Recent Insights From Medicare Data on Billing

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This video was adapted with permission from Podiatry Today.

Transcript

My name is Dr. David Freedman. I'm a podiatrist. I practice in Silver Spring, Maryland. I've been in practice 37 years plus at this point in time. I graduated from what was called Pennsylvania College of Project Medicine, which is now Temple, and I've been involved in my practice growing it to become now a single specialty 22-state practice. I do currently reside as the APMA coding chair. I've been a member of the coding committee at APMA since 2005. And the reason why that's important is that my history is that I did a lot of education in coding compliance prior to that and then subsequently was elevated to that level of being on the committee, and then have been the chair for the past about five years. I am a board member of US Foot and Ankle Specialists. We've been in practice as a group since 2011, originally it's Foot and Ankle Specialists of the Mid-Atlanic, and I was a Chief Compliance Officer. So I've had a lot of experience in reviewing thousands of records, understanding medical data, and I serve as a Certified Professional Coder, a Certified Surgical Foot and Ankle coder, a Certified Professional Medical Auditor, Compliance Auditor for my group, and I do this on a consulting basis for many practices around the country currently as well. I also do services with our local Medicare carrier known as Novitas, and I am the Carrier Advisor Committee Member Representative, (and have) been that way for many years as well.

How can interested parties learn about CMS claims data and statistics?

This is something that has been put out for many years. I've been the principal person in reviewing data points provided by the APMA to us, taking that data and putting together important points of interest that we as podiatrists need to know about. So I started doing this and the data points were coming nicely. We would get data about two to three years after Medicare made it public. So the most recent one I had done previously was through 2018 and this year I was able to put together a 2021 presentation. Again, it's about three years behind because CMS does not post this publicly. It's about three years in arrears.  But I can and will hopefully shed light on the 2021 data as related to the previous history as podiatry bills for services.

How often is this data updated and when does that usually happen?

So that's several good questions, because CMS does surprise us when it does get updated. There's like I said, it's about three years in arrears type of situation. So we currently in 2024 have 2021 data. So, it usually happens around the beginning of the year that you get the data download, and then you can dive into the data through multiple Excel spreadsheets. You can download the data at the CMS website that has this. And anyone can do that as well.

What has the recent data revealed and are there any significant trends that we need to be aware of?

So, a basic trend is, first of all, how many Medicare enrollees are there in the United States? And as of 2021, it was almost 64 million Medicare enrollees. Those we're talking about are primarily over the age of 65, but it does include a lot of people who could be even under 18, all the way up to 64, who are on disability claims. And those numbers are small. The primary number that we look at is the total number of enrollees that are 65 and plus when it comes to Medicare data so that number in 2021 was about 64 million and In the age banding goes from the data from 55 to 64, to 75 to 84, to 85 to 94, 95 years and over, to patients that are over 100. We are now counting a lot of data and they represent over 95 probably represents only about 1% of the actual data points.

Now another area that may be important to some is Medicare Advantage. We always hear about that there's a lot of Medicare Advantage around the country and Medicare Advantage is private insurance that is being paid by CMS and Medicare to administer Medicare benefits to enroll leads. Most Americans don't understand it's not the same as Medicare because it's now private insurance. About 43% of the population of the Medicare population was enrolled in Medicare Advantage and that was about 27 and a half million members in 2021. So, by no means is it all or is it even 50 %? It may be around 50 % now in 2024. Interesting is that certain states stand out when they have the amount of Medicare Advantage, and those would be like Florida, Texas, Pennsylvania, New York, California, Ohio, Michigan. Those are your typical states.

A territory which is really interesting, which may be something that people don't realize is some places the penetration of Medicare Advantage is much higher. And in the territory of Puerto Rico, for example, 506 000 of 616 000 plus are enrolled in Medicare Advantage. So, in that territory, over 82% is in MA plans. And that's a significant issue for providers there, because they have to deal with many Medicare insurances that just don't administer Medicare the same way as traditional CMS Medicare plans.

Are there any other notable trends in specific areas like surgery or wound care?

In podiatry, for example, we look at the wound care type stuff, we think about that. We think more like the debridement of ulcers and things like that. I have the data for all providers, and in the years prior to 2011, I think we had the CPT® codes, 11040, 11041, they went away and they were replaced by 97597. So, but we do have a lot of data in the 11042 through 11047 range. And the data always showed that 11042 was a highly utilized CPT code and it continues to be. There were a total of 253,000 beneficiaries in the outpatientsetting and 218,000 in the facility setting. So close to almost 470,000 services were provided in Medicare just for CPT 11042, and that doesn't include the other ones. So, there is significant utilization of thesevarious CPT codes that are there for debridement.

The other ones that are also shown would be the application of wound grafts. So the preparation codes, the 15002, et cetera, and then the application codes like 15271, 15272, et cetera. And again, we only have 2021 data, but clearly 15002, which is preparation of the wound graft site for the leg or the ankle area, we had the total number of services in 2021 were between a facility and outpatient were about 26,000 services. And then, again, this is just Medicare. And then when it comes to application of the skin substitutes, for example, 15271, we can see that was one of the higher utilization ones, and that was at about 100 and 15,000 applications or services were used just with that one CPT code. And there's, again, the other applications as well. So, you can see with wound care. Pretty high utilization there.

What do you hope clinicians will remember about this topic?

Depending on the practice that you have, you have to know what the specific CPT codes that you build, let's say your top 10 or top 20, are what the frequency is, how you compare across the board for all providers and maybe our specialty as well. You have to be aware that because Medicare is on the rise of doing audits and these include what are called TPEs, SMRCs, RACs and they do a lot of auditing from the standpoint of looking it back at utilization to see whether it was medically appropriate, medically necessary and you want to try to stay within the bell curve but you also want to be able to know that your services were medically appropriate, that the documentation was appropriate, and that, you know, the patients are getting the care that they are being billed for.

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