KUDOS!

 We received a nice thank-you note from a member who had some challenges with CPT® codes 11720 and 11721. Their office is now able to obtain appropriate financial reimbursement without frustration.

We want to share what we were able to pass on to our members thanks to the guidance of Jeffrey D. Lehrman, DPM, Certified Professional Coder, and Certified Professional Medical Auditor.

For Medicare Part B beneficiaries in Pennsylvania, Novitas has two different policies that govern covered foot care (below). 

• These are separate policies with no overlap between the two. 
• Each time a patient is seen for covered foot care, it is essential to determine and document which policy the patient is covered under without confounding the two. 

The two policies are: 

1.  Routine Foot Care:https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35138&ver=39&name=336*1&UpdatePeriod=828&bc=AAAAEAAAAAAA&

2.  Debridement of Mycotic Nails:https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35013&ver=31&name=331*1&UpdatePeriod=841&bc=AQAAEAAAAAAA&

The Routine Foot Care policy generally covers patients who have both:

1. One of the qualifying systemic diagnoses in the policy

AND 

2. Class findings

This policy makes no mention of onychomycosis or pain, or limited ambulation.

The Debridement of Mycotic Nails policy covers patients who have both: 

1. Onychomycosis

AND

2. One of three secondary diagnoses listed in the policy

This policy makes no mention of a systemic diagnosis or class findings.

Novitas has posted the long-awaited finalized LCD and Article for "Surgical Treatment of Nails" effective 1/30/2022.

In summary, as your MPMA CAC representative, I provided in writing numerous recommendations as did I engage the APMA Health Policy and Practice and suggested changes to the policy several months ago (during the draft process).

Additionally, via the Webex CAC Open Meeting for Novitas, I provided verbal testimony about the numerous concerns in the proposed policy. Supportive arguments were provided to justify changes prior to the finalized version. Article - Response to Comments: Surgical Treatment of Nails (A58961) (cms.gov)

The updated policy is not effective until January 30, 2022 f or those that utilize these CPT codes 11730, 11732,11750, and 11765.

All MPMA members should review the LCD and LCA (Billing Article) to better understand the changes.

The most significant change addresses the frequency of performing these procedures. Be aware of an "8-month" period where you can't bill the same T Code (TA-T9).

However, the carrier states that under certain circumstances, exceptions may be considered.

This is from the LCA "For a medically necessary repeat nail excision on the same finger or toe, use modifier 76 (repeat procedure or service by the same physician or other qualified health care professional) or modifier 77 (repeat procedure by another physician or other qualified health care professional). The medical record documentation must be specific to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated. Compliance with the use of modifier 76 and modifier 77 may be monitored and addressed through post payment data analysis and subsequent medical review audits."

It is my understanding that APMA will provide additional information since a similar policy is applicable for First Coast (another major Medicare carrier).

The plan is to review this on the next MPMA membership Zoom in January.

The future LCD link is here: LCD - Surgical Treatment of Nails (L34887) (cms.gov)

The future LCA link is here: Article - Billing and Coding: Surgical Treatment of Nails (A52998) (cms.gov)

Originally shared in the July/Aug 2020 PPMA Newsletter

Response provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: As we get further into this pandemic, I am seeing more diabetic patients who have had their PCP appointments delayed for longer periods of time. An increasing number are now not seeing their PCP within the six-month time frame required for a Q8 or Q9 modifier as required by CMS for DM footcare coverage, thereby causing them to self-pay due to a situation that is out of their control. Has CMS adjusted to this situation with any sort of waiver during the pandemic?

A: No, no change has been made. When the patient qualifies for footcare via the Routine Foot Care pathway, and their qualifying condition has an asterisk in the policy, the patient must be under the active care of a doctor of medicine or osteopathy (MD or DO) or NPP for the treatment and/or evaluation of the complicating disease process during the six- month period prior to the rendition of the routine-type service or if the patient had come under a physician’s or NPP’s care shortly after the services were furnished. The PA Novitas policy is here: https://tinyurl.com/ybjdp8vl. 

