12/13/2025 Allen M. Jacobs, DPM
-25 Modifier and RFC
The -25 modifier appended to “routine care“ visits
is a subject about which I am now passionate. For
the last several years, Michael Warsaw and I have
spoken on this subject in detail at the St. Louis
Podiatry Seminar and will do so again this year.
Why? My job as a podiatrist is in no small part
the evaluation of the diabetic patient for risk
factors which increase the likelihood of skin
breakdown, infection, ulceration, and ischemia.
When such risk factors are present, my job is to
either treat or refer or both. My job is also to
improve the patient’s quality of life.
As a profession, we have accepted the role of
diabetic foot care. This is wide-reaching. Yes,
Charcot’s joint reconstruction and stabilization
is important. Yes orthoplastics is important. Yes
ulceration management is important. However, the
need for preventive care is greater in terms of
number of patients presenting to our offices.
Preventive care of the diabetic foot is multi-
factorial. Preventive care of the diabetic foot
requires time and effort in the evaluation and
treatment of the foot. Preventive care of the
diabetic foot requires reimbursement through the
-25 modifier.
Preventive care of the diabetic foot demands the
-25 modifier. I would argue that reducing the risk
of amputation requires proactive as much or more
than reactive intervention. It is more cost
effective to prevent an ulceration than to treat
an ulceration. More important than cost reduction
in dollars is cost reduction to the life and
quality of life of our patients. I would argue
that few diabetic patients attend our offices for
“ at risk “ foot care needing only care for
onychomycosis. Individuals such as David Armstrong
have a devoted career to demonstrating the need
for podiatry care in amputation prevention.
Let me sight some very basic and simple everyday
problems that point to the multifactorial nature
of diabetic pathology. Ther there are hundreds of
examples that we can give on the top of our heads.
The patient is referred by their primary care
position, to the office for diabetic toenail care.
The patient has a focal dense pressure counter
pull over the second metatarsal head. The patient
has an associated bunion. The callous and bunion
are not painful due to diabetic neuropathy. We all
know that this pressureless location is high risk
for possible neuropathic duration.
Determination as to why the calluses present and
appropriate efforts at offloading are required to
prevent the ulcer from forming. In addition, the
patient must be educated regarding the risk factor
associated with this callous. So what are the
options? Tell the patient to come back another day
because to address this problem would place the
podiatrist at risk for a Medicare audit? should we
tell this elderly patient that we are sorry for
the difficulty in getting to the office, any
possible transportation issues, the inconvenience
or those that must assist this patient in coming
to the office, but it’s just too bad because we
cannot risk a Medicare audit. should we tell them
that they will have to pay an additional co-pay
for the required visit? Is that what Medicare
wishes?
A patient presents to the office for “at risk foot
care“ on the referral of their primary care
position. They are not noted to have significant
edema. They also have some degree of sensory
neuropathy. We understand that edema is a risk
factor for ulceration due to shoe pressure as well
as the need to determine the actual etiology of
the edema. Therapies for edema reduction. In
addition to evaluation of the ideology of the
edema are important.
Compression therapy, elevation, may be required.
Again, the patient is not complaining about the
edema and was unaware of the significance of this
problem. Do we simply cut the toenails and ignore
this? Do we simply say go back to your primary
care physician who has ignored this problem and
failed to treat it thus far? Do we tell the
patient we need to evaluate this but I cannot do
it today because I fear using the 25 modifier and
having a Medicare audit?
A patient presents for “at risk foot care. All
they know is that “I am diabetic and my doctor
told me not to cut my toenails myself“. A
neurological examination by you function,
consistent with diagnosis of diabetic neuropathy,
which was unappreciated by the primary care
physician,or even the patient themselves. The
patient must be educated regarding the diabetic
neuropathy, we must evaluate for any entrapment
neuropathy, such as tarsal tunnel or spinal
stenosis, and if appropriate initiate therapy to
try to reduce the progression of the neuropathy.
Do we ignore the problem? Do we tell the patient
to come back another day? what if the patient was
referred for numbness of the foot as a primary
concern. We would do a peripheral neurologic
examination and likely initiate appropriate
therapy for the neuropathy. You would charge an EM
visit for that and be paid. Yet, if you do that on
the same day that a patient is receiving “at risk
foot care“ and attach a 25 modifier OIG has
determined this is representative of abuse.
Many diabetic patients are older, suffer from a
variety of problems which result in gait
instability and predisposition to falling. Who is
evaluating these patients for full risk and making
appropriate therapeutic interventions such as gait
and balance training with the use of an engaged
assistive device? OIG has determined this is
representative of abuse.
Many diabetic patients are older, suffer from a
variety of problems which result in gait
instability and predisposition to falling. Who is
evaluating these patients for fall risk and making
appropriate therapeutic interventions such as gate
and balance training or the use of a gated
assistive device before the patient falls and
breaks their hip and dies apparently , apparently
not the podiatrist because to do so and look
beyond toenail care his potential abuse of the 25
modifier.
