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Male Speaker: Dealing with reimbursement issues for 2019, which I guess in today's day and age, it is just as important to have this kind of information so that we can be reimbursed appropriately for what we do. It was obviously insurance companies try to do just the opposite to us.
We're asking Dr. Paul Kesselman, who is from New York in the Long Island, he's a specialist in DME and wound care regulations for over 20 years. He is the leader for the APMA DME work group and meets regularly with Medicare officials, and has worked with orthotic professionals as well.
I've heard Dr. Kesselman speak in the past, he's very knowledgeable, very engaging, so please welcome Dr. Paul Kesselman.
Paul Kesselman: Good morning everyone. How many people here are from New Jersey? Okay. So I didn't prepare any slides on your encounters with Horizon Blue Cross Blue Shield, but we should have some time for some Q&A regarding that matter. So at that point, please feel free to ask any questions and â why is the clicker not working?
Paul Kesselman: Ah, okay. So here's my disclaimer which basically says the opinions that I present are mine. They are not referred to by anybody else, and so these are my opinions.
Conflict of interest. Basically I'm the CEO of my own compliance company, Park DPM. And I do work for several DME manufacturers and manufacturers in general on compliance issues for them.
So our learning objectives are here. We are going to skip over a lot of slides because of time. But I want you to know, I'm going to â we are preparing a PDF for you that will have about 65 to 70 slides in them. If we don't â if we have time, we'll go over the ones that we've killed for just for today. So I've selected a few topics for our discussion, half an hour discussion today.
The first one is target probe and educate. This is the new way that all the Medicare max, not just DME, are doing things. We've all heard about these, you know, pro â prepayment probes from Medicare, 90% failure rates and that sort of thing for therapeutic shoes, cam walkers, AFOs and a whole host of things.
So just to let you know, here's the schematic diagram. It's a little complicated. But the basic way that this works is that Medicare chooses you, not by the code necessarily, but they choose you because you are possibly an outlier. And what I mean by that is that maybe you're doing more than someone else in your same zip code or country is doing. And you maybe a specialist in that area and that's perfectly fine. You shouldn't ever be ashamed to excel and specialize in something.
So, you know, assuming that you're doing more shoes than someone else, so they're going to â the DME MAC is going to choose you. If it's biopsies, if it's bunionectomy, Novitas is going to choose you. Somebody is going to choose you for a target probe and education, and they're going to ask you for a bunch of charts. They may ask you for up to 40 charts in a quarter.
The good thing about this is if you pass, if you give them all the information and more than what they â you need, they're going to leave you alone for a year, all right. Now chances are, they are not going to ask you for 40 charts. Chances are they're going to ask you maybe 5 or 10 charts, because how many of you were doing 40 pairs of shoes in a quarter? You know, â or 100, or 120, that's something that going to make you standout from other people. So if that is not the case, you don't really need to be too concerned. If you get called in for one of these things, you know, maybe to send in five or ten charts like I said.
So you'll send them the charts, the nurse will review them and you'll get a decision. The decision will be you pass, will leave you alone, or you need some educational advice and you can say, "Okay, why don't you come down to the office and we'll come in and do an educational form for us?" And they will do that. It cost you nothing, nothing. Okay?
The problem, and I'm just putting these here, these are just comparisons between the two while versions of auditing. So you can read them while I'm talking. The difference is that, or essentially that the nurse reviews will come down. They'll do some education with you, they'll look at some charts for you. The problem is, and you'll see in one of these slides down the road, that the educators don't always have all the information that they should. And sometimes, they are clearly wrong.
So we have a one case about two years ago where I had a well-known podiatrist in the DC area call me and said, "Paul, they are wrecking me over the calls about shoes saying that I can't do my own physical examination that the MD or DO needs to do this and I can't." I said that's the most ridiculous thing I've ever heard.
So I got on the phone with someone who is a level or two above, the nurse audit is for the DME max, told him what happened.
