Coding Pearls

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?

“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.

“My clinic is at the local hospital. I send X-rays to the radiology department. They are eventually read by a radiologist. However, I actually evaluate the x-rays and interpret them myself. Can I bill that component of the radiology fee? And if I do, will it affect the radiologist reimbursement?”