08/19/2025

MEMBERSHIP ADVOCACY IN ACTION

SUMMARY OF CAC/PIAC MEETING

Dear TPMA Member, 

Your membership dues directly fuel advocacy efforts like these. Every hour APMA spends pushing back against harmful policies, negotiating with payers, and influencing Medicare rules translates into real financial impact for you. The proposed changes highlighted below—including increased reimbursements, better recognition of podiatry-specific services, and ongoing payer negotiations—are a direct result of the advocacy your dues make possible. Ultimately, this work goes right back into your pocket through higher reimbursements, reduced administrative burdens, and stronger protections for your scope of practice.

Dr. Kyle Ballew attended the quarterly CAC/PIAC virtual meeting on August 13, 2025.  The information below is a summary of topics discussed.

SUMMARY OF CAC/PIAC MEETING

Medicare Physician Fee Schedule (PFS) Proposed Rule

APMA Health Policy & Coding Advisor Jeffrey Lehrman, DPM started the meeting, providing an overview of the CY 2026 Medicare Physician Fee Schedule Proposed Rule (PFS) and noting that the comment period is currently open and APMA staff are working closely with the Health Policy and Practice Committee (HPPC) to prepare the APMA’s response. The CY2026 proposed Conversion Factor is 3.62 percent with an estimated total 4% increase for podiatry. This increase is a result of, in part, from APMA advocacy and supporting a 2.5% increase provided for Medicare physicians under the One Big Beautiful Bill Act.

CMS proposes to increase the Work RVUs (wRVUs) to 28750 and 28755. The wRVU for 28750 is currently 8.57 and is proposed to increase to 8.75, and the wRVU for 28755 is currently 4.88 and proposed to increase to 6.76. These increases are a direct result of recommendations made by the AMA/Specialty Society RVS Update Committee (RUC), in which APMA is actively involved to represent our members' interests.

CMS is also advancing its transition from the current MIPS program to “MIPS Value Pathways” (MVPs), with the goal of creating less siloed, more concise, and specialty-specific reporting. APMA has long advocated for more meaningful measures and provided feedback on a podiatry-specific MVP last year. CMS accepted almost all of APMA’s suggestions and has proposed a Podiatry MVP for CY2026.

Another significant element of the proposed rule addresses global services during the post- operative period. CMS has expressed concern that post-op visits are not occurring at the expected frequency, and in some cases, patients are not returning to the physician at all. Because services with a global period factor in post-op visits (such as the five visits bundled into CPT 28296), CMS is questioning whether payment should continue for services that are not being delivered. APMA strongly disagrees, emphasizing that DPMs do provide these visits, and will express opposition to any future changes. APMA will continue to encourage members to submit CPT 99024 for all post-op visits, including telehealth visits when they meet all requirements.

 Skin Substitute Reimbursement: Proposed Changes:

The proposal also includes substantial changes to skin substitute reimbursement. Under its proposal, CMS would implement identical skin substitute payment methodologies in both the private office setting and the hospital outpatient / ASC setting such that the application and the product are reimbursed separately in both settings with no bundling. CMS also proposes reclassifying most products from biologicals into one of three FDA regulatory categories (PMA, 510(k), or 361 HCT/P) and reimbursing them at a flat $125.38 per square centimeter in the first year. APMA has formed a subgroup to address this issue to ensure that members’ concerns are fully reflected in APMA’s comments to CMS. APMA will submit its formal comments in response to the proposed rule on or before the comment period closing date of September 12, 2025.

Wasteful and Inappropriate Service Reduction (WISeR) Model

APMA shared a recorded explanation of the CMS WISeR Model, a voluntary six-year pilot aimed at reducing waste through automated prior authorization. The model would apply to 15 CMS services and be implemented in six states (NJ, OH, OK, TX, AZ, WA). Skin and tissue substitutes are included in the services but only applicable to MAC jurisdictions and states that have an active LCD in place (NJ, OH, OK, TX). While participation is optional, providers who do not submit prior authorization could have claims subjected to pre-payment medical review (something already occurring in some cases). The model does not change documentation requirements or coverage criteria, and decisions could be provided within CMS’s chosen timeframes, which APMA believes are inadequate. In a letter sent to the agency, APMA opposes the model, citing concerns that prior authorization delays patient care, but supports the use of “gold carding” for providers with a track record of appropriate use. APMA encouraged members to share the explainer video and be aware of the association’s position against expanding prior authorization in Medicare.

Payer Advocacy

APMA continues to engage with payers to address reimbursement concerns. Recently, the Association submitted a letter to Cigna regarding its policy change for modifier 50 when billed with bilateral imaging services. Cigna now requires bilateral services to be reported on a single claim line with one unit and modifier 50 and will only reimburse at 150% of the allowable. APMA contends this policy is inconsistent with CMS policy and arbitrary. Cigna has acknowledged the concern and is reviewing the issue.

APMA also now meets quarterly with Aetna to address issues impacting providers, as well as obtain updates from Aetna about policy changes or education needs that our members should be aware of.

For details on these and other advocacy efforts, see APMA’s comment letters.

Therapeutic Shoes for Diabetics (TSD) Workgroup

APMA formed -TSD Workgroup, led by APMA President Dr. Brooke Bisbee to focus on improving access to therapeutic shoes for individuals with diabetes. While the HELLPP Act, which would add podiatrists as covered physicians under Medicaid, revise Medicare documentation requirements for diabetic shoes, and address certain Medicaid payment rules, has not been reintroduced this year, APMA remains engaged with bill sponsors and will reassess legislative strategy. Given ongoing challenges with the current therapeutic shoe policy, APMA is pursuing a regulatory approach through CMS and the DME MACs. The workgroup is gathering data to demonstrate the impact of limited access, with reports of delays of 6–8 months and many providers leaving the program. There is interest in collaborating with other specialties, such as family medicine and wound care, to strengthen advocacy. APMA has created a list of potential partners for outreach.