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
Total Part B Total Part B RUC (billions) all Allowed DPM % of EFFECT allowed DPMs Total charges % increase (billions) % increase 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 5 th 2) 99213 ranking has remained 1 st 3) 99214 ranking has remained 13 th 4) 99203 remained same, 3 rd ranked 5) 99202 remained same,12 th 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
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