He got on the phone with the nurse review or â and basically told him they were wrong. And that was the end of that. Hopefully that kind of transition from one type of audit to another, and those educators are now been all properly trained, but you need to know your stuff, okay? And know that the auditor is wrong.
Again, will it be option â will you go on a journey to the next round if you pass? You will not. If you want to have something else targeted and probed by Medicare, you can do that voluntarily. You can say, listen I want you to come and give me an educational beyond something else. And they'll do it. And it cost you nothing, all right? But again, my word to wise is still know the policy.
Remember also in terms of quarter variability. So if you look at these reports, and you'll see, well, one quarter we had a 40% error and the next quarter, we had a 25% error. You said, "Wow, that's good. My colleagues are doing a better job." Well, not so fast because you don't know that the mixture of people who are probed and educated that second time may have done better. Or maybe if they got worse, maybe they got a whole bunch of new people in who were novices and didn't know what they were doing.
So the percentage error rates are not exactly what I would like to call reliable, all right? They're just a guide. So, again, so are you going to go into an optional or mandatory second round? You'll go into a mandatory second round if you fail the first one.
And they'll just keep targeting and probing you. They can go up to three rounds. And if you fail the third round, you better call an attorney because the next people that are going to come in are not going to be so nice. They're going to be human health services, the OIG and all that sort of stuff. And then you're going to need â you know, you're going to need the help of an attorney.
So you need to look at the LCD policies and think about what the LCD is saying and what you need to do. And we're going to talk a little bit about that in another topic in just a couple of minutes.
So again, TPE issues, MACs offer one on one training. The MAC portal, a big thing. Everybody here is from the Northeast, yes? Yeah, okay. Your tidbit if you're already not on this, go to Noridian's DME MAC's website, the DME MAC A and sign up for their portal. You got to be on the portal. It takes a little bit of doing. I'm going to tell you to also get â and how many people have patients who were snowbirds who live in Florida? And that's the illegal residents.
Well, guess what, your DME MAC claims shouldn't be going to Noridian. They should be going to myCGS, they should be going to Cigna Government Services, which is Region C. You need the portal for them too and we're going to discuss those reasons why in a few minutes.
It's a pain in the neck, but I will tell you, it's a lot better than staying on the phone. It's a lot faster. You can get information. You can file appeals on the portal. You can do a lot of really interesting things that you cannot do on the IDRs or speaking to customer service anymore. CMS is cutting back on the ability for customer service people for live reps to interact with you. And they're going to ask you, did you do this, did you do that? And if you say yes, and they find out later that you're lying, you're in bigger trouble than you would have been, you know, had you just told the truth.
So just make sure that you do that.
Also, your liability carrier office audit insurance, I was â somebody cornered me before and I discussed this with him. Vendors offer audit insurance also, but, you know, the best source is Medicare portals, the LCD policies and your liability carrier.
Okay. So we had some issues here, I thought we were going to skip over this, but this is fine. This is the perfect example. We had a 48% error rate in fourth quarter, a 39% error rate in the third quarter. This has to do with custom fabricated hinged AFOs and pneumatic CAM walkers. And again, one of the reasons no response to in additional documentation request, the documentation doesn't support custom fit and the documentation doesn't support covers, so.
Therapeutic shoes, again, we're down from 90% error rate to a 43% error rate. And I will tell you if you look at the Medicare, BMAD data, which is the utilization data for podiatry. We are now â we provide about a third of the shoes and I'd say about 90% of the claims, go through and are paid.
So for those of you who left the game because you were getting this random premade payment audits and all this sort of stuff, 90% that the claims are getting paid. Why are you leaving that money on the table? That's something you should ask yourself as well.
Okay. I don't think that we're skipping through this â here we go. All right. So myriad codes. What do I mean by a myriad code? Here's three examples. Okay. We have a pneumatic CAM walker, we have non-pneumatic CAM walker and we have a plantar fascia night brace. These are the three most common myriad codes that podiatrists dispense.