A patient has cracking and scaling on the bottom
of the foot. They have thin trophic skin and are
at risk for skin breakdown and infection or
alteration because of this. You perform a
peripheral dermatologic examination, educate the
patient regarding this risk, factor, and initiate
appropriate topical therapy. If this were the only
reason for the visit, you would submit charges for
an EM visitand be paid. suddenly, because “at risk
foot care“ was also provided the EM visit is
suspicious and subject to evaluation for fraud and
abuse.
A patient has a planter medial, first metatarsal
head callous. They have a bunion, a pronated, gait
structure, edema from congestive heart failure,
sensory neuropathy, and dry skin. Anyone nose this
is a risk factor for ulceration and must be
addressed appropriately. This takes time and an
appreciation of the factorial nature of diabetic
foot ulceration. I would argue that only a
podiatric position has the knowledge and skills to
evaluate and treat the patient with multi-
factorial potential ideologies for diabetic
ulceration.
The signs and symptoms of peripheral vascular
disease is frequently not obvious in the diabetic
patient. Screening for vascular disease is
critical, and in fact the failure to recognize
such disease may be construed as medical
negligence by some attorneys. I suppose we need to
ignore any vascular evaluation or simply perform
such an evaluations and not be reimbursed for our
time to evaluate and educate and refer patients
for additional studies when required.
“At risk foot care“ is more than toenail care or
callus care. It requires knowledge of
dermatologic, neurologic, vascular, muscular,
skeletal, and biomechanical factors which, in
isolation or combination may result in skin
breakdown,ulceration, infection, or amputation. It
requires proactive evaluation and treatment of
legitimate pathology that must be attended to.
So what are the options? Well, you can follow the
path suggested by some and engage in a cash only
practice telling the patient and family that I
would like to protect you from amputation but you
will have to pay for this. That is certainly a
legitimate thought.
You can tell the patient that they require care
beyond toenail care, but they will have to return
to the office for a separate visit. You would
explain to the patient that you would be very
happy to care for all their needs on one visit but
unfortunately, OMG does not feel the same way.
Forget the difficulty some of our older patients
have with ambulation, forget transportation,
problems, forget having to depend on others for
your doctors visits. I’m sorry that’s just the way
Medicare runs things.
You can do everything for free. after all, you are
a doctor and are expected to always do what’s best
for the patient even if it results in financial
disaster to your office. You can charge for an
office visit and throw in toenail care at no
charge and hope that no one finds out that you are
not billing for “a surgical procedure“.
The whole situation is ridiculous and needs to be
addressed. My suggestion is to continue
utilization of the 25 modifier and do what is best
for the patient at all times. I would suggest
however, that you be very careful with your
documentation. Remember, the documentation must
justify the EM visit. That is the critical element
in my opinion.
Ultimately, we do not know what criteria were
applied by OIG to determine that the 25 modifier
is misused. We do not know the content of the
medical records reviewed.
What we do know is that a comprehensive diabetic
foot evaluation will frequently demonstrate the
presence of multiple factors which can contribute
to skin breakdown and ulceration. What we do know
is that every published study demonstrates the
addition of a detailed foot care service reduces
the risk of major amputation by up to 75%. What we
do know is that the majority of our diabetic
patients are depending on us to prevent or at
least reduce the risk of amputation.
When I first meet a new patient who is diabetic, I
asked them what type of foot evaluation they have
had previously period more often than not the
answer is none, or at best a 10 gram filament test
was performed by the primary care physician. I let
the patient know that my job is to reduce the
incidence of amputation if possible. I then go
about performing a comprehensive diabetic foot
evaluation, which is multisystemic. I will then
discuss with the patient and their family risk
factors present and educate the patient regarding
strategies for ulcer prevention.
I will initiate appropriate therapy for these
problems. On follow up visits, I will assess
response to treatment and make appropriate
adjustments. I believe the key to obtaining
adherence to recommendations is educating the
patient and family at the time of the initial
visit. Even problems, such as onychomycosis have
been demonstrated to be associated with increased
risk for infection and ulceration and amputation.
Even a simple problem such as onychomycosis in the
diabetic patient requires legitimate treatment
with topical or systemic therapy. However,
systemic therapy requires in some patient’s
laboratory screening and evaluation for side
effects of these medication’s. I suppose we should
do this for free and take responsibility but
derive no remuneration according to Medicare.
“At risk foot care“ is more than care of toenails
or calluses. Care of the diabetic foot is more
than knowing how to do a good TMA or arguing
whether a gastrocnemius process or TAL should be
performed. It is more than ulcer care. The key is
prevention.
Allen M. Jacobs, DPM, St. Louis, MO
