11/07/2023

Claim Denial-Medicare UPIC Audit

I was recently denied on a claim during a Medicare UPIC audit. The claim was for an inital visit 99202 and cutting of toenails and callous. Below you will see how it was billed. What errors did I make? I was under the assumption that you can bill for 99202 even with performing a procedure related to the DX used for the initial visit. Am I mistaken? 99202 (25) linked to B35.1 11056 (Q8) linked to 703.0 + 170.203 11721 (XU) linked to B35.1 + m79.674+ m79.675

Looking at the justification from the UPIC contractor, they seem to be clear on what was missing from the sampling that caused a rejection rate of 52% for both routine foot care and the new patient office visit. The templated notes do not go into enough detail that is necessary per the LCD & LCA. Rules can change over the course of 3 years, and given the lack of resources during the pandemic, the contractor most likely was not looking as stringently as they are now if this was last done in 2020. If you do not agree with the decision from the post payment appeal, it would be in your best interest to follow the appeal instructions from the contractor and justify why the documentation as it stands is sufficient to justify medical necessity for routine foot care. We are not able to make an adequate determination by only looking at one example of all the charts requested, but I think the outline from the contractor is sufficient to substantiate their position for the partial recoupment.