The difference is the newer codes, the number one code at the last digit with a number one or the higher digited code I should say, is a custom â is a off-the-shelf code. Even I get confused sometimes.
So what they did was they took the old code, which was the lower numbered code and they gave it a new definition. And they gave you a new code with the old definition, which is just the opposite of what logic would've told them to do. But they did it, I think to confuse us. If I'm confused, I know you guys are confused.
Why am I talking to you about this if the fee schedule is the same? Now the fee schedule is the same. So I'm going to drop a bomb on you before we go to the next slide. Okay.
The reason I'm telling you this is because when you get audited for this, if you used a higher digited code and all you said was, "I dispensed a pneumatic CAM walker," guess what? You're not getting paid or they're asking for money back. Or if you dispensed a plantar fascia night brace, and you didn't say it was custom fitted and it was â and I'm a podiatrist and I have the unique talent to do the custom fitting and what did you do to custom fit in? I heated the upright. I grinded this, I spot glued and added additional materials here. You got to do something that the average DME supplier or patient couldn't do. Adjusting a strap or moving a pad or cutting something with a pair of scissors just doesn't cut it. Sorry for the pun.
So that's the number one reason why you want to use the right code. And I would venture to say that most of you are not doing custom fitting for off-the-shelf â I'm sorry, for pre-fabricated devices.
So all of these are pre-fabricated. It's just that the higher digited pair â of the pair, is off-the-shelf and the lowered number one is custom fitted.
Okay. Old code, new definition, new code, off-the-shelf. Okay.
All right. So what do you need â why do you need this information now in addition to the auditing issues? Because right now, there's a program called â called competitive bidding, which is a little bit on hiatus until the year 2021 â 2021. All right. And what they're doing with competitive bidding is they're reformulating the whole process, this effects wheelchairs and walkers and stuff that we just don't do, glucose test strips, things like that.
So what they're doing in 2021 is they're reintroducing the program and they're adding more things. One of the things they're adding is knee braces and spinal orthotics. So they're finally venturing into orthotics and prosthetics, which the American Orthotic and Prosthetic Association has been battling for years, since the competitive bidding program started.
What that is â what that is going to entail is â again, if you just envision these codes now, what they're doing with the spinal and custom â I'm sorry, the spinal and the knee braces is the fees are being cut for the off-the-shelf versions by about 30% to 40%.
And right now the reason they can't do that is there's a law that says, if you expand a code, which is what they essentially did with these three codes, they expanded the lower digit code from a â at the time it was â it didn't matter whether it was custom fit or a pre-fab, off-the-shelf. Now they're blowing the thing up into two different things. That's what I mean by expanding the code.
So they've expanded the code now and the Medicare law is that when you expand a code, you cannot have a fee differential. But there's a backdoor and there's always a backdoor. There's always a way around the regulation. And the way around the regulation is for them to put in the off-the-shelf version into competitive bidding. And that's exactly what I think is going to happen with CAM walkers and night braces. Okay. So be prepared for that.
So if you are doing custom fitted devices now, make sure you document it. You're probably going to get audited. And if you document everything correctly as I suggest you do, you'll be fine. And then when competitive bidding comes in, you're not going to have to worry about it, because the custom fitted part of the partner of the myriad code is not going to be subjected to competitive bidding.
And you also by the way, don't â as a physician, you have an exemption. You don't have to be a contracted competitive bidder. You don't have to put in a bid and get accepted and all that other nonsense, okay? You just have to accept the competitive bid fee that everybody else â all the OMP providers are going to have to do. All right. But they're going to have to get ex-contracted, you will not.
You also, you want to avoid that 30% or 40% cut in pay. You also want to avoid getting audited now. Why am I telling you all this? It's so far down the road, yes, we're going to try and fight it. We're going to try and figure out a way to fight it. And I'm still working with AOPA, we're going to do what they do for knee devices and spinal braces. I work with them very intently.
So in addition to the cut in pay, what I'm concerned about is all you guys out there are going to get smart and wake up one day and say, "Well, you know what?"