One thing to take note of given the COVID-related situation you are encountering: Nowhere does it say this visit has to have been face-to-face or in-person. Therefore, a non-face-to-face visit counts. So, if the patient has not “seen” the provider who is caring for their qualifying condition in the last six months, be sure to also check for any non-face-to-face visits that may have occurred with that provider.

Because the policy as-is does not say the date last seen needs to have been an in-person or face-to-face visit, we do not need what follows, but it will make you feel better if you have any hesitation about what I wrote above. 

On April 30, 2020, CMS released, “Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program Interim Final Rule with Comment Period,” which can be found here: https://tinyurl.com/y9m9o4o4.

On page 157, it says, “We finalized on an interim basis that to the extent an NCD or LCD (including articles) would otherwise require a face-to-face or in-person encounter or other implied face-to-face services, those requirements would not apply during the PHE for the COVID-19 pandemic."

Originally shared in the Nov/Dec 2020 PPMA Newsletter

Response provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: Why do the Aetna “Silver” PPO Plans Pay Less than Others and Paid Less Medicare Rates in 2020, but in 2018/2019 Had Paid the original Medicare Rates?     

A: The payer in question here is a private payer. Therefore, the doctor contracts are with that payer to determine their fee schedule. This is very different from the public payer, Medicare, where all providers of all types in the same region are paid based on the same fee schedule. When dealing with a private payer, it is up to the doctor to agree to a fee schedule. This is often addressed in the doctor’s contract with the payer. 

Too many of our members sign those contracts without legal representation or sometimes without even reading them at all. The first step in considering what has been submitted here is to check to see if this plan is in violation of the contract the doctor signed. If the payer is in violation of this contract, this is a legal issue between the doctor and the plan. However, if the payer is not in violation of the contract the doctor signed, they are stuck with whatever they agreed to.   

Unfortunately this is not something PPMA can help with too much because PPMA cannot negotiate on behalf of their members, and is limited in what it can do due to antitrust laws.  

To answer the two questions that were handwritten on that form [PPMA’s Peer Review Committee Form], these private plans do not have to pay Medicare rates, and they can adjust their rates to whatever they want as long as the contract the doctor signed allows them to. 

Medicare Advantage plans are required by law to provide the same coverage as original Medicare. This is often a mistake to say they have to provide the same payment, and that is not true. Coverage and payment are two different things. They do not have to pay the same as original Medicare.

The summary is, because this is a private plan, they can do whatever the doctor allows them to do based on the contract they signed. This can all be negotiated and too many of our members just sign these agreements without legal expertise or negotiation.

Originally shared in the Jan/Feb 2021 PPMA Newsletter

Answers provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: What CPT code should I use for initial nursing home
encounters? Can podiatrists use CPT 99304?


A: CPT codes 99304–99306 describe initial nursing facility care. Yes,
podiatrists can absolutely submit initial nursing facility evaluation and
management (E/M) codes for Medicare patients.

Medicare does not recognize consultation codes. When Medicare stopped
recognizing consultation codes on January 1, 2010, it then instructed specialists,
including podiatrists, to use the initial nursing facility CPT codes when
seeing a nursing facility patient for the first time during that patient’s
admission.

Podiatrists should use initial nursing facility codes for Medicare patients if
that encounter qualified for what the facility would consider a “consult,” even
if the specialist was not the admitting/primary doctor. Since there are now
multiple doctors using those initial encounter codes, the admitting/primary
doctor must use an “AI” modifier on the initial E/M encounter.

This change did not alter the fact that in order to submit any E/M code, one
must meet the thresholds of complexity for that code. Complexity refers to
the key elements of E/M coding (history, exam, decision-making) in what
you performed; what you documented; and what was medically necessary for
that level. If counseling and coordinating dominate the visit, time may be
used to select the appropriate level.

These thresholds and time requirements are relatively high for the lowest
level initial nursing facility E/M (CPT 99304). Therefore, CMS clarified that
it is appropriate for specialists to use the subsequent nursing facility E/M
codes for initial encounters that do not meet the complexity thresholds for
CPT 99304. This is an important point. Even though podiatrists can use
initial nursing facility E/M codes for Medicare patients, every initial encounter
does not automatically qualify for the use of an initial encounter E/M.
For Non-Medicare payers that still recognize consultation codes, podiatrists
should still use consultation codes for nursing home consults.