APMA is deeply concerned by a recent Office of Inspector General (OIG) report addressing podiatrists’ claims for evaluation and management (E/M) services billed with modifier 25. The report, titled “Podiatrists’ Claims for Evaluation and Management Services Did Not Comply with Medicare Requirements,” makes a sweeping claim regarding podiatrists’ compliance that fails to recognize the value of care delivered by our profession and is not reflective of care delivery and claims billing today.
While APMA fully supports efforts to ensure proper Medicare billing, the framing of the report is troubling and risks creating a misleading narrative about podiatric medical practice. Podiatric physicians regularly perform procedures while also performing significant and separately identifiable evaluation and management services at the same encounter, making appropriate use of modifier 25 both clinically justified and common.
The OIG’s finding that 44 out of 100 sampled claims did not fully comply with Medicare requirements must be interpreted with great caution, particularly in light of the time that has elapsed since the services in the report were furnished. An audit of 2019 data does not reflect how care is currently delivered, documented, or billed. Furthermore, CMS and its Medicare Administrative Contractors (MACs) have undertaken several initiatives in the intervening years to improve provider education and reduce improper payments.
We also underscore that sample-based extrapolations—such as the OIG’s estimate that roughly $39.6 million of the $222.5 million paid during the audit period may not have complied with requirements—can easily overstate alleged improper payments. Such extrapolations also fail to capture the clinical nuance involved in day-to-day patient care.
APMA calls on CMS and the MACs to ensure that any additional oversight or educational efforts recommended by the OIG are transparent, supported by clear guidelines. They should also recognize and accommodate the clinical realties of patient care. APMA encourages its members to make use of the association’s 25 modifier resources to help ensure compliance with Medicare requirements. Visit our 25 modifier tool kit at www.apma.org/25modifier and take advantage of our E/M resources page at www.apma.org/EM.
APMA remains committed to working collaboratively with CMS, OIG, and other stakeholders to strengthen documentation and compliance standards while protecting podiatrists’ ability to deliver timely, medically necessary care to millions of Medicare beneficiaries.