Information Needed for Potential Class Action Lawsuit

Background/Issue

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