is limping at the end of a soccer game, check their feet out.  Also a good piece of advice is to check and make sure their shoes are not "too" tight.  Again, some soccer players walk a fine line of shoes that are too tight because they want that "touch" on the ball.  If their shoes are too tight ditch them and go at least a 1/2 bigger.  

Calcaneal Apophysitis(Sever's Disease)

This is probably the most common problem I see in soccer players between the age of 9 and 14.  The calcaneus is your heel bone.  What is unique about this age group is that sometime between the ages of 8 and 14 the big growth plate on this bone starts to ossify, or fuse and become a part of the bone.  As this process gradually happens over this 4 year time span, your young athlete may experience this problem more than once in their little soccer career.

Another name for calcaneal apophysitis is Sever's disease, but do not let the term "disease" fool you it is not associated with any true disease process.  But this can be very painful for your young athlete and should be seen by a foot and ankle specialist to rule out any other problem. Your child will tell you they have pain in their heel and you will google heel pain and convince yourself you child has plantar fasciitis.  They most likely do not!  

Treatment for this is pretty simple when confirmed as calcaneal apophysitis.  We have the child ice at least twice a day and put them on an anti-inflammatory for a week or two.  Usually your child's ability to continue to play soccer will truly be based on their pain threshold.  If the pain is bad, we usually will recommend a week or two of rest. 

If you are interested in learning more about other foot or ankle problems please feel free to check out our website at: http://centeranklefootcare.com/index.html. Dr. Henne and myself are Board Certified by the American Board of Foot and Ankle Surgery and treat many different foot and ankle problems. Our goal is always to get you back on your feet as soon a possible and use surgery as a last resort.

Michele McGowan, DPM
Center for Ankle and Foot Care
3150 Citrus Tower Blvd Suite B
Clermont, FL 34711
352-242-2502  

Plantar fasciitis and ICD10 coding, what do you need to know?

This is an easy one, you just need to know the new ICD-10 code from the old ICD-9 code.  The plantar fasciitis, much to my surprise, does not have laterality.  So the old plantar fasciitis ICD-9 code was 728.71 and now is M72.2.

I'm guessing that when ICD-11 hits this will change, but for now it is a pretty simple and straightforward conversion.

So a new patient with right foot plantar fasciitis would look like this:

ICD-10 Diagnosis codes:
M72.2       Plantar fasciitis
M79.604   Pain in limb right limb
M77.31     Heel spur right calcaneus(if on x-ray there is a spur and you dictate it, I would recommend this code as well.)  Being as specific as possible is going to be very important in ICD-10. The M77.31 specifies laterally for right side and the code for left heel spur is M77.32.

CPT procedure codes for this patient would be:
99203       If you have documented well and spent the appropriate amount of time with the patient you have a new patient encounter of this level.
73630 R   If you are taking X-rays in office to rule out stress fracture or evaluate possible heel spur, this is the 3 views of the foot with the appropriate right sided modifier.  But this is where we see our laterally with plantar fasciitis in the x-rays.

I hope this helps makes your life a little easier in the ICD-10 new world of billing. I know in my practice I see a ton of plantar fasciitis, so I was happy to see these codes were not terribly convoluted. If you do not have a "superbill" we have a quick reference sheet, for what we see as podiatrist most common diagnosis, available at our website at http://centeranklefootcare.com/catalog/c14_p1.html
this is an editable rtf and pdf format.

Good luck with your billing!

Michele McGowan, DPM

If you are a podiatrist, you treat diabetic feet......It's what you do! Know the ICD-10 codes you need to know for treating your diabetic patients.

 •Many people getting lost in the trauma coding but unless you are in a very high trauma practice, these should not be your main focus.

•Don’t get distracted by the coders who can’t pronounce calcaneus•Know your most common procedures and know how to code them

At risk foot care•Billing 11721•You need to document your class finds and have your Q modifiers correct•Diagnosis needed:•Must have diabetes diagnosis•Choices:•E11.40 DM2 Neuro Comp•E11.51 DM2 PVD Comp•E10.40 DM1 Neuro Comp•E10.51 DM1 PVD Comp•Must have Nail pathology
•B35.1 Mycotic Nail•If Neuro Modifier being used the DM diagnosis had it but would consider using G60.9 which is peripheral Neuropath

