In the world of podiatry billing, details matter — and one wrong detail can cost your practice thousands. One of the most surprising billing errors we’ve encountered involved a podiatrist who performed surgery on the right foot, but every single note, code, and modifier submitted to insurance said it was the left.
That discrepancy led to a full claim denial — and a complete loss of revenue for a medically necessary procedure.
🚫 What Went Wrong?
Although the procedure was performed correctly, the documentation told a different story — or rather, it failed to tell the right one.
The CPT codes, ICD-10 diagnoses, and all modifiers listed “left foot.” From the insurance company’s perspective, there was no proof that surgery had taken place on the right foot at all. And if the records don’t support the service billed, they won’t pay.
Sadly, this type of error isn’t rare. We see it frequently, not just with surgical laterality, but with:
- Incorrect or missing modifiers
- Diagnosis and procedure mismatches
- Vague or incomplete clinical notes
🧠 Documentation Is More Than a Requirement — It’s a Defense
When an insurance payer asks for your records, your documentation becomes your voice. It’s the only proof of what actually happened during the visit or procedure.
If your documentation doesn’t clearly align with your codes, it’s more than a technicality — it’s a revenue blocker.
Every provider should ask:
- Does my documentation reflect exactly what I did?
- Are my CPT, ICD-10, and modifiers supported by my chart?
- Did I document laterality, timing, and global periods correctly?
✅ The Role of a Billing Partner
At A Step Above Health Management, we take a proactive approach to billing. Our team carefully reviews documentation and coding for inconsistencies — flagging issues before they turn into denials.
But even the best billing company can’t code what isn’t properly documented.
That’s why we encourage all providers to:
- Take time to document accurately (don’t rush!)
- Understand what your codes and modifiers actually mean
- Use modifiers like 25, 59, 24, and 79 correctly — especially in podiatric care
💡 Bottom Line
Your notes aren’t just paperwork — they’re the foundation of your revenue. If your documentation doesn’t align with your codes, your claim won’t get paid.
But with accurate, thorough charting and a billing team that knows podiatry, you can avoid costly mistakes and pass audits with confidence.
Need help reviewing your documentation and coding?
At A Step Above Health, we specialize in identifying the hidden billing issues that are draining your revenue. If you’re tired of surprise denials or costly errors, we’re here to help.
📲 Let’s connect. Your revenue deserves the right support.