"We're going to start doing custom fitting." And you're going to have this wholesale change from one code to another. And you don't think the bean counters in Medicare are going to notice that, right? Anybody think that? Good.
So you got to figure out what you want to do. You want to take a chance now or take the lump of coal later. And that's something that I'm not going to â I can't tell you what to do other than to say, "Document what you do."
Same or similar, all right, we've got about 12.5 minutes. I think this is the big topic, there's one other topic I'm going to cover and then we're going to be done and we'll probably have a little bit of time for questions. Okay.
Does anybody here not know what this â what I'm talking about when it comes to same or similar? Raise your hands. You all know what it is? You don't know? Okay, we have a couple of people that don't know.
So same or similar basically is if the patient had something similar to what you want to propose to give them within a five-year period, Medicare's going to say on the first go-around, "We're rejecting it. We're not paying for it." Okay. This is where your provider portal comes in really helpful. Because what I'm going to tell you to do is if you have a patient that comes into the office and they need a CAM walker, they got a fracture. And they need the CAM walker, the first thing your front office staff or you should do is â when you â after you decided to put them in the CAM walker is an addition to asking the patient, "Have you ever had one of these devices?" Some of the patients, they could say, "Oh, yeah." Others are going to lie or they're just not going to remember.
So it's beholden on you. Right then and there, that office is to get on the Medicare MAC, put in their information and do a same or similar search, both on the Noridian site and the myCGS site. And the reason for that, as I said, your patient's a snowbird.
The billing is supposed to go to CGS, or maybe they switched where they lived. The bottom line is the portals don't interact with each other. The payments do, so you could send it in after you've done a same or similar search on the Noridian site and find out it's still subject to same and similar because my CGS paid for it. So you got to sign up for both and do a same or similar search on both of them.
The other thing is â so now, you've got information, the patient had an ankle gauntlet, given to them five â three years ago because they had an ankle sprain by someone else. Okay, we'll make the situation a little bit more complicated because if you did it, you should know. Somebody else did it, you're not going to know.
So now you found out someone else did it, what are you supposed to do? In your note, you say the patient had an ankle sprain on the left side because the portal's going to tell you which side the gauntlet was dispensed for. And you say the patient had an ankle sprain left side, three years ago, it has nothing to do with the current condition. They needed â we acknowledge it's under the Medicare same or similar provision but this is different, and it's a different anatomical site, and blah, blah, blah, blah, blah. That is your best powerful offense as a good defense to start off with.
So you have it in your note from the very beginning. It's going to get denied but when you send it in for appeal through the portal, it will get paid. And we have a young practitioner on our APMA DME work advisory group, he's got an, I'd say, he's a 95 percentile of getting all of his claims paid.
So here's a table for you with the codes that are subject to same and similar. It makes no sense. We are working on a resolution with CMS, but working with the DME MACs was an absolute waste of time.
Because they're bound by what the Federal Register says. And the interesting thing about the Federal Register for orthotics, it says a five-year useful lifetime for orthotic devices except when deemed inappropriate by the secretary. And secretary means the secretary of HHS. What does that mean? We don't need to wait for the inept Congress to work on it. It means it's a stroke of a pen. And right now, the way need braces are set up, there is a one, two, and three-year look back, not five as there is for AFOs.
So the person we met with the CMS was very reasonable. He wants data from us. He wants information from us. We're hoping to get a meeting with him sometime within the next couple of months, working with American Orthotic and Prosthetic Association and get this five-year look back changed to, like, a one year period or even 90 days for some acute care products like a CAM walker. Anybody here who thinks that a CAM walker's going to last for five years is out of their mind, I mean, you know, you're lucky you get them to last for six weeks with a metatarsal fracture, so.
We're looking to get that resolved, and as I said, share the information instead that are really â they carry your share payment data, but the portals don't, so you suddenly â it's your obligation to do both.
