David J. Freedman, DPM, FASPS, CPC, CPMA ● Board Member, US Foot and Ankle

Specialists and Foot and Ankle Specialists of the Mid-Atlantic of the Mid-Atlantic (FASMA)

● Certified Professional coder ● Certified Professional Medical Auditor ● Compliance Auditor ● Codingline Expert ● A Past President, Maryland Board of

Podiatric Medical Examiners ● Past Chairperson, 9th and 10th Annual

National APMA CAC PIAC meeting ● CAC member Maryland ● 31+ years of Coding Experience ● APMA Coding Committee, member

and advisor since 2005

2018 “BMAD” Presentation of the 2017MEDICARE

Part B REIMBURSEMENT

STATISTICS FOR PODIATRY

Presentation

2017, Medicare Part B total allowed charges were $138.1 billion dollars. Of this total, claims submitted by podiatrists represented $2.19 billion or 1.6 percent.

. Most of the data tables presented in this report include summary data for the top 300 procedures/services for podiatrists, based on 2017 allowed charges ranking.

top 300 procedures/services accounted for 92.8 percent of podiatric Medicare allowed charges in 2017.

2017 vs 2016 difference: 1) Total Part B allowed charges were $139.1 Billion. This Increase in allowed charges for all providers by 2.7 Billion compared to 2016. 2) $10 million Increase in podiatric allowed charges, compared to 2016 which had a 20 million increase previously. 3) Claims submitted by podiatrists represented 1.6% in 2017 which represents the same % as was in 2016. 4) The top 300 procedures/services accounted for 92.8% in 2017 vs 93.1% of podiatric Medicare allowed charges in 2016.

A/B MAC Jurisdiction Map 2018

Source: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/AB-MAC-Jurisdiction-Map-Oct-2017.pdf

DME Jurisdiction Map as of 2018

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/DME-MAC-Jurisdiction-Map-July-2016.pdf

A/B MAC AWARDS/CONSOLIDATION Noridian JE Exp 10/20–CA, HI, NV, American Samoa,

Guam, Northern Mariana Islands and JF New Contract 7/2023–AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY = 16

Novitas JL Exp 8/21– DC, DE, MD, NJ, PA, N.VA & JH Exp 7/19– AR, CO, LA, MS, NM, OK, TX ) and First Coast JN – Exp 2/22 FL, PR, US Virgin Islands =16

NGS -J6 (JG)Exp 5/20 – IL, MN, WI and JK Exp 1/22– CT,NY,MA, ME, NH, RI,VT =11

Palmetto GBA JM(J11) Exp 10/22 – NC, SC,VA, WV and JJ AL, GA, TN Exp 9/2022 = 7

WPS -J5 (JG) Exp 12/19 – IA, KS, MO, NE and J8 Exp 11/2023 IN,MI –6

CGS J15 (JI) Exp 8/23 KY, OH =2 Source: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MedicareAdministrativeContractors.html

RUC EFFECT

Total Part B (billions) all

allowed charges % increase

Total Part B Allowed DPMs

(billions) % increase

DPM % of Total Allowed

2007 110.9 0 1.73 1 1.60 2008 114 3 1.81 5 1.60 2009 116.9 3 1.89 4 1.60 2010 122.9 5 2.03 7 1.70 2011 126.7 3 2.13 5 1.70 2012 128.1 1 2.17 2 1.70 2013 128.0 (>-1) 2.21 2 1.70 2014 129.2 1 2.18 -1 1.70 2015 132.9 3 2.16 -1 1.62 2016 135.4 2 2.18 1 1.61 2017 138.1 2 2.19 <1 1.59

Continued Reporting in 2017 The BMAD file provide again had the 4 new HCPCS modifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a Separate encounter; XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure; XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner; and XU Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

Table 12B: 2017 Medicare Part B, Top 250 Services Utilizing Modifier for Distinct Procedural Service ALL providers (Distinct procedural service modifiers: 59, XE, XS, XP, XU)

Table 12A: 2017 Medicare Part B, TOP 50* Services Utilizing Modifier for Distinct Procedural Service Podiatry (Distinct procedural service modifiers: 59, XE, XS, XP, XU)

2017 Bunionectomy Podiatry vs Ortho

What really is the value of Surgery? Two very common Podiatric procedures: 1) 28285 - (2) 99212 & (2) 99213 + 0.5 99238-half day discharge E&M is 50% or $275.71 of total fee $554.03 2) 28296 - (3) 99212 & (2) 99213 + 0.5 99238-half day discharge E&M is 34% or $320.39 of total fee $939.73 99212 National value $44.68 and 99213 National value is $74

2017 Other Surgery Podiatry vs Ortho

So why should you care about this web site?

E&M “NEW” Trends among specialties

Table 5I: 2017 Medicare Part B, Top 300* DPM Services. Allowed Frequency Data by Specialty,

Place of Service=ALL,

2017 Podiatric E&M ranking changes compared to 2016:

1) 99212 ranking has remained 5th

2) 99213 ranking has remained 1st

3) 99214 ranking has remained 13th

4) 99203 remained same, 3rd ranked

5) 99202 remained same,12th ranked

2017 Podiatric E&M ranking vs Ortho vs General Sx vs

Derm Summary:

1) 99203 Is most frequent NP Code by Podiatry, Ortho, General Sx, Derm but not Gen/Fam/Int. and Other Physicians are more commonly submitting 99204

2) 99213 continued same for 2017 as the most frequently allowed in Podiatry, Ortho, Derm, Gen Sx and Other Physicians except 99214 with Gen/Fam/Int

2017 Place Of Service

2017 vs 2016 Modifier 25 by Specialty Table 2A-2F: 2017 Medicare Part B, Evaluation &

Management Services Utilizing Modifier-25*

2017 Hospital Evaluation & Management Services Utilization vs. 2010

2017 vs 2010 Wound Care Utilization. Is something happening to podiatry providing

wound care?

