Stay Ahead of Audits in Your Office
And learn to perfect your podiatry modifier usage going into 2026. During her HEALTHCON Regional 2025 presentation “Podiatry Compliance Essentials: Preparing for Audits and Avoiding Denials,” Jennifer McNamara, CPC, CDEO, CPMA, CRC, CPC-I, CGSC, COPC, COSC, explained that podiatry has always been on the audit radar due to a high volume of denied routine foot care and nail debridement claims, the frequent improper use of modifiers, and a history of improper medical necessity documentation in claims involving wound care and skin substitutes. Read on to learn more about perfecting your use of necessary modifiers and understanding important recent updates for the use of skin substitutes in 2026. See the CMS 2026 Skin Substitute Updates McNamara explained that per the Centers for Medicare & Medicaid Services (CMS), skin substitutes may be: These materials are to be used for chronic or non-healing wounds like diabetic foot ulcers or venous leg ulcers. The materials are not to be confused with full skin grafts, but are used instead to provide a scaffold to allow a wound to heal. At the time of McNamara’s presentation, CMS was still proposing a shift to move away from current biological payment treatment that could impact practice office reimbursement. The agency was still considering classifying many skin substitutes as incident-to supplies. “They don’t understand that you’re a physician office; you’re an ambulatory surgical center [ASC]; you’re an outpatient department. You don’t get to bill separately for certain things. The supplies are just included in the procedure,” she said. “What Medicare is proposing then, if it’s not a true biological, they will reimburse you,” McNamara explained. She highlighted a couple of typical podiatry HCPCS Level II codes for biologicals, including Q4101 (Apligraf, per square centimeter) and Q4106 (Dermagraft, per square centimeter). Previously, these were separately paid as biological products. However, according to the 2026 Medicare Physician Fee Schedule final rule, they will now be compensated as incident-to supplies starting January 1. Incident-to defined: These are medical supplies that are used as part of a doctor’s professional services. They are billed under the doctor’s provider number, even if other staff members actually provide them. The supplies are considered “incident-to” if they are an important, but a secondary, part of the doctor’s diagnosis or treatment. The doctor must be actively involved in the patient’s care and provide direct supervision for these supplies to be classified as incident-to. “In other words, they are going to bundled in with the procedure,” McNamara said. Prove Medical Necessity for Skin Substitutes To prove medical necessity for skin substitutes, make sure you have ample documentation showing its necessity and you understand how to avoid red flags for audits. McNamara suggested that the patient have at least four weeks of standard wound care before the first application (for example, debridement, off-loading, compression). You must then document weekly wound measurements, which include the wound’s size, depth, and the progress of the healing. It’s important to know what most Medicare Administrative Contractors (MACs) will allow within their plans. For example, most will limit skin substitute applications to eight within a 12- to 16-week period. Keep in mind that if the provider performs more than four applications, the MACs may require modifier KX (Requirements specified in the medical policy have been met) to show medical necessity. McNamara also stressed that it’s important to use the correct application code from the 15271 to +15278 (Application of skin substitute graft…) range paired up with the correct HCPCS Level II product code. McNamara gave some helpful tips on how to avoid auditing red flags when billing your skin substitute claims: You may also need to educate practitioners about how certain codes connect to procedures. “They may just consider units [differently than you do] because of how they were trained clinically, but they don’t necessarily consider how to match this up to a code,” McNamara explained. Stay Compliant in Routine Foot Care McNamara suggested that demonstrating a connection between a systemic condition and proving medical necessity significantly increases the likelihood of receiving payment for routine foot care claims. Routine nail trimming, corn or callus removal, or hygienic foot care are not covered without a systemic condition diagnosis as these are considered simply part of personal grooming, not medical treatment. When routine foot care is linked to a risk or systemic condition, the services are covered due to: Make note: When billing for routine foot care services, you will need to include documentation showing the ICD-10-CM systemic condition, clinical findings proving the patient’s risk, and notes stating a clear medical rationale as to how failure to provide care could result in ulcers, infections, or other complications for the patient. McNamara suggested that you keep a log of overpayments and underpayments for routine foot care claims in your office. Performing a self-audit can also be helpful to see where the problem areas are. Ensure the members of your coding staff are familiar with the appropriate use of the most commonly used routine foot care codes and modifiers, such as: Conduct refresher trainings when necessary with your staff to avoid overpayments, underpayments, and audits in the future. “Are you having missing class findings? Is that why you’re not getting paid for all of these? Is it a frequency issue? Is it a modifier issue? What is the issue you are facing? Track it,” McNamara said. McNamara recommended tracking staff productivity to figure out if members of your staff are doing the right job for them. “If they aren’t happy in their job, or they’re just not getting it, they’re not helping the organization,” she added. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
