Medicare Advisory Liaison

19th Annual Joint National Podiatric CAC-PIAC Representatives’ Meeting

I recently attended the 19th Annual Joint National Podiatric Carrier Advisory Committee (CAC)-Private Insurance Advisory Committee (PIAC) Representatives meeting, held in Alexandria, VA, November 15, 2019, on behalf of the IPMA This annual meeting presents a unique opportunity for CAC and PIAC representatives to hear from experts and leaders in both private and public insurance issues. It also allows for representatives to hear from other CAC and PIAC representatives about new and ongoing trends, both regional and national that might impact our members.

This year’s meeting once again covered the full spectrum of reimbursement issues. Featured speakers included returning public and private insurance policy experts, Kelli Back, Esq., and Cindy Moon, MPP, MPH, as well as a number of representatives from the public insurance arena – Rochelle Fink, MD, JD, the FDA Liaison from the Centers of Medicare and Medicaid Services (CMS), and Noridian Comprehensive Error Rate Testing (CERT) representatives, Bekah Nelson and Pat Peick. Additionally, APMA Coding Consultant Jeffrey Lehrman, DPM, provided a comprehensive overview of the coming changes to the Evaluation and Management (E/M) codes in 2021, and DME expert Paul Kesselman, DPM, presented on upcoming 2020 DME trends.

Cindy Moon, MPP, MPH, vice president at Hart Health Strategies and APMA consultant provided a Medicare policy update including updates to the 2020 CY Medicare Physician Fee Schedule (MPFS) and MIPS participation in 2020. Of note:

2020 MPFS

  1. Final 2019 Conversion Factor is +0.14% over 2019; The conversion factor increase from #36.04 to $36.09. This is due to a six month period starting now with no inflation update meaning the conversion factor will not increase in any meaningful way.
  2. Podiatrists should see a 2 percent increase in reimbursement under Original Medicare Fee For Service;
  3. Effective January 1, 2021, E/M Documentation changes will allow for more flexibility in documenting E/M Services – physicians will be able choose between medical decision making, time; and
  4. Effective January 1, 2021, level 2 through 4 E/Ms codes for new and established patients will be consolidated but level 5 will remain separate.

2020 MIPS

  1. Largely maintains the same policies from 2019 to 2020 (low volume threshold, performance category weights, and reporting options remained the same)
  2. Performance threshold to avoid a penalty will be 45 points now, instead of 30 points (2019)
  3. CMS contemplating switch from individual performance categories to unified framework – MIPS Value Pathway Measures (MVPs)

Ms. Back, APMA’s long-standing private insurance consultant, provided an update on trends in the private insurance world, including addressing Medicare Advantage (MA) issues. She addressed the recent concern of the uptick in recoupments pursued by MAOs and providers’ rights in addressing those. She also reviewed network adequacy rules, how to deal with onerous record requests, and new non- traditional benefits available under some supplemental plans for beneficiaries with serious chronic illnesses such as diabetes.

Dr. Lehrman provided an in-depth summary of the changes to E/M coding, planned to start 2021. Under these changes, DPMs and other physicians would now have a choice to Medical Decision Making (MDM) or time in determining what level of E/M coding to appropriately bill.

Ms. Nelson and Mr. Peick presented on CERT Compliance, an issue directly impacting members. They provided updates on ongoing improper payment concerns and trends as related to services DPMs routinely provide (therapeutic shoes, surgical dressings), and advice on how to best address where documentation most routinely falls short. Following Ms. Nelson and Mr. Peick, Dr. Kesselman provided an update on the 2020 DME upcoming trends and advice. He addressed portal login issues for DMEMACs, documentation pitfalls to avoid, same and/or similar denials, and how members can best protect themselves from non-payment due to denials and non-coverage of some services or devices.

Dr. Fink presented in depth on the recent changes to the Local Coverage Determination (LCD) process and Carrier Advisory Committee (CAC) role, wrought by the passage and enactment of the 21st Century Cures Act. CMS intends these changes to improve transparency and provide CAC representatives with more meaningful and direct contact with their Carrier Medical Directors.

Additionally, extended group discussions were held to allow representatives to bring up ongoing or new public and private payer issues in their states and receive input and advice from their peers who may have dealt with similar issues in the past. Numerous states expressed issues with billing with the 25 and 59 modifier, as well as routine foot care claim denials. Additionally a common complaint was increasing frustration with Medicare Advantage plans not providing reimbursement for services otherwise covered under Original Medicare.

Jeffrey A. Crowhurst DPM CAC Representative for Illinois

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