2017 Wound Care Utilization vs. 2010.

Table 9a: 2017 Medicare Part B, Top 50* DPM Services by State % Paid TOP 10 STATES

*(Top 50 DPM services - ranking based on 2017 allowed charges for podiatry specialty category)

Podiatry doing well in claims processing? Total part B % claims paid in 2017 were 82.6%

this was an overall increase from 2015 at 82.4%.

Wyoming best overall in 2017 with 95.4%, improves from to 95.2% in 2016.

Top 4 in 2017 falls to Wyoming, Montana, South Carolina, S. Dakota, were best above the 94.1%

Top 10 in 2017 or A+ include: Wyoming, Montana, South Carolina, South Dakota, Washington, Virginia, PR/VI, RRB, Oregon, and Arizona tied Iowa 93.4-96% claims paid clean.

48 of 53 states/jurisdiction were 90% or better in 2017 that is 9 more states that improved.

Table 9a: 2017 Medicare Part B, Top 50* DPM Services by State BOTTOM STATES

*(Top 50 DPM services - ranking based on 2016 allowed charges for podiatry specialty category

What Do these lower % claims paid mean? New York in 2017 22.8% of the claims were denied! You

get the C+ score

Florida gets a C+ you also did poorly on 20.4%!

Ohio get’s a B-, the rate was also not great at 17.3%

Nebraska needs to keep an eye out as 11.5% denied and Minnesota 11% failed

Is something wrong when more than 10% of claims are not approved? (CERT Rate was 9.5%)

Total PART B % was paid at 82.6% in 2017- This is the benchmark and podiatry is all above that mark except Florida and New York (Ohio you just missed this).

Podiatry Top 15 for 2017 vs 2016

RFC Combo coding help or hurt you financially in 2017; 11721 Vs.

11720+11719 or 11720+G0127? 11721 $44 (National average 2017 same as past 4 yrs)

Example #1

11720 $32(same as 2013-2017) + 11719 $11(up $1) = $43 (National average 2017 we see a $1 increase)

Example #2

11720 $32 + G0127 $17 (no change) = $49

(National average 2017-2015)

Table 3A: 2017 Medicare Part B, Top 300* DPM Services - Data for Podiatry Listed by Descending HCPCS

This chart shows in 2017 vs 2016 remained same-44% of Medicare total allowed charges

paid to top 5 states. Table 9A

Table 9A: 2017 vs 2016 Medicare Part B, Top 50* DPM Services by State, then calculated

enrollees/DPM

1) 2013 had peak-downward trend in $ of DPM services 2) Upward trend in total allowed charges since 2015 3) 2017 Medicare enrollees same (- Advantage) 4) Ave dollars per service increased to $63.14

we have more nerve injection data?

Table 13A: Medicare Part B, Amputation Services

So, are the decreased number of Diabetic Shoes and Inserts dispensed having an impact on preventing amputations?

Amputations in the US had increased 2012-2014, then 2015 there was a decrease but in

2016 there was a significant increase!

11305,11306, 11307 any concerns?

11755 Biopsy of Nail Unit any concerns?

CPT 77077: Why is the joint survey CPT code

being used?

CPT 99201: Why is the CPT code being used?

So who is performing LOPS?

Modifier 59: Which codes do you think are the most

common?

Modifier 59, XE,XS,XP, XU For ALL Providers which CPT Codes Rank High?

POS For Podiatry, which place of service

represents the top location and what is different for

2017?

POS For Podiatry, ASC, what are the top 10

procedures being reported

You Need to Run Your Own Data For Your

Practice! The following is an example using my

practice for 2018 Top 30

DME Regions:

Remind all about the False Claims penalties: refund of paid claim PLUS 11-22K per

false claim billed. Once Identified you have 60

days to refund or these could be considered a false

claim, so let’s talk DME

DME top 20

Diabetic shoe trends 2010-2017 Podiatry allowed in 2010 was $41,192,045 and

represented 33.9%, the average allowed charge was $67.

Podiatry allowed in 2017 was $24,077,490 and represented 34.8%, the average allowed charge was $71 up $1 from 2016.

Podiatry has seen in past 8 years the total allowed amount drop by 42%, and from 2016 to 2017 there was another 4% drop.

All specialties the allowed frequency in 2017 = 979,139 vs 2010 it was 1,826,426. From 2010 to 2017 that means there has been 47% drop.

Why are Podiatrists still billing these codes in 2017 when they really are

dispensing L4361 or L4387?

Looking at our L3000 series DME CODES another year shows red flags to me and you?

Don’t You Feel that L3000 - L3060 should not be billed to Medicare and Paid vs If billed must show it is Statutorily Not Covered? GY NOT KX

How often does a podiatrist provide a foot orthotic that is attached to a leg brace to a shoe for Medicare Beneficiaries? Almost Never!

So now you have seen the statistics Seven years in a row, you make the call.

We need to be concerned that the rank for L3000 and L3020 are still too high and went up.

Should you still be concerned seeing L3000-L3060?

A lot of doctors play the DME Game. Should a podiatrist bill for a wrist brace?

ICD-10 Extra Data analysis for the top 25 ICD-10 codes

submitted by my group 2018

Thank You for participating in the 2018 BMAD

Presentation of 2017 Data David J. Freedman, DPM, CPC, CPMA, CSFAC

Email: dfreedman@footandankle-usa.com