01/06/2026 Allen M. Jacobs, DPM
Modifier -25 Derangement Syndrome
Though the courtesy of the ARCHE healthcare
amputation prevention program, I had the December
25 OIG office of Audit Services report. I do not
profess to be a practice management expert, nor an
expert at statistical analysis. With that stated,
I believe the paranoia infecting the primary care
podiatry health care providers is not justified.
It is a -25 derangement syndrome.
The "study" examined the ICD-10 and CPT codes for
essentially what is callus or nail care by paring,
cutting, or debridement. The appropriateness for
the utilization of the -25 modifier, ie-the
concurrent billing of an E/M code for a
significant and distinct pathology unrelated to
the routine care code was also examined.
To begin with, the sampling frame consisted of
155, 811 claims paid to podiatrists, of witch ONLY
100 were selected for careful review. You read
that correctly, 100 charts out of 155, 811. I'm no
statistical wiz, but really? Of the 100 selected,
for review, "44 podiatrists' claims for E/M
services "did not comply with Medicare
requirements".
Somehow, in some manner, this was extrapolated by
OIG to conclude that for the TOTAL charts reviewed
( 155,811), $39.6 million was paid for billings
which did not comply with Medicare regulations.
Three issues were cited: Insufficient or no
documentation, incorrect coding, or billing for an
E/M not significant and separately identifiable.
I my opinion, all of these issues may be easily
addressed by podiatrists. Rather than practice
avoidance medicine and avoidance charting, make
appropriate corrections to you documentation and
practice defensive charting. In this manner, you
may provide the needed services to your patients
without fear of OIG retribution. This is
particularly critical in the care of our high risk
patients, in whom multifactorial and multisystemic
evaluations and therapeutic interventions are
frequently required.
With regard to "Insufficiently documented
services, the OIG presented the following example:
11730 was billed for nail avulsion together with
an E/M visit. The chart was said to be illegible.
The note allegedly did not support the "need to
remove the toenail" and lacked description of the
secondary disorder to justify the E/M visit. The
answer is quite simple: take the time to provide
better documentation. Your note should state what
you saw and considered to conclude that a nail
avulsion was required. That is all which was
needed, then, now, and in the future. Medicare
REQUIRES a legible chart. Is that really
difficult? If you bill an E/M, have a note
describing the clinical findings, differential
diagnosis, and treatment. This is particularly
important for the high risk patient in whom "minor
problems" are not minor. Dictate that concern and
risk in your note. In todays world, how difficult
is it to think for a second and dictate a proper
note. When you chart, assume the note will be
reviewed by a third party insurer or a lawyer.
Document accordingly. That is ALL IT TAKES!
In a second example, that of incorrectly coded E/M
service, OIG provides the following example; An 84
year old new patient was diagnosed with a wart.
17110 was billed for removal of the wart. A 99204
was also charged with documentation to support the
need for a 99204. In fact, the reviewer would have
AGREED TO A 99203! For a new patient with a wart!
The solution again is simple. Submit charges for
what you did and document to support those
charges. That is the total solution. You can pay
to attend all the practice management programs you
wish, a listen to all the "experts" who make a
living telling you this over and over again. Just
bill for the services which you provided and
support that in your note. If you do, let anyone
review you charts. You will not care.
Documentation and honest billing is the simple
cure.
As an example of incorrect coding, a case was
cited in which the podiatrist billed a 11044. The
chart only documented a 3, not 4 lesions. THERE
WOULD HAVE BEEN A SAVING OF 6 dollars! Again, just
bill for what you do and document accurately. What
angers me is the OIG focus almost pathological
near-neurotic obsession over toenails and
calluses. Wrong is wrong, we get it. But why not
look at unnecessary interventional cardiology
procedures, unnecessary orthopedic procedures,
unrequired opthalmologic procedures. When we read
about MD/DO fraud, they speak in millions and
millions of dollars. There is a lot more fraud and
abuse in the MD/DO world which costs a lot more
money than a podiatrist over-charging six dollars.
Yeah, our mothers all told us that two wrongs
don't make a right. BUT $6?
As an undergraduate at Temple University my last
class of the day was Latin. I would drive home
with a fellow student. Every day, as we drome down
Broad Street, as we passed Temple Medical school,
EVERY DAY, he would point left at the school and
say "license to steal" That was in 1968. At the
time, I did not understand what he was saying.
Sadly, now I understand all too well.
top being lazy with your documentation. Poor
documentation is not infrequently a factor in
malpractice cases and thirst party reviews. Think
before you dictate: where could I be questioned or
criticized and answer honestly in your
documentation. It is that simple.
Now that I have offered you audit protection, you
can, in the tradition of Soupy Sales (if you know
who he was and what he did you are old, very old)
send me the money you would have paid to attend a
practice management seminar which would have told
you the same thing. I accept cash, checks, and
most credit cards. And I'll document your payments
for the IRS and state of Missouri. Just in case of
an audit.
Allen M. Jacobs, DPM, ,St. Louis, MO
