Part B Insider (Multispecialty) Coding Alert

Published on Tue Jul 25, 2006 PDF

Why fraudulent diagnosis codes landed a podiatrist a 33-month prison sentence

Same-day evaluation and management (E/M) services and routine foot care (RFC) often present Medicare coding troubles for podiatrist practices, but treading carefully when applying modifier 25, and knowing your RFC how-to's can save you reimbursement headaches. Here's why.

True story: A podiatrist's office billed same-day office visits and surgical procedures when two separate services weren't rendered. The podiatrist also tried to pull a fast one on Medicare by billing for 16 ingrown toenail surgeries that were found to be routine foot care services. The podiatrist "listed fraudulent diagnosis codes on Medicare claim forms and falsified progress notes in order to receive reimbursements," according to a U.S. Department of Justice news release. Result: Late last year, a Las Vegas podiatrist was sentenced to 33 months in prison for 67 counts of healthcare fraud.

Podiatry is one of the leading users of modifier 25 (Significant separately identifiable evaluation and management services...), and Medicare continues to keep a close eye on appropriate use. The E/M service to which you append 25 must be significant and separately identifiable from the procedure rendered on the same day.

Lesson 1: Practices must recognize that all minor procedures have built into them a small degree of history, exam and medical decision-making, says Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Shrewsbury, NJ. Modifier 25 indicates for the payor that the E/M goes beyond the included history and physical to a much more significant level.

Lesson 2: As frustrating as it can be for podiatry offices, Medicare is firm that RFC--paring or cutting of corns and calluses (11055, 11056, 11057); trimming of nondystrophic nails (11719, G0127); and nail debridement (11720, 11721)--is never covered without documentation of a systemic condition.