An OIG audit is far less dangerous when you've already found the problem yourself. Independent podiatrists who conduct periodic self-audits create a documented record of compliance effort — which matters significantly in any subsequent enforcement conversation. This checklist covers the 12 highest-risk areas in podiatry Medicare billing. Set aside two hours once a quarter and work through it.
How to Use This Checklist
For each item, pull a sample of 10–15 relevant claims from the past 90 days along with the corresponding chart notes. You're looking for patterns, not just individual errors. A single non-compliant claim is a documentation problem. Ten non-compliant claims following the same pattern is a systematic issue — and the kind of pattern an auditor will extrapolate across your full billing history.
When you find a problem: document that you found it, document what you did to fix it, and implement the fix before the next billing cycle.
Routine Foot Care: Is the Class Finding documented at every visit?
Pull 15 recent 11055–11057 claims. For each chart note, verify that the physical examination documents specific Class Findings — not just a diagnosis code in the problem list — on that date of service. "No change" is insufficient.
Nail Debridement: Does the nail count match the CPT code billed?
For 11720/11721 claims, verify the chart note documents the specific number of nails treated — not just "bilateral toenails" — and that this count is consistent with the CPT code billed. 11720 = 1–5 nails. 11721 = 6 or more.
Nail Debridement: Is mycosis OR systemic condition documented for every claim?
Every nail debridement claim needs either: (a) documented clinical findings of onychomycosis, or (b) qualifying systemic condition + Class Findings. Verify one of these two pathways is clearly documented in each chart note.
Systemic Condition: Is the qualifying diagnosis in the visit note — not just the problem list?
Many EHRs auto-populate problem lists on every note. That's not the same as documenting the condition in the current visit. The qualifying systemic condition should appear in the history or assessment section of the visit note itself.
Medical Necessity: Is there a statement linking the condition to the service?
For every routine foot care and nail debridement claim under the systemic condition pathway, the chart note should contain at least one sentence explaining why this patient's condition makes professional foot care medically necessary. Even a single clinical statement suffices.
Frequency: Are claims within LCD limitations for your jurisdiction?
Pull a 12-month view of nail debridement claims by patient. Flag any patient with claims that appear more frequent than your MAC's LCD allows. For claims exceeding the standard frequency, verify that the chart note documents specific clinical rationale.
Same-Day Billing: When 11055–11057 and 11720–11721 appear on the same date, are they distinct and properly modified?
Same-day billing for both code families requires clearly distinct documentation for each service and appropriate modifier usage (often Modifier 59). Review any dates where both code families appear on the same claim.
Plantar Fascia Injection (64455): Is conservative treatment failure documented?
For each 64455 claim, confirm the chart note or prior records document that conservative treatment (physical therapy, orthotics, stretching, NSAIDs) was attempted and failed before injection. Many LCDs require 4–8 weeks of documented conservative care.
Surgical Procedures: Is the medical necessity narrative complete?
For hammertoe corrections (28285) and other surgical procedures, review the pre-operative documentation. Conservative treatment trial, functional impairment description, and surgical necessity should be clearly documented. "Patient desires correction" is insufficient medical necessity.
LCD Currency: When did you last verify your MAC's current LCDs for your highest-volume codes?
This is a process check, not a claims review. Pull up your MAC's website right now and verify the current LCD for routine foot care in your jurisdiction. Check the effective date. If it's different from what you've been operating under, read the changes immediately.
Billing Patterns: Does your billing pattern for high-risk codes look like an outlier?
MAC automated systems flag statistical outliers. If 90% of your Medicare claims are for routine foot care on diabetic patients, that's not necessarily wrong — but you should understand your billing pattern and be able to defend it with documentation.
Diagnosis Code Accuracy: Do the diagnosis codes billed match the chart documentation?
Review a sample of claims and verify that every diagnosis code billed is supported by chart documentation. A diagnosis code for "diabetic peripheral neuropathy" requires documented clinical findings — not just an assumption based on the patient's diabetes diagnosis.
What to Do When You Find a Problem
For template/process issues (no completed claims affected):
Fix the template or process immediately. Document the change you made and when. Train relevant staff. Move on.
For a small number of non-compliant completed claims:
Document that you identified the issue and corrected the process. Consider whether voluntary refund is appropriate — a healthcare attorney can help you evaluate this. Do not simply ignore identified non-compliant claims.
For a systematic pattern across many claims:
Consult a healthcare compliance attorney before taking any action. You may need to consider voluntary repayment under the CMS voluntary self-referral disclosure protocol. The goal is to address the issue proactively before it becomes an enforcement action.
Practices that conduct documented self-audits, fix issues they find, and maintain a record of ongoing compliance effort are in a fundamentally different position than practices that have no compliance program when an audit arrives. The existence of a proactive compliance program is a mitigating factor in OIG enforcement — it doesn't eliminate risk, but it changes the conversation significantly.
How Often Should You Run This Audit?
For most independent podiatry practices, a quarterly self-audit covering your highest-risk codes is the right cadence. Annual is the absolute minimum. If you've never done a self-audit, do one now — whatever time of year it is.
The two hours this takes quarterly is the best compliance investment you can make. It's far less expensive than the alternative.
Disclaimer: General compliance information for educational purposes only. When you identify potential compliance issues in your billing, consult a qualified healthcare compliance attorney before taking corrective action.