Coding Pearls

“We received a request for medical records from Qlarant, who apparently is contracted with Medicare to review records for medical (and, of course, payment) necessity. In this case, they’ve asked for chart notes for ten different patients, one date of service for each patient. We’ve never been subjected to this type of review previously and want to do everything possible to make sure that we submit the appropriate and sufficient records and that we submit them in the appropriate manner. Obviously, we’re also concerned that this inquiry is a fishing expedition that could trigger some larger audit. Is there any advice that you can provide that might help us through this process? In our review of the records that were requested we did notice a few minor billing errors, but we believe that the records substantiate payment for all treatment that was performed.”

As of December 24, 2025, CMS has withdrawn (not delayed) the Local Coverage Determinations (LCDs) for skin substitute grafts that were scheduled to take effect on January 1, 2026. Because these unified policies have been eliminated, there is currently no revised version of that specific LCD scheduled for 2026.

“Diabetic pt came in for “At Risk,” Routine foot care. This patient is coded with E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene.

In 2002, an OIG report found that Medicare inappropriately reimbursed podiatrists for Routine Foot Care Services that were found to be medically unnecessary and insufficiently documented. Since the OIG had not reviewed podiatry services since that report back in 2002, an audit was conducted to determine whether these compliance issues continued to exist during the subsequent audit period, 2019 and 2020. The audit examined whether podiatrists’ claims for Routine Foot Care Services related to a covered systemic condition complied with Medicare’s requirements. Of the 100 claims that were sampled, 49 claims for Routine Foot Care Services related to a covered systemic condition did not comply with Medicare requirements. As a result of the audit, the OIG opined that CMS’s oversight may not have been sufficient to prevent improper payments. The OIG estimated that of the $18.2 million paid by Medicare during the audit period, approximately $4.4 million did not comply with Medicare’s requirements.

In 2019, the OIG performed an audit of claims that were billed by podiatrists for E/M services. The audit examined whether podiatrists’ claims for E/M services billed with the 25 modifier, which indicates that the E/M service was significant and separately identifiable from a minor surgical procedure billed on the same date of service, one that has a postoperative global period of 0 or 10 days, complied with Medicare’s guidelines. One hundred (100) claims were sampled, and it was found that forty-four (44) claims did not comply with Medicare’s guidelines. The OIG estimated that $39.6 million of the $222.5 million paid by Medicare during the audit period was inappropriate. It was found that during the audit period, CMS’s oversight may not have been sufficient to prevent improper payments.

I have a patient with diabetic peripheral neuropathy and foot ulcers. I have been debriding the ulcers every two weeks, and we have billed out CPT 11042. Cigna has denied our latest two claims and the EOB says, “Procedure code is invalid for DOS and global.” There is no global for CPT 11042 and there should not be a procedure code invalid for any DOS with these claims. Any thoughts on what to do next?

“I know with Medicare and Medicaid you bill any DME the date of dispensing. I am curious about commercial insurance plans. Can you bill the day you cast for devices?”

Can the use of an interpreter (ie. different language spoken, hearing impaired) increase the level of E/M service based upon time?

Acceptable methods for handwritten signatures are: 1. A legible full signature 2. A legible first initial and last name 3. An illegible signature accompanied by signature log or attestation statement 4. Initials over a printed or typed name 5. Electronic signature

“Need advice on codes and modifiers.... My associate removed painful hardware from a previous Lisfranc dislocation repair (only removed the hardware from the 1st met-cuneiform joint, not the other tarsometatarsal joints), and redid a 1st met - med. cuneiform arthrodesis with new hardware. He also did a sliding calcaneal osteotomy with fixation. He did a 1st proximal phalanx osteotomy. All on the right foot. Highmark insurance in PA was the health insurance carrier.