08/09/2022    Name Withheld

CMS Audit

Last week, I received a letter from First Coast
Service Options, my jurisdiction for Medicare
Administrative Contractor (MAC), informing me that
CMS (Centers for Medicare and Medicaid Services)
has authorized First Coast to conduct a Targeted
Probe and Educate (TPE) review process. Simply
stated, I am going through a Medicare review. The
TPE review process includes three rounds of a pre-
payment or post-payment probe review with
education. This is set up to be an educational
process from Medicare to make sure my
documentation pertaining to routine footcare and
nail services meets the requirements Medicare sets
in place for reimbursement of these services.

TPE review processes are very common for many
services that Medicare determines have a high rate
of errors, fraud or abuse. DME, wound care,
routine footcare, and more are common areas for
these probes. They are started when CMS determines
that an individual physician's billing tendencies
are "outside" of the norm as compared to other
physicians within the same specialty. I won't get
into the technical aspect of the TPE's but the
bottom line to this pre- and post-payment review
is that if your documentation doesn't meet
Medicare's requirements, recoupment of payment by
Medicare is possible.

If you should receive a letter like this, it is
important to have legal guidance and education.
After receiving this letter, my first call was to
my malpractice carrier (PICA) to seek guidance.
PICA's malpractice policy includes medical
representation for such audits. I am sure other
malpractice carriers provide some type of medical
representation in these situations. Please note,
this representation by carriers includes legal
defense, not coverage if recoupment of payment is
necessary. If anyone gets this type of letter from
CMS, it is imperative that you seek legal help. In
many cases, this type of guidance is included in a
malpractice policy. Seeking this help in no way
should be considered an admission of wrong doing.
It is an invaluable tool a physician has at their
disposal to provide legal guidance in these
situations.

Name Withheld

Other messages in this thread:

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07/18/2024    Michael G. Warshaw, DPM, CPC

Noridian CMS Audit for CPT 11730

CPT code 11730 is defined as the following:
Avulsion of nail plate, partial or complete,
simple; single. Unfortunately, it is one of the
most frequently audited CPT/procedure codes due to
the improper performance and documentation of this
procedure.

Here are the important facts regarding the
performance and documentation of CPT code 11730:

1. Documentation must describe the symptoms and
complaints which establish medical necessity for
the treatment.
2. Nail or Nail border must be separated and
removed to and under the eponychium.
3. Local anesthetic (type and quantity) must be
documented. If not used, provide
rationale (i.e. Neuropathic patient, patient
refused, medical contraindications).
4. Post-operative instructions and follow-up care
should be documented.
5. If the medial and the lateral borders are
removed on the same nail, only one service can be
billed.
6. Cannot bill an I&D and avulsion or partial
avulsion on the same nail.
7. CPT codes 11730 and 11732 for nail avulsion will
be denied if billed for the same finger less than 4
months (16 weeks) or the same toe less than 8
months (32 weeks) following a previous avulsion.
8. For a reasonable and necessary repeat nail
avulsion on the same finger less than 4 months (16
weeks) or the same toe less than 8 months (32
weeks) following a previous avulsion, the KX
modifier must be appended to the claim. The medical
record documentation must be specific as to the
indication, such as ingrown nail of the opposite
border or new significant pathology on the same
border recently treated.

With respect to the request from Noridian for 4
Medicare patient medical records, specifically for
CPT code 11730, the fact that the office notes are
handwritten should not be an issue if an exact copy
of the medical records in question are typed and
accompany the handwritten records when they are
submitted.

If the medical records in question are “not in the
great detail CMS guidelines suggest,” it would be
highly inappropriate to alter or change the
documentation, especially since the procedures were
performed “last year.” If the office notes include
the chief complaint/HPI, the objective findings and
the treatment, specifically that local anesthetic
was injected and the nail border in question was
avulsed to and under the eponychium, hopefully this
will pass the test.

This is my opinion.

Michael G. Warshaw, DPM, CPC, Mount Dora, FL

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01/25/2023    Lawrence Kobak, DPM, JD, James Tudor, XPX, PCA

CMS Audits for Routine Foot Care

Lately, we have been involved with a spate of CMS
audits involving routine foot care. The chief
problem the government auditors still find, is a
lack of proper documentation.

First, there is sometimes a failure to sign the
chart note in a timely fashion. Secondly, the
services must be medically necessary. When not
diagnosing onychomycosis, the necessity is
evidenced by referencing class findings. This is
often misunderstood. If you are using two Class B
findings, at least one of them must be for an
absence of either the DP or PT pulses in the foot
or feet being treated.

The other Class B finding may consist of any three
of the advanced trophic changes: decrease or
absence of hair growth, thickening nail changes,
discoloration, skin texture being shiny and/or
thin, and akin color being rubor or redness.
Alternatively, the second Class B finding may be
the other absent pedal pulse; i.e. absent DP and PT
pulses on the foot (feet) being treated.

If you only have one Class B finding of an absent
pulse, you will need an addition of two Class C
findings. Class C findings consist of a finding of
claudication, cold feet, edema, paresthesias or
burning in the feet. Class A findings only requires
one finding of a non-traumatic amputation of a foot
or toe(s).

Common deficiencies found in notes include:
1. Inconclusive as to whether the patient is under
the active care of a physician for the complicating
disease, such as diabetes;
2. Necessity of care given status of patients
systemic condition(s) in context with current
activities such as pain upon ambulation;
3. Errors or omissions in general recordkeeping,
such as illegible notes, undated notes, name of
patient missing, not signed by podiatrist;
4. Class findings poorly describe in chart;
5. Deficient procedural documentation (location or
method of procedure unclear, treated nails are
unidentified or note is inconclusive, lack of
substantial narrative;
6. Cannot ascertain if nails were trimmed or
debrided; there is a difference! It involves a
different CPT code. Debridement involves reducing
the thickness of the toenail- state how this was
accomplished.
7. Chart does not support the frequency of
services- especially when treating the same thing
more frequently than every 60 days.

Lawrence Kobak, DPM, JD, James Tudor, XPX, PCA