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Fall 2025 |
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Presented by ADSRCM for AI-Driven Outsourced Services/Staffing & ADS for In-Office Automation for Podiatry
Through its newly announced Wasteful and Inappropriate Service Reduction (WISeR) initiative, CMS will focus on what it says is expensive, unnecessary care as covered by original Medicare and use prior authorizations (PAs) to help accomplish their goals.
Per CMS, WISeR is designed to protect federal taxpayer dollars since also, according to CMS, “wasteful care” includes services provided to patients that yield no clinical benefit which can also put patients at risk for unnecessary procedures. CMS goes on to say that waste in healthcare represents as much as a quarter of healthcare spending in the US. The Medicare Payment Advisory Commission estimated that close to $6 billion in Medicare spending in 2022 was spent on services that provided minimal benefits.
Examples that have been identified by CMS as being particularly vulnerable to fraud, waste, abuse, or inappropriate use include, but are not limited to, skin and tissue substitutes (are you doing wound care?), electrical nerve stimulator implants, and knee arthroscopy if for knee osteoarthritis. The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if significantly delayed.
Worse news is – also according to CMS – that AI will play a major role in creating prior authorization requests. But CMS does point out that final decisions on PAs and whether certain procedures can ultimately be performed and be reimbursed for on a patient-specific level will be driven by licensed providers, not technology. Incentives will be paid to providers based on performance while respecting the goals of reducing spending.
Click here for the CMS press release on WISeR, a full description of the initiative’s details, and links to additional information and fact sheets.
(Our automated PA option will help you combat what appears to be a looming increase in them. Pre-appointment eligibility verifications, out-of-network alerts, access to our patient responsibility estimator to help avoid surprises, and proactive denial alerts, will all help you protect your revenue in advance. Interactive balance-due texts, emailable patient statements, and online payments through our Medics Portal will help support you being paid as patients’ balances are created.)
“Podiatric burnout” sounds like it could be a procedure. But what it is - according to a recent Podiatry Management News survey - is that almost 90% of podiatrists have at least “some burnout.” But in its darkest form, the article states that worst case burnout is contributing to an increase in suicide. Among other things, the article mentions having to deal with Medicare, EHR, and rising expenses as being stressors.
The obvious fixes to these three specific stressors are (1) to have the automation needed to stand up to Medicare (as noted in the previous article on prior authorizations), (2) to use a specialty-specific, intuitive, hands-free EHR that supports ambient, natural language data capture for expedited encounters, and (3) to consider an outsourced RCM service that would not only increase revenue, but which also has a behind-the-scenes team to help consolidate your onsite staffing.
The article closes with suggestions for eliminating stress to the extent you can, and with a reminder message about the importance of maintaining a healthy life/work balance.
(Our clients have AI-driven automation for Medicare, and they can access the ONC-certified MedicsCloud EHR for podiatry with its built-in MedicsSpeakAI for ambient, natural language data capture to help expedite and simplify encounters. ADSRCM clients use our outsourced staffing as part of our service, helping to consolidate their in-house staffing.)
Click here for the Podiatry Management News “Are Your Burnt Out” article and survey details.
Not to make light of the burnout issue, but the following could contribute to that although not necessarily (as you’ll see).
The first thing to know: the ICD-10-CM code set for 2026 took effect October 1, 2025. So, it’s a thing by the time you’re reading this; the new codes must be used. And we’re not talking about a handful of new codes. There are 487 new code additions, 28 deletions, and 38 modifications. These include codes related to foot and ankle care, including changes involving lower extremity ulcers, diabetes, and more.
Here are the podiatry highlights:
Type 2 Diabetes
The 2021 International Consensus Report defining type 2 diabetes in remission, coauthored by the ADA, EASD, Diabetes UK, the Endocrine Society, and others, defines type 2 diabetes in remission as, "a return of HbA1c to <6.5% (48mmol/mol) that persists for at least 3 months after stopping glucose lowering pharmacotherapy."
