12/17/2024

Your Assistance Needed for Two Potential Lawsuits

APMA is requesting your assistance regarding two proposed lawsuits:

1. The first is a potential class action lawsuit regarding Modifiers 25 and 59. Health plans may be inappropriately denying and/or underpaying podiatric practices when appropriately documented separate, distinct services are provided at the same encounter. For example, it appears that some claims containing Modifier 25 have been bundled by certain health plans’ electronic claims processing software, thereby reducing the payment amount. If you have experienced similar issues, please complete the following short survey, which should take less than 15 minutes: Inquiries about Your Practice. Consider including your billing and coding staff in the survey. Additional information about this lawsuit is provided further below for the first question of the survey.
   
   
2. In the second case, the North Carolina Foot and Ankle Society and South Carolina Podiatric Medical Association are seeking podiatrists nationwide who are experiencing issues with recoupment for skin substitute products. Medicare Advantage Organizations such as Humana MA are prohibited from placing coverage restrictions that are more restrictive than CMS coverage guidelines. Providers around the country have been experiencing a significant increase in denials for skin substitute products by Humana’s Medicare Advantage plan as Humana enforces Policy Number HUM-1208-000, a policy more restrictive than published Medicare coverage. Providers are considering filing a federal suit against Humana MA. If you have interest in participating in this suit, please email Stephen Bittingerat Polsinelli, PC, or call 440-823-0664. Participants must agree to join the proceeding by January 10, 2025.
   
   

   Background/Issue with Modifier 25 and 59

   APMA is soliciting members’ interest in pursuing a resolution to specific health plan payment issues described below. If the findings and observations mentioned below have occurred or are occurring within your practice, we would appreciate your cooperation by responding to the inquiries listed, as well as your participation in future efforts to seek resolution to these matters.

   Certain podiatric patients may require separate, distinct services at the same encounter. The coding guidelines for submitting appropriately documented separate, distinct services at the same encounter are documented in various coding publications, including those published by Centers for Medicare and Medicaid Services, American Medical Association, and various health plans.

   Of particular interest to podiatric practices may be the use of the following modifiers on claims:

   • Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.[1]
   • Modifier 59 – Distinct Procedural Service1

   Findings

   It has been observed that certain health plans may be inappropriately denying and / or underpaying podiatric practices for professional services when appropriately documented separate, distinct services are provided at the same encounter. For example, it appears that certain claims containing Modifier 25 have been bundled by certain health plan(s)’ electronic claims processing software, thereby reducing the payment amount. In many cases, this practice of automatic denials / reductions contrasts with payers’ own medical policies and/or reimbursement policy manuals.

   To assist APMA in these efforts, please complete the following short survey (which could take less than 15 minutes). If you have questions about the survey, please contact APMA staff at healthpolicy.hpp@apma.org. If your office utilizes coders or billers, you may wish to include them in answering your questions, particularly related to calculating the frequency of these occurrences and estimating the aggregate dollar amount of the denials/underpayment, as well as the administrative costs (time) it takes to work these denials.

   Inquiries about Your Practice
   
   [1]   Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2023 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).