12/17/2025 Allen M. Jacobs, DPM
-25 Modifier and RFC And Diabetes
Regarding the use of the -25 modifier in order to
allow maximal and optimize care of the diabetic
patient, particularly the older patient, we must
recall that there is true fraud, "honest fraud",
and he created billing or billing "gamesmanship".
True fraud in my opinion is a conscious/willful
effort to deceive a third-party such as Medicare
in order to receive payment. I suspect that many
of our colleagues are accused of fraud and abuse,
when in fact they are guilty of "honest fraud",
meaning that they provided needed and legitimate
services but failed to meet documentation or other
requirements.
Many of the billing and coding seminars, in my
opinion, fail to provide the necessary detailed
documentation required to satisfy the E/M office
visit together with the provision of so-called "
surgical services" meaning needed skin and nail
care. Speakers at these meetings emphasize the
definition of the -25 modifier, but quite frankly
are individuals who make their living lecturing,
and some have never been in a successful private
practice. They offer advice but have never had to
meet the demands of the increasing elderly
diabetic population and their need for evaluation
and management of the variety of pathologies which
in isolation or combination increases the risk for
skin breakdown, ulceration, infection, gangrene,
and limb loss.
It has long been my belief, as I stated in a
previous communication to PM News, that the
education of the patient or caretakers is critical
in order to obtain adherence to recommended
protocols for the management of the older patient
with known diabetes. The initial visit is the
key. You are now able to be reimbursed for time
as well as medical decision making. You are also
able to be reimbursed for the complexity of the
pathology and decision making. As a result, the
opportunity for education and detailed discussion
of your overall and reducing the risk of
amputation is available to every primary care
podiatric healthcare provider.
The key is to document appropriately. It is the
content of the documentation that is important.
Let us examine a simple seemingly benign foot
problem as an example. For example, one of the
most common dermatologic issues which confront the
elderly diabetic patient is xerosis cutis. This
may be the result of diabetic autonomic neuropathy
with sudomotor deficit, or may be the result of
aging. In either event, we are talked from the
time we are a young podiatrist that diabetic
patients tend to have dry skin and require therapy
for this. Why? Because xerosis cutis can result
in fissuring and scaling, can result in a
secondary tinea pedis infection, can result in
skin breakdown and infection. Xerosis cutis is
not a "minor problem" in the elderly diabetic
patient.
If a patient consulted the primary care podiatrist
with a singular concern of dry cracking and
fissuring of skin, we would prescribe appropriate
therapy and we bill an office visit. However, if
the patient had presented for "at risk footcare",
suddenly, the concurrent management of the skin
disorder requiring an E/M -25 billing, becomes a
source of concern for the primary care podiatrist
who is fearful of an OIG audit. The presence of
the skin changes, differential diagnosis such as
that of tinea pedis or other skin disorder, and a
statement recognizing the fact that the patient is
an older diabetic and who we wish to optimize skin
health and prevent ulceration and breakdown,
should be included in the office note.
Similarly, the note should indicate education of
the patient or caretaker regarding the need for
adherence to recommended therapy, and a
prescription made. Furthermore, again in my
humble opinion, if a prescription is to be written
for a product that could otherwise be dispensed by
the podiatric healthcare provider, there is
further opportunity to ensure the use of a proper
therapeutic intervention as well as add additional
income to the practice and a legitimate manner.
Xerosis cutis is a minor problem in most people.
It is not so in the older diabetic patient with
PAD or neuropathy or extensive skin change. Other
examples of dermatologic disorders more prevalent
in the diabetic patient include tinea pedis,
diabetic dermopathy, necrobiosis, pruritus
secondary to sensory neuropathy/small fiber
neuropathy, pre-ulcerative pressure calluses,
onychomycosis, intertrigo and webspace tinea
pedis, just to name a few disorders that should be
and in fact must be evaluated and treated in the
diabetic patient.
When I dictate an office note, I recognize that
the note must relate a content to satisfy multiple
levels of potential evaluation. The note should
reflect your clinical thinking and how you arrived
at a conclusion to make a particular diagnosis and
determine a treatment option for a particular
patient. We also want to consider content in that
note to satisfy third-party regulatory parties
such as OIG/Medicare LCDs. We must also consider
the fact that "at risk" means just that, at risk.
Our diabetic patients particularly the elderly are
indeed at increased risk for limb loss. Some
patients will progress to limb loss and spite of
our best efforts. The progress note therefore
must serve to satisfy multiple potential purposes.
Many years ago, I purchased a secondary practice
from an area podiatrist who woke up one day and
actually determined that he was going to quick
podiatry that very day. He called me informing me
that he literally closed his office that day and
had no intention of ever returning to the office
again. I canceled my afternoon patients and
visited him to determine whether or not I wish to
quickly add this practice to my existing practice.
He had an interesting philosophy over 30 years
ago. He actually disqualified patient's for
Medicare coverage. At the first visit, his notes
indicated that, for example, the patient did not
have painful toenails, did not appear to have
onychomycosis, had adequate vascular status, and
did not qualify for Medicare coverage.
Furthermore, in order to obtain "routine footcare"
the patient had to commit to being evaluated and
treated every 6 weeks. I am not suggesting that
one pursue this option. A variation of this
course would be the cash only concierge practice.
This is certainly one manner in which the Medicare
demands can be eliminated.
The podiatrist selling the practice (which I did
purchase) pointed out that he was free of the
ridiculous documentation requirements of Medicare
by functioning in the manner he did. He pointed
out that his cash payment every 6 weeks was in
excess of that which he would have received had he
participated in Medicare with fair time
requirements between visits and required
documentation. He pointed out that the "at risk
patient" received for better care than they would
being seen every 10-12 weeks to satisfy Medicare
requirements. Of course, no one is suggesting
that it is ethical to willfully disqualify
patients for Medicare coverage if in fact if the
patient qualifies for Medicare coverage. This
would of course be fraudulent behavior. However,
the underlying point of that individual was
understood. Those that have called for a
concierge type of "cash only practice" do have a
legitimate argument.
Allen M. Jacobs, DPM, St. Louis, MO