If the type 2 diabetes in remission diagnosis played a role in the management provided during an encounter, that should be reflected in the ICD-10-CM coding that accompanies the encounter. The new, complete ICD-10-CM code will be:
E11.A Type 2 diabetes mellitus without complications in remission
Shin Ulcers
Non-pressure chronic ulcers of the lower limb are exhibited by ICD-10-CM codes beginning with the code stem L97- (Non-pressure chronic ulcer of lower limb, not elsewhere classified). Only until October 1, 2025, will these be the only 4th character options for this code stem:
of thigh
Previously, there was no coding option to represent a non-pressure chronic ulcer of the shin.
On October 1, 2025, with the introduction of a new inclusion term for L97.2- ("Non-pressure chronic ulcer of shin."). With this change, non-pressure chronic ulcers of the shin will now be represented by the L97.2- codes.
Aggressive Fibromatosis
Aggressive fibromatosis (aka, "desmoid tumor") is an abnormal growth that can develop from muscle connective tissue and aponeuroses. It is (1) nonmetastasizing, (2) may demonstrate local infiltration into tissue, and (3) typically displays a high risk of recurrence following surgical removal. This differs from typical plantar fibromatosis (Ledderhose Disease) which is typically confined to the fascia, does not involve muscle, and is not infiltrative in nature. Prior to this new code set, there was a diagnosis code representing desmoid tumor (D48.11), and effective October 1, 2025 "aggressive fibromatosis" will be added as an inclusion term under D48.11.
Multiple Sclerosis
While prior to October 1, 2025, G35 (multiple sclerosis) was a complete code, starting October 1, 2025, G35- will no longer be a complete code and will require additional characters. As a result, the following new codes:
Financial Insecurity
Social determinants of health can play a role in evaluation and management (E/M) level selection. Financial insecurity, for example, in the diagnosis coding that accompanies an encounter, Z59.86 (financial insecurity) was a complete code. But starting October 1, 2025, Z59.86 will no longer be a complete code and will require additional characters. This change creates the following new codes:
(ADSRCM helps ensure correct coding is used based on current published NCCI edits and LCD/NCD edits, alleviating that stressor from our clients!)
Click here for more details and Information from CMS on all ICD-10-CM changes.
A Fresno CA podiatrist and a medical sales representative pleaded guilty to conspiracy to commit health care fraud. The defendants admitted to defrauding Medicare and Medi-Cal from June 2021 and January 2024.
The podiatrist had clinics in Fresno, Madera and Stanislaus counties. According to the US Attorney’s Office press release, skin grafts were purchased by the podiatrist, but he allowed the salesperson to apply them to Medicare and Medi-Cal patients despite not being a licensed health care provider. Reimbursements made to the podiatrist resulted in him paying the salesperson.
Their scheme was uncovered after an investigation by the U.S. Department of Health and Human Services Office of Inspector General and the FBI. Sentencing is scheduled for January 20, 2026. Both face a maximum of ten years and a $250,000 fine.
We hope you enjoyed the read!
See us at November’s Goldfarb Clinical Conference in King of Prussia, PA, or contact us at 844-599-6881 or email rcminfo@adsc.com for more information about driving revenue, productivity/staffing, and clinical charting, either with ADSRCM as an outsourced service or with the MedicsCloud Suite from ADS if in-house automation is preferred. See us at the Goldfarb Clinical Conference in King of Prussia, PA, November 6-9!
Disclaimer: Articles and content pertaining to governmental information (e.g., CMS, Medicare, Medicaid, coding, etc.) are presented by ADSRCM according to our best understanding of them. www.cms.gov or other reliable websites should be consulted, or any organization(s) should be contacted directly for details, or if clarifications are needed. ADSRCM and ADS are not responsible for any typographical errors or for changes that may occur after this newsletter was produced. Visit www.adsc.com to view our most up-to-date information.
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