Okay, here's some good news. The good news is Medicare introduced several codes on remote patient monitoring. Now, I'm not going to tell you to run out there and start billing all these codes, but in the next couple of weeks, you're going to start seeing advertisements from a lot of companies producing orthotic devices that are geared and other devices that we prescribe and dispense.
And they're all going to have these little chips in them, and these chips are going to allow you to monitor the patient's use of a CAM walker, let's say, a pair of socks, all sort of stuff. And you're going to be able to bill this out to Medicare, and these are the fees. They're going to pay you $21, okay, for the initial set up, that's initially discussing the use of the device with the patient. An average of $69 for doing the remote monitoring and that's, chances are, that may be a service that you work with, that will build Medicare for that.
And then there's a $57 charge that's approx â that's a national average, so, maybe, probably going to be higher here in New Jersey, in Pennsylvania, and New York. So let's say it's $60, if you have a hundred patients that you're monitoring for diabetic shoes, and that's not a hundred that you're giving every month, but that 's a hundred patients in your total practice. Do the math folks. That's a lot of money.
But you have to write a report. It's probably going to take it 10 or 15 minutes to get up and running on these things, and then once you do it, it's just going to be a matter of repetitive things, looking at how bad the patients use it, calling the patient, letting them know that, you know, what's going on, and so on, and so forth.
So what I want to tell you is, again, don't run out and start billing these codes yet, they're there. We're trying to get more explanation but the gurus that I have spoken with, and they have spoken with me, we all believe that these codes are absolutely appropriate for podiatry. Now, whether they're going to be useful for, you know, things like dressings and other things, I don't know. But, you know, nowadays, you can put a chip in just about anything. And just imagine, you're going to be able to tell your patient, "I know you weren't wearing your orthotics." You know you weren't wearing you CAM walker.
And furthermore, there's going to be some that are going to be able to tell you what the patient was actually doing, were they running? You have a run â you have the sports medicine practice now, the patient is â you have a lot of patients who are runners, you're going to be able to know their speed, how long it took them to do a certain distance and that sort of, thing. I mean, it's just mind-boggling what's going to happen here. And I will tell you more that technology in terms of orthotics and prosthetics, is really going to be mind-boggling. You're going to have devices that are going to actually be able to change their density, and their functionality, while the patient's actually using them.
So the question I had for some of the companies and some of their compliance groups was, well, what if the devices uncovered, like, a foot orthotic? Doesn't matter. Doesn't matter. Their response to me is, "It doesn't matter." I don't know that I'm taking that as a fact yet, but it's possible. But just imagine for the non-Medicare population and there was a letter in PM news a couple of days ago from somebody who suggested that â an insurance company was asking him for evidence-based medicine for foot orthotics, could you imagine what this will do for the research on foot orthotics, and how helpful they are for patients if we can monitor the patient's use, show that the patient's improving in real time, I mean, it's just amazing.
So this is something that I think is really exciting, keeps to â and to keep an eye on for the next â you'll see some announcements very, very soon.
Telehealth Services, this was something that was recently posted on coding line. Two thousand pages regulation, all right. So they're state regulations. Are podiatrist included or not? Not in every state. State of Texas, they are not. There's other states where they are, and I don't know what about New Jersey, I don't know even about my own home, State of New York. I know that the regulations have changed drastically from last year to this year. So there was one posting on coding line. Yesterday, that was quite frankly incorrect, okay.
The other, I'm not so sure about. I haven't gotten through the 2,000 pages of regulations yet. So, you know, whether we're going to be able to use them or not, I don't know, but Telehealth, where you're looking â where you're actually looking at the patient remotely is very different than remote monitoring. So you need to understand these two separate different sets of codes. The Medicare's and the insurance company's idea is that it's going to keep the patients out of your office and therefore, it's going to cost them less money.