   Mycotic diabetic foot care for DM type 2 with neuro might look like

•Procedure code: 11721 Q8•Diagnosis codes:
•E11.40•B35.1•G60.9•Procedure Codes: 11055,11056 Q8•Diagnosis codes:
•E11.40•B35.1•G60.9•L84

Mycotic diabetic foot care for DM type 2 with neuro might look like

    Procedure code: 11721 Q

    •Diagnosis codes:

•E11.51
•B35.1
•I73.9
•Procedure Codes: 11055,11056 Q9
•Diagnosis codes:
•E11.51
•B35.1
•I73.9
•L84
Mycotic diabetic foot care for DMtype1 with neuro might look like
•Procedure code: 11721 Q8
•Diagnosis codes:
•E10.40
•B35.1
•G60.9
•Procedure Codes: 11055,11056 Q8
•Diagnosis codes:
•E10.40
•B35.1
•G60.9
•L84
Mycotic diabetic foot care for DM type1 with PVD might look like
•Procedure code: 11721 Q9
•Diagnosis codes:
•E10.51
•B35.1
•I73.9
•Procedure Codes: 11055,11056 Q9
•Diagnosis codes:
•E10.51
•B35.1
•I73.9
•L84
•If you are a practicing podiatrist seeing diabetic patients can decrease the possibility of them having a non traumatic amputation tremendously
•In the study by Weck, et al, in Cardiovascular Diabetology, 2013. Instituting a structured diabetic foot program can yield a 75% reduction in amputation rates and a near four-fold reduction in inpatient mortality.
•It has been proven time and time again in peer reviewed literature, that these patients who have diabetes that visit the podiatrist are much less likely to have an amputation of an extremity. 
• Podiatric medical care in people with history of diabetic foot ulcers can reduce the high level amputation between 65% and 80%. Gibson, et al, Int Wound Journal 2013. 
Ulcer diagnosis in diabetics
•If your patient is Type 1 diabetic with an ulcer the diagnosis code is:  E10.622
•If your patient is Type 2 diabetic with an ulcer the diagnosis code is: E11.622
•These codes are the highest level of specificity for the types of Diabetic Ulcers we see in the office (do not confuse with pressure ulcers, different codes)
•This is a good improvement, as all of the ulcer codes used to be jumbled together whether they were pressure, diabetic ect.
•Coding for Diabetic Foot Ulcer debridement
•11042, 11043 and 11042 use modifier L or R
•There is no laterally in the diabetic ulcer codes themselves so laterally is still in your procedure codes
•Diagnosis: 
•E11.621 Type 2 dm with foot/ankle ulcer
•E10.622 Type 1 dm with foot/ankle ulcer
•To be specific as possible I would consider also coding their diabetes
•Choices:
•E11.40 DM2 Neuro Comp
•E11.51 DM2 PVD Comp
•E10.40 DM1 Neuro Comp
•E10.51 DM1 PVD Comp
•Yes they have diabetes and an ulcer. But documenting the DM2 Neuro E11.40, for example, is letting them know that the diagnosis of ulcer is “due to” the Neuro Complications
•This makes this much more specific

Check out our website at: http://centeranklefootcare.com/catalog/c14_p1.html for a superbill for podiatry most common codes

ICD-10 It is almost here! What podiatrist need to keep in mind-don't lose yourself in the details!

The October 1st deadline is quickly approaching for ICD-10.  Of course the question we are all asking is- "am I ready?"  But the follow up questions are, "is my staff?", "is my billing company?", "is my coding person?"  The reality is none of us truly know.  Insurance companies have the upper hand on this one.  We can only try our best to be prepared but the absolute word of caution I have for you is, do not rely on anyone else other than yourself to know what you need to know.  As a podiatrist, you know you have to be a little more scrappy than the other specialties.  We know modifiers, as we have the craziest modifiers and are a modifier specialty in our procedure codes.  So you should not fear the new diagnosis codes that are followed by: A D G S for the trauma fracture codes for example.

