Coding

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)

“I saw an established patient who returned to the office for At Risk,” Routine Foot Care. The patient also had a new complaint of heel pain. I obtained X-rays the foot and gave a steroid injection in the heel. Can I bill for the Routine Foot Care and those treatments as well?”

“I performed a Lapidus bunionectomy that went on to a subsequent nonunion of the arthrodesis site. We are planning a return to the operating room to revise it. Any suggestions on the best ICD-10 code and best CPT code to use in this situation?”

For an unannounced Durable Medical Equipment (DME) site visit, you'll need to have readily available documentation demonstrating compliance with DMEPOS supplier standards, including licensure, insurance, inventory, complaint resolution protocols, and instructions for beneficiary use. The inspector will verify this information and may also take photographs of the facility. This should not be a surprise. When you applied for your DME ID number, you filled out the Medicare enrollment application, form CMS-855S, and when you signed the application, you agreed to follow the rules. Here are the rules for what needs to be present when an unannounced DME on site visit occurs.