APMA News - January/February 2021 - 19

CAC-PIAC Meeting Addresses 2021 E/M Change and More
Nearly 70 podiatrists, APMA staff members, and industry
experts participated in the 20th Annual Carrier Advisory
Committee (CAC) and Private Insurance Advisory Committee (PIAC) Meeting on Saturday, December 5, 2020. The CAC
and PIAC representatives are your component-level experts
on carrier- and plan-specific insurance and reimbursement
issues. The meeting was led by CAC-PIAC chair Sarah Whittaker, DPM, and held virtually due to the ongoing COVID-19
public health crisis.
Attendees gained insight into a range of issues, including
the CY 2021 Medicare Physician Fee Schedule Final Rule
(MPFS). Cindy Moon, MPP, MPH, vice president with Hart
Health Strategies, and Jeffrey Lehrman, DPM, APMA Health
Policy and Practice consultant, walked participants through
notable updates for 2021. APMA is pleased to confirm that
the changes to office/other outpatient E/M coding advocated
for by APMA will indeed take effect in 2021. Additionally,
CMS finalized a decreased conversion factor of $32.4085, or
a 10.2-percent reduction from 2020. Overall, CMS estimates
a slightly negative impact for podiatrists (-1 percent) for total
allowed charges. However, APMA believes it is likely the
changes to E/M coding will result in most podiatrists seeing
an overall positive impact.
" When CMS made its estimate, it looked at historical data, "
said Dr. Lehrman. " However, the E/M changes will make a significant difference. The reimbursements increased, and podiatrists
will have access to higher codes, so we feel it is likely podiatrists
will in general do much better than the CMS estimate. "
[Editor's Note: At press time, the Consolidated Appropriations Act of 2021 was passed with provisions including a
one-year, 3.75-percent increase in the MPFS designed to help
relieve the impact of COVID-19 on health-care providers.
That change and other provisions of the legislation will likely
result in a 5-percent increase in Medicare reimbursement for
podiatrists in 2021.]
Additional information about the CY 2021 MPFS can be
found at www.apma.org/Medicare.
Other presentations covered LCD development and reconsideration as well as DME. DME Workgroup Chair Paul Kesselman, DPM, addressed concerns related to increased L3000
auditing and DMEMAC Same or Similar policy. More information about these topics can be found at www.apma.org/
L3000 and www.apma.org/sameorsimilar, respectively.
APMA's private insurance consultant Kelli Back, JD, discussed issues related to Medicare Advantage and private insurance. She discussed APMA's advocacy efforts to resolve the
onerous and burdensome chart review that members are experiencing and discussed the differences in appealing a Medicare Advantage claim between a contracted and non-contracted provider. Members can read more on this topic at
www.apma.org/PIRG.
APMA workgroups are addressing payer denials or reimbursement reductions when the 25 modifier or the 59 modifier is used in a claim, and members of the working groups
shared their resources and guidance. The 59 modifier work-

group developed a Routine Foot Care and 59 and X[E, S,P, U]
Modifier Claims Tool Kit to help members when Medicare
Advantage plans, Medicaid Managed Care Organizations, or
other commercial plans deny covered nail care (CPT®
11720/11721) when callus care (CPT 11055-11057) is provided on the same date. To help members resolve these issues, the workgroup has created template appeal letters, articles, documentation guidance, and education webinars. The
tool kit is available at www.apma.org/59toolkit.
APMA has also increasingly heard from members that payers
are denying claims that are properly billed with the 25 modifier, or that private payers are significantly reducing reimbursement for an E/M service when a 25 modifier is used. As a reminder, the 25 modifier is used when a significant, separately
identifiable evaluation and management service with no work
inherent in the procedure itself by the same physician occurs on
the same day of the procedure or other service. It is also important to note this guidance applies to both new and established patient encounters. To help members, the 25 modifier
workgroup has created and updated resources including webinars, articles, and proper use guidelines. These resources are
available at www.apma.org/25modifier.
As with traditional in-person CAC-PIAC meetings, attendees spent time in breakout groups to discuss regional concerns. This key feature of the meeting allows representatives
to share experiences and collaborate on solutions to common
issues. Some of the topics covered included Anthem's AIM
Small Joint Surgery Guidelines and APMA's joint advocacy efforts with other podiatric and orthopedic societies to revise
the guidelines.
Also during the meeting, Andy Bhatia, DPM, was recognized as the " CAC-PIAC Representative of the Year. " Dr.
Whittaker was elected to serve a second year as chair.
Your CAC-PIAC representatives are tasked with taking the
information they learned during the meeting back to you and
your component. You can find a list of representatives at
www.apma.org/cacpiac. Be sure to pay close attention to
APMA publications throughout the year for updates about
these topics and other reimbursement news. Contact healthpolicy.hpp@apma.org for more information. n

Quick links list
If you would like to know more about the many topics
covered during the CAC-PIAC meeting, you can find information on APMA.org.
* www.apma.org/em2021
* www.apma.org/Medicare
* www.apma.org/L3000
* www.apma.org/sameorsimilar
* www.apma.org/PIRG
* www.apma.org/59toolkit
* www.apma.org/25modifier
* www.apma.org/cacpiac

APMA News January/February 2021

http://www.apma.org/59toolkit http://www.apma.org/25modifier http://www.apma.org/medicare http://www.apma.org/cacpiac http://www.apma.org/L3000 http://www.apma.org/L3000 http://www.apma.org/sameorsimilar http://www.APMA.org http://www.apma.org/em2021 http://www.apma.org/medicare http://www.apma.org/L3000 http://www.apma.org/sameorsimilar http://www.apma.org/PIRG http://www.apma.org/PIRG http://www.apma.org/59toolkit http://www.apma.org/25modifier http://www.apma.org/cacpiac

APMA News - January/February 2021

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