After one week of billing you will remember easily that when seeing fractures these letters will trail your diagnosis:

• A, Initial encounter for closed fracture
• B, Initial encounter for open fracture
• D, Subsequent encounter for fracture with routine healing
• G, Subsequent encounter for fracture with delayed healing

I have struggled to the level of specificity that is truly needed for your claim to be considered clean.  If you bill 73630 for example, for x-rays right side for a right foot 2nd metatarsal fracture non-displaced, the exact code is S92.324A.  There is also a code of S92.301A that is fracture of metatarsal closed right foot that would most likely get this claimed covered for you as well, but none of us are exactly sure yet. On my superbill I did not included every fracture of every bone.  My recommendation is to have a cheat sheet for fractures of metatarsals laminated and put in your office and at every desk in your office where staff members sit. We have this cheat sheet available and included with our Podiatry specific ICD-10 Superbill.  This is available at our website at: http://centeranklefootcare.com/catalog/c14_p1.html

But at the end of the day, what you need to make sure you know how to bill inside and out is your most common diagnosis with your most common procedures.  Sure I see trauma, but I see a lot of plantar fasciitis, posterior tibial tendonitis, peroneal tendonitis, ankle sprains, ulcers and diabetic foot care.  I will tell you that these are clear and very straightforward for the most part in ICD10. We are all in this together and should not be overwhelmed by the bean counters. 

Good luck as October 1st, 2015 nears closer!

Michele McGowan, DPM

Are you frustrated with impending ICD-10 quickly approaching? We have made it a little easier for other podiatrists!

If you have not yet put together a Superbill to make it easier for yourself or your staff you may want to check out ours.  We have put together the 50 plus most common codes used by podiatrists, because we are podiatrists this was the easy part.  The hard part was converting each code to the level of specificity needed for ICD-10.  There are many mumbling conversations where people are excited to not have to code perfect for the beginning of the ICD-10 transition, but our specialty of podiatry is so specific, why not do it right from the start?

We have available a customization format where will email you a word, rtf and pdf  format.  The superbill has the most common podiatry diagnosis and the most common podiatry procedure codes.  It is an excellent way to keep you and your staff from going crazy trying to convert on the fly.  You may need to change some codes if some of the codes change, but this will be easy as you will have the master copy!

This Superbill is available on our website at : http://www.centeranklefootcare.com/catalog/c14_p1.html 

Below are just some of the podiatry specific diagnosis on our superbill that is pictured above but with the specific detail needed.

• abscess  toe
• hallux valgus
• hammer toe
• achilles tendonitis
• tarsal tunnel
• diabetic foot care codes
• plantar fasciitis
• ankle sprain
• ulcers
• and much more 

Good luck to everyone as you prepare for this next journey in healthcare!

Fellow Podiatrist, Are You Ready For ICD-10?

When we thought in 2013 that ICD-10 was going to happen in 2014 we did extensive work on getting ready for the changes.  As the ICD-10 was postponed until this year, were lucky enough to be able to say "yes we are ready for ICD-10!" 

Of course, there are so many layers to being ICD-10 ready.  Yes we have an amazing EMR and Billing company that are linked seamlessly.  This does make the transition much easier.  But being a little type A personality and wanting to make sure we were the captain of our ship, we painfully went through our most commonly used diagnosis codes and then converted them into the ICD-10 format.  Our practice is a very typical podiatry practice with a very nice mix of in office procedures, out-patient surgeries and of course in patient diabetic debridements and amputations.  

We wanted to make this transition easy for us and our staff. Here you can see our example and the way we made this easy on our superbill:

The ICD-9 on the left hand side with the ICD-10 on the right hand side with brief description in the middle will make the transition easier for all hands involved in the billing process. As we completed the over 50 most common diagnosis that might be seen by a typical podiatrist and the most common procedure codes all on one sheet of paper we thought we were set. Then we were approached by another podiatrist who was looking for something like we had just completed.  He was happy to not have to do the leg work and wanted to pay us for our time.  Though it took forever to complete this task, I could not see charging him an arm and a leg(no pun intended) so we came to the agreement of $75.  We gave it to him in an email in word document which he was able to adjust and edit to his liking.  We gave him the disclaimer that we can not predict if insurances will change the game with some of these codes but these are these most accurate conversions with the correct side designations. 

So with the same disclaimer in tow, we would like to see if anyone needs a concise complete one page superbill that you can customize by adding or subtracting codes at your leisure.  If you do not have a superbill that is ICD-10 ready, ours is a very good start to making your transition with less stress.  We are in no way shape or form promising that insurance companies will not try to continue make all of our lives more difficult as doctors, but that this may help your transition be smoother. 

If you are interested in using our superbill, check out our website where you can order it online and we can email it to you directly in a format that you can edit it in Word or PDF.  http://www.centeranklefootcare.com/catalog/c14_p1.html