‘Aha!’ Moments During 2020 Virtual Wound Clinic Business Seminars

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

The 12th year of Wound Clinic Business (WCB) began in Austin, Texas on March 13, 2020—the very day when the COVID-19 pandemic stay-at-home orders were released. The