Medicare audits are a reality for podiatry practices, and while audits can feel intimidating, many are preventable. In our experience at JARALL, audits are rarely random. They are typically triggered by identifiable patterns within billing, coding, or documentation.
Understanding the most common Medicare audit triggers allows podiatry practices to reduce risk, improve compliance, and avoid costly recoupments.
High Utilization of Specific CPT Codes
One of the most common audit triggers is consistently high utilization of certain CPT codes compared to peers. Medicare monitors billing patterns closely, and outliers often attract scrutiny.
In podiatry, this can include:
- Routine foot care codes
- Debridement services
- Surgical procedures billed at high frequency
Even when services are medically necessary, unusually high volume can raise red flags if documentation does not clearly support the frequency and complexity of care.
Inconsistent or Insufficient Documentation
Documentation issues are among the leading causes of unfavorable audit outcomes. Medicare expects clinical notes to fully support the services billed.
Common documentation concerns include:
- Missing medical necessity statements
- Incomplete histories or exam details
- Lack of progress notes supporting ongoing treatment
Documentation must clearly explain why a service was performed, not just what was done. Weak or templated notes can trigger audits even when care is appropriate.
Incorrect Modifier Usage
Modifiers are essential in podiatry billing but are also frequently misused. Improper modifier application can signal billing errors to Medicare systems.
Common problem areas include:
- Overuse of modifier -59
- Incorrect use of bilateral modifiers
- Modifier application without supporting documentation
Repeated modifier errors can suggest compliance gaps and increase audit risk.
Billing Services Not Typically Covered by Medicare
Certain podiatry services have limited or conditional coverage under Medicare. Billing these services without clear documentation of medical necessity can quickly trigger audits.
Examples include:
- Routine foot care without qualifying conditions
- Services lacking documented systemic disease
- Non-covered services billed without ABNs
Failing to properly distinguish between covered and non-covered services is a frequent audit trigger.
Sudden Changes in Billing Patterns
Abrupt increases in billing volume, coding complexity, or reimbursement can also raise concerns. Medicare systems monitor trends over time, and unexplained spikes may prompt review.
Triggers can include:
- Rapid growth without documentation changes
- Sudden increases in higher-level E/M codes
- New services billed without supporting protocols
Growth is positive, but it must be accompanied by consistent compliance practices.
How Practices Can Reduce Audit Risk
While audits can’t always be avoided, risk can be significantly reduced by:
- Conducting regular internal chart audits
- Ensuring documentation supports every billed service
- Staying current with Medicare guidelines
- Reviewing denial and payer feedback trends
Proactive billing oversight helps identify potential issues before they escalate into audit findings.
Preparation Is the Best Defense
At JARALL, we emphasize that audit readiness is not about reacting to notices — it’s about building compliant billing habits every day. Practices that prioritize accurate billing, proper documentation, and transparent reporting are far less likely to face disruptive audit outcomes.
Understanding common Medicare audit triggers empowers podiatry practices to protect revenue, maintain compliance, and focus on patient care with confidence.