It's nice to be in the loop on current billing matters, even when you're not the one addressing them directly. I'm going to share with you some of the top Medicare denials that Podiatrists face today, and how to avoid them.
1. If you provide routine foot care, this is likely your number one trending denial.
Common CPT codes include 11055, 11056, 11057, 11719, 11720, 11721, and G0127. When billing these codes, either a class findings modifier (Q7, Q8, or Q9) or a primary diagnosis code (such as B35.1) that implies medical necessity must be accompanied.
When routine foot care is clearly needed but the coding parameters cannot be merited to support it, such complicated matters can often be bypassed by providing the PCP, attending physician, or referring provider information (box 17) along with their last seen date with patient (within 6 months). I recommend adding this to the patient intake form, so it's always available when needed as a backup.
2. DME denials are also very common in podiatry, orthotics, braces, and cam walkers especially. When billing for an ankle brace, for example, Medicare will want to know whether it's left or right, so don't forget LT or RT modifiers. When billing bilateral DME, Medicare normally requires separate charge lines rather than placing LT and RT on one line with two units - which is a common error we find in some providers' superbills.
Commonly missed modifiers for DME include NU (New purchase) and KX (implies all documentation and coverage guidelines met). Some HCPCS will not be reimbursed without these.
3. Surgical denials are most prevalent when the POS code doesn't match the facility type. Be sure to check that the service location's NPI and the charge line's POS code are properly aligned with their Medicare credentialing.
Like DME, another surgical billing issue can be related to lateral issues. Depending on your MAC, they may prefer the 50 modifier with multiple units when billed bilaterally, all on the same charge line. Also, don't forget to specify toe modifiers when applicable.
4. This one may seem obvious, but we still see it so often on the superbills we review before submitting. When billing consultation visits such as evaluation and management codes, a 25 modifier is needed on the E/M code if bundled with other procedure codes. In some cases, the other bundled codes will require a 59, XU, XP, XS, or XE.
5. In any case, RVUs are important and easily overlooked. The procedure code with the highest RVU rating should always be listed on the first charge line. It's ideal that you have a PM software and clearinghouse with reliable scrubbing that will catch such errors.
Be sure to reach out if you ever have any questions in regards to billing and coding matters.
Be sure to share this information with any other fellow podiatrists who you believe would benefit from it.