APMA Working for You in 2020: Advocacy Victories | APMA
APMA Working for You in 2020: Advocacy Victories

APMA celebrated many major advocacy accomplishments protecting and enhancing podiatric medicine in 2020. Download the handout of APMA’s 2020 advocacy wins!

COVID-19 Relief Legislation Includes Victories for Podiatrists

APMA has been aggressively advocating for podiatric physicians and surgeons in COVID-19 relief legislation since the early days of the pandemic. In late December Congress passed a $900 billion COVID relief package. As a result of APMA’s efforts, the bill includes significant victories for podiatry:

  • The bill provides for a one-time, one-year, 3.75-percent increase in the Medicare Physician Fee Schedule to provide relief during the COVID-19 public health emergency. With this increase and other changes included in the legislation, podiatry is expected to see an overall 5-percent increase in Medicare reimbursement in 2021 rather than an expected 1-percent decrease.
  • Congress also issued a three-year mortarium on HCPCS Code G2211, and prohibited CMS from making payments prior to January 1, 2024, for this inherent complexity add-on code. HCPCS Code G2211 was finalized in the CY 2021 Medicare Physician Fee Schedule, and APMA had previously urged CMS and Congress to postpone implementation of this code (formerly referred to as GPC1X). APMA, along with AMA and other medical specialties, stated that this code was not clearly defined, and CMS over-estimated its assumption on the utilization, which negatively impacted the conversion factor and in turn caused a decrease in other codes as a result of Medicare’s budget neutrality requirements.   
  • Congress also extended Sequestration relief for three months. The CARES Act suspended the Medicare Sequestration cuts for all Medicare fee-for-service claims until the end of the year, and the latest COVID-relief extends the suspension. APMA appreciates this short-term relief and will continue its long-term advocacy efforts to end the Sequestration cuts.
  • APMA succeeded in including a non-discrimination provision in Surprise Billing provisions to prevent provider discrimination. Surprise Billing provisions also include a 30-day open negotiation period for providers and payers to settle out-of-network claims. If unable to settle, the parties may access binding arbitration.

Visit www.apma.org/COVID19 for all of APMA's COVID-19 resources.

Victory! TRICARE Regulations Updated to Allow DPMs to Refer for PT/OT Services

TRICARE released a final rule fixing its outdated regulations to allow DPMs to refer TRICARE patients to Physical Therapy and Occupational Therapy Services (PT/OT) as well as speech pathology. The enforcement of the rule caused significant issues for podiatrists and their patients because podiatrists had to send patients back to their primary care provider for a referral. To fix this outdated rule, the APMA Health Policy and Practice Department engaged in advocacy efforts that included direct conversations and letters with Department of Defense (DOD) officials and worked with APMA’s Legislative Advocacy department obtain support from Rep. Brad Wenstrup, DPM (R-OH). READ MORE

APMA Victory—AUC Implementation Delayed to 2022

In August CMS announced it is delaying full implementation of the Appropriate Use Criteria (AUC) requirements for advanced imaging orders to 2022. APMA expressed significant concerns over the readiness of this program since 2019, and had asked for delay or cancellation of the program entirely throughout the COVID-19 public health crisis. READ MORE

NCCI Erroneous Edit Correction Victory

APMA led a joint effort with AAOS and AOFAS that resulted in the National Correct Coding Initiative (NCCI) correcting an erroneous NCCI edit related to CPT 28296 and CPT 28289. Previously, the NCCI edit that pairs these two codes places CPT 28289 in Column 1 and CPT 28296 in Column 2, implying the work involved with CPT 28296 is a component of CPT 28289 when these procedures are both performed at the same site. NCCI reversed that listing with the update reflected in the next quarterly procedure-to-procedure (PTP) edit update. READ MORE

CPT Win for Novitas Providers

In 2019, three new CPT® codes were released (CPT 20932–20934) that deal with allograft use. Novitas, a Medicare Administrative Contractor (MAC) responsible for 11 states and Washington DC, did not allow payment to podiatrists when these codes were submitted. Following an initiative led by Maryland and DC region Carrier Advisory Committee (CAC) Representative David Freedman, DPM, Novitas has now updated its procedure file to allow payment to all podiatrists for these codes. READ MORE

DPMs Designated Essential Critical Infrastructure Workers in COVID-19 Response

After months of APMA's advocacy, the US Department of Homeland Security Cybersecurity & Infrastructure Security Agency (CISA) explicitly included podiatric physicians in its definition of physicians classified as essential critical infrastructure workers during the COVID-19 public health emergency. READ MORE

CMS Confirms AAP Loan Recoupment Delay

CMS is holding off on garnishing Medicare providers’ payments related to the Coronavirus Aid, Relief, and Economic Security (CARES) Act Medicare Accelerated and Advance Payment Program (AAP). APMA expressed its significant concerns in August—specifically that the repayment terms are overly strict and would cause additional, unnecessary financial burdens for providers. READ MORE

VICTORY! NCCI Updates Policy Manual for Medicare, Use of -59 Modifier!

As a result of APMA’s advocacy efforts, the National Correct Coding Initiative (NCCI) updated Chapter I of the NCCI Policy Manual for Medicare Services in Section E.1.d.(3), Example #2, to reflect a prior determination by CMS specifying that use of Modifier 59 or X[ESPU] is acceptable if the procedures described by CPT® 11720 and 11055 are conducted on lesions that are anatomically separate from one another—even if on the same digit.

Effective January 1, 2021, the NCCI Policy Manual Chapter I now includes an example that reads as follows:

Example 2: The Column One/Column Two code edit with Column One CPT code 11055 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion) and Column Two CPT code 11720 (Debridement of nail(s) by any method(s); one to five) should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. Modifiers 59 or –X{EPSU} should not be used if a nail is debrided on the same toe on which a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint is pared. Modifiers 59 or –XS may be reported with code 11720 if 1 to 5 nails are debrided and a hyperkeratotic lesion is pared on a toe other than 1 with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided.

This victory ensures the NCCI Policy Manual language is consistent throughout and accurately reflects CMS policy.

APMA’s 59 Modifier Workgroup was formed last year to address this discrepancy and develop a Routine Foot Care and -59 modifier toolkit.  The toolkit includes educational materials and resources 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.

The workgroup is pleased with this victory and will now work towards the coverage of nail debridement without any restrictions related to callus paring or cutting.

For more information visit www.apma.org/59toolkit.

WPS Wound Care LCD Victory

APMA’s formal reconsideration request to Wisconsin Physician’ Services (WPS) to correct its problematic Wound Care Local Coverage Determination (LCD) led to several changes. WPS released Future Local Coverage Determination (LCD): Wound Care (L37228) on December 26, 2019. In it, WPS approved and implemented many of the changes APMA requested, including:

  1. Listing of diabetic foot ulcer as an ulcer type covered by this LCD
  2. Listing of Stage 2 pressure ulcer as an ulcer type covered by this LCD
  3. Allowing debridement of all partial skin thickness ulcers (CPT 97597/97598)
  4. Removal of NPWT criteria in the LCD which conflicts with DME criteria


DMEMAC Surgical Dressing LCA Victory

In March, the DMEMACs modified the Surgical Dressing LCA to state that the person who performs the weekly evaluation required for patients in a nursing facility and patients with a wound that is heavily draining or infected may have no financial relationship with the supplier. APMA expressed concern that this may lead to unintended consequences for physician prescribers who were also the suppliers, as occurs when podiatrists both prescribe and dispense DME. After this effort, the LCA was revised to add the following sentence: "This prohibition does not extend to treating practitioners who are also the supplier."

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