Coding

“We had a patient present with a fracture of her foot. The debate in the office is the ICD-10-CM definition of “subsequent care” as it refers to trauma. We saw the patient, diagnosed a fracture, and chose to treat with conservative care. Would those follow up visits be considered “subsequent care” or “initial care” while we follow through with the initial treatment for the fracture? Thank you for the input.”

“We are wondering if you might be able to help us with the following matter. We are finding that it may be possible that insurance companies may pay for interpretation services for patients. Are you able to confirm this? If so, do we put something specific on the claim and send the invoice as well? We are just trying to figure out how to offset some of this cost as most of the patients that require interpretation are coming in for nail care and it costs us more to pay the company than we get for services provided. Any help you can provide would be greatly appreciated.”

Consider an internal audit referred to as a compliance audit of your chart notes/medical record documentation and billing/coding to determine if you are potentially at risk of an audit or clawback by CMS, the Centers for Medicare and Medicaid Services or by a commercial health insurance carrier and determine what steps need to be taken to mitigate those risks. It is inevitable that in all likelihood a provider will be audited. An audit should never be more than an inconvenience. It should not be a life-changing event. If a clawback takes place, it would be bad enough if face value reimbursements were requested after the fact. Unfortunately, this is usually not what occurs. The assumption is that since the billing, coding and documentation did not support the claim(s) that were filed, the requested amount to be repaid will be far greater. Interest, penalties and an extrapolation is instituted referred to as the Statistically Valid Random Sample or SVRS that will result in an amount that needs to be repaid that is far greater than what was initially reimbursed.

The Proper Use of the 25 Modifier

“I am a retired DPM and closed my business. Medicare is wanting recoupment on some DME items from 3 years ago. They can’t recoup it through the claims obviously since I’m not practicing. They are asking me to directly send in the money. Do I need to pay this and then appeal? Should I appeal and not pay? What are the rules in this situation?”

For the “At Risk,” Routine Foot Care patient, can a mycotic toenail be debrided, and a corn/callus be trimmed on the same toe?

“I have a patient who had a bunionectomy. The patient was diagnosed with a post operative infection within the global period which required evaluation and management. I billed for an office visit, but Medicare will not pay. What am I doing wrong? I used 24 as a modifier.”

“I have had a RAC audit for a L1951 (from performant) claiming an overpayment stating, “the custom- fitted orthosis did not include a detailed description of the necessary modifications.” L1951 is a prefab which does not require modifications. Where can I go to get any documents (Medicare preferred) stating that L1951 is prefab and as such does not require modifications to respond to this demand?”

“Can I bill a level 4 E/M code if a patient presents with multiple unique, separate identifiable complaints that I am treating? For example: A patient comes in with complaints of a hammertoe and plantar fasciitis. I am treating both. Can I code a level 4 code and be justified based on the time?”

Top 10 Edits in May 2025 Source of information, National Government Services, Inc. (NGS)