Evaluation and management codes for 2021, big victory this past year. What you should understand is that you're still going to have to do a history, you're still going to have to do a physical. But what's really going to make the difference in terms of what code you're going to use, is your medical decision management and its complexity, and how much time is â or how much time you spend face-to-face with the patient. So face-to-face time with the patient isn't you walk out of the room while the X-rays are developing, you walk out of the room to call their physician, you walk out of the room to call their daughter, or their son, or spouse. That does not count. You have to count for all the time you're with the patient.
So this is something that you're going to â will have some time to let â you'll get some more lectures, and more handouts from APMA and other sources, I'm sure, in the next few months. And that's it. So we've got about a minute-and-a-half. Questions? Please use the microphone, that's why they put them up. Or somebody will come around.
Male Speaker: I have a new brace company and on the appeal of five-year rule, can you hear me?
Paul Kesselman: Yeah, I can hear you. But I don't know if they can hear you, but I can hear you.
Male Speaker: On a five-year rule, a computer program, the first time you send in that you want a different brace even though they've been prescribed an Arizona brace or whatever in the last five years, it will automatically reject you.
Paul Kesselman: That's correct.
Male Speaker: So it's a computer program, nobody looks at it.
Paul Kesselman: That's correct.
Male Speaker: And then what you do is you go to appeal level one and as long as you document why you need a different brace, they all okay it. And documentation means that there's a new deformity, that they've had a new condition such as a stroke, that with the previous brace they developed sores, they couldn't wear it, they've had a weight gain of 20 pounds or weight loss of 20 pounds.
So all you have to do is document it and they'll okay it.
Paul Kesselman: For the most part, he is correct, all right? But what I would suggest, you take it a step further in that your initial documentation, don't respond to them with that information because if it's not in your notes, it doesn't matter what you say on an appeal. It must be in your notes from day one. And that's why you don't take the patient's word for it. You look back yourself and look at the portal, see what's dispensed and kind of carve your note based on that.
I'll be in the back for a little while. I'm actually heading to Philadelphia today for a meeting, so â but I'll be here this morning.
Female Speaker: I have one more question, I'm sorry.
Paul Kesselman: Thank you.
Female Speaker: Hello? One more question.
Paul Kesselman: Oh, sure.
Female Speaker: When would Medicare cover for custom orthotics if they ever do.
Paul Kesselman: Okay. Medicare will almost never cover a custom foot orthotics. Is that what your question was? Foot orthotics? Okay. There's one situation. Everybody here see the movie Forrest Gump? Okay. So you remember the scene with the metal braces because of polio? All right, if you have a patient that has that type of brace, that inserts into the shoe or is attached to the shoe in some fashion, then the orthotic that goes into that shoe will be covered by Medicare and they will cover fee for service.
Now, I need to gun and make a comment about this because the BMAD data for Medicare shows that podiatrists have been paid year after year approximately $6 million for foot orthotics. That's at $500 a pair. So you guys do the math and figure out many podiatrists are billing this to Medicare.
I had a very heavy orthotic and prosthetic practice when I was in fulltime practice. I think I did three of which two were the same patient. So basically, it means I did three times but only for two patients. So these people are really outliers. And I had one guy who called me and he's gotten paid like $150,000 for Medicare on foot orthotics and he was at a regional meeting and he heard this that it was â and I said that he should call Dr. Kesselman. He called me in a panic. And I said, before you talk to me any further, I need to advice you, you need to speak to an attorney.
Don't be caught in that position. If you used the KX modifier, you darn well better be adherent to the Medicare policy or the insurance policy that you're dealing with. Otherwise, it's not a covered service. The patient wants you to submit it to Medicare. Do it, it's the modifier GY which says statutorily non-covered and the patient will get a patient responsibility rejection which you could not submit to the secondary carrier and hopefully the secondary carrier will be pay. There's issues with that, but we've run out of time. And I thank you.
Female Speaker: What about diabetics?
Paul Kesselman: Diabetics are not covered for foot orthotics. Only inserts.
Male Speaker: How about shoes?
Paul Kesselman: Shoes, the ACA series codes.
Male Speaker: Once a year?
Paul Kesselman: Once a year.
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