Common In-Office Procedures And Reimbursement: What You Should Know

In residency, our primary focus is on the big surgical cases. Cases involving flatfoot reconstruction, ankle fractures and/or external fixation are the types of cases in which we hope to participate. However, this isn’t the reality of smaller, private practice settings where the majority of residents will eventually practice. For this reason, we need to recognize not only the importance of more common podiatric procedures but the differences in reimbursement for facility and non-facility procedures. 

Facility procedures refer to those performed at a hospital (including a physician office in and owned by a hospital), ambulatory surgery center, nursing home, etc. The non-facility location refers to a privately-owned physician office. The facility reimbursement is lower as it assumes that the physician is not paying for the staff, supplies or other overhead. The non-facility reimbursement is supposed to help cover such expenses. This reimbursement difference is not present for all Current Procedural Terminology (CPT) codes but it does apply for many podiatric procedures.

Another aspect to consider is time management. For example, an instep fasciotomy is a quick procedure that does not require any special equipment. If one does the procedure at the hospital, the physician timeline might begin with the doctor’s arrival at 7:00 a.m. for a 7:30 a.m. case. By the time the patient is brought back to the operating room, positioned, adequately anesthetized and has sterile prep, it is nearly 8:00 a.m.. The actual procedure takes 15 minutes or less, and the patient is awake and inthe post-anesthesia care unit (PACU) by 8:30 or 9:00 a.m.. The physician returns to his or her office for scheduled patients after about two to three hours. 

All of these steps occur, only to recieve a lower reimbursement than if done in the office. Consider the same potential patient in the office setting. The physician has control over when the patient is scheduled for the procedure. The physician can see other patients while the patient is prepped by staff for the surgery. The procedure takes 15 minutes or less. The physician moves to the next treatment room and begins seeing more patients with no additional loss of time. This scenario holds a higher reimbursement with no lost time at the clinic. 

Aside from time and monetary advantages, office procedures must be safe for the patient. There also needs to be enough space and the right equipment for the physician to perform the procedure. One must perform this risk-benefit analysis for every case. The patient also must be able to tolerate being awake for the procedure. If so, not needing anesthesia services aside from local anesthetic could potentially save the patient thousands of dollars in hospital bills. 

Below is a discussion of some of the in-office procedures podiatrists commonly perform in my area. I will list applicable CPT codes and reimbursement estimates. Codes are only examples and may vary depending on the level of documentation of the procedure. Your coding may be different. Any coding feedback in the comments is very appreciated. These reimbursement estimates are based on the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool (see https://www.cms.gov/apps/physician-fee-schedule/overview.aspx), using the first result. Depending on your Medicare Administrative Contractor (MAC),the fee schedule may be different. 

Neurolysis. Podiatrists often perform intermetatarsal nerve decompression in the office for a symptomatic neuroma. In our area, this is colloquially termed a neurolysis procedure although one leaves the nerve intact. This procedure involves making an incision in the intermetatarsal space and transecting the intermetatarsal ligament to allow the nerve more space and free any entrapment the ligament is causing. One would close the incision with nylon only and no deep sutures. The office cost for this procedure is low. It is typically billed as 64726 or “release of plantar digital nerve.” Reimbursement for this code is around $281. This procedure takes approximately 15 to 20 minutes. Anecdotally, our regional attendings state this procedure works well for intermetatarsal neuromas and the majority of patients do not need future neurectomy. 

Instep Plantar Fasciotomy. Although covered in part above, it is another procedure that takes approximately 15 minutes, requires little instrumentation and surgeons close it only with nylon skin sutures. CPT 28008 applies for “incision of foot fascia,” and reimburses around $450 at the non-facility rate. One may use the CPT code 28060, “partial removal of foot fascia,” if he or she performs a plantar fasciectomy. This reimburses approximately $540 at the non-facility rate. Again, this can be very cost-effective in the office setting. 

Tenotomy. Podiatrists commonly perform flexor tenotomies in the office for digital contractures that can lead to or have created a wound. One can perform these procedures with an 18-gauge needle or a blade, depending on preference and need for capsular release. Skin closure is all that is necessary in terms of suture. The CPT code 28010 for “percutaneous tenotomy of toe” pays around $240 in the office setting.  A flexor tenotomy can take less than a minute with a few additional minutes for suturing, making this a very cost-effective office procedure.

Amputations.Partial and complete digital amputations can be simple and quick procedures depending on the situation. For the right patient, the office may be a reasonable choice of venue. For an amputation at the interphalangeal joint, one may use the CPT code 28825 for “partial amputation of a toe,” which reimburses around $558. If the surgeon performs an amputation at the metatarsophalangeal joint (MPJ), CPT 28820 reimburses around $583 in the office. 

Office procedures can be efficient and profitable as well as being beneficial to the patient. Patients can avoid large hospital bills while still undergoing a procedure. Office-based procedures can be a vital part of providing adequatecare as well as being financially beneficial to one’s practice. 

Dr. Bishop is a third-year resident at Alliance Community Hospital in Alliance, OH.