APMA News - January/February 2018 - 38

Reimbursement

APMA Policy Efforts and Reimbursement
Victories for Podiatrists in 2017
Last year was a year full of challenges to reimbursements for
providers, particularly podiatrists. APMA has been an active advocate on behalf of its members and has been successful in eliminating or mitigating several of those challenges.

sion Removal, Subsection (3) and Chapter III, Section L,
General Policy Statements, Subsection (12) (now 13) with
respect to coding of the -59 modifier with CPT 11055-11057
(Paring or cutting of benign hyperkeratotic lesions) and CPT
11720-11721 (Debridement of nail(s) by any method(s)),
stating that CPT 11055-11057 included performance of nail
Defeated Orthotics and Prosthetics Proposed Rule
debridement and therefore was not separately reimbursable
using the -59 modifier. After submitting comments and holdAPMA successfully defeated a CMS proposed rule, released
ing conference calls with both NCCI and CMS, APMA was
in January 2017, under which DPMs and other previously
able to persuade CMS to reverse its adoption of NCCI's edits
exempted qualified practitioners would have had to obtain adto the -59 modifier, which ran in direct opposition to CMS'
ditional certification and licensown previous guidance. Morees to furnish and fabricate cusover, the edits interfered with
One of the biggest reimbursement
tom prosthetics and orthotics.
critical treatment of Medicare
APMA submitted formal combeneficiaries in allowing more
efforts APMA focused on in
ments to CMS in March and
appropriate access to at-risk
2017 was MIPS and MACRA
mobilized a significant grassfoot care, which is invaluable
roots advocacy initiative among
in identifying diabetic foot ulimplementation. We continue to
members, affiliated organizacers. CMS has posted the proproduce our educational webinar
tions, and state component soposed changes at www.cms.gov/
cieties, which also submitted
Medicare/Coding/National
series, "MACRA Made Easy,"
comments. APMA met with
CorrectCodInitEd/Down
which has been viewed by
representatives of the CMS Cenloads/modifier59.pdf, which
ter for Program Integrity in perwent into effect on January 1,
more than 3,500 members.
son to discuss this onerous and
2018. APMA will now use these
inappropriate proposed change
changes to address similar confor qualified physicians, including podiatrists, whose advanced
cerns with Humana as well as other payers, which also have
education and training negate the need for additional licensing
current policies that have been detrimental to DPMs with reand certification. APMA also collaborated closely with the Amerspect to at-risk foot care.
ican Academy of Orthopaedic Surgeons (AAOS), the American
Occupational Therapy Association, the American Orthotic and
A5513 Negative Modeling Issues
Prosthetic Association, the American Physical Therapy Association, and industry representatives to defeat the proposed rule.
Technology advancements often outpace regulatory lanAPMA extends its appreciation to Rep. Tim Walberg (R-MI),
guage and fixes. Currently, negative models are generally not
who helped address APMA members' concerns directly with
recognized as meeting the statutory requirements for reimCMS. While we will continue to work in partnership with
bursement under A5513, and instead must be billed using
stakeholders and Congress to find a permanent legislative fix
A9270, which is a statutorily non-covered HCPCS code. Afthat will codify the physician exemption, we extend our sinter numerous meetings with internal and external stakecere thanks to the nearly 1,000 members who submitted letholders, and receipt of comment letters submitted both diters against this proposed rule to CMS via eAdvocacy. Your voicrectly and in partnership with the American Orthotic and
es added the necessary weight to our own efforts to persuade
Prosthetic Association, CMS has agreed to postpone enforceCMS to maintain the exemption.
ment of the proposed initiatives until May 2018. APMA
hopes that CMS will adopt APMA's recommended suggestions to improve the process, and ultimately that negative
-59 Modifier Success
models will be recognized as meeting A5513 requirements.
Under the proposed change, new standards would include
In 2016, the National Correct Coding Initiative (NCCI)
the use of digital or virtual models to direct mill custom diedited two sections of the NCCI Chapter III, Section E, Le38 APMA News January/February 2018
http://www.cms.gov/Medicare/Coding/NationalCorrectCodIniEd/Downloads/modifier59.pdf http://www.cms.gov/Medicare/Coding/NationalCorrectCodIniEd/Downloads/modifier59.pdf http://www.cms.gov/Medicare/Coding/NationalCorrectCodIniEd/Downloads/modifier59.pdf
Table of Contents for the Digital Edition of APMA News - January/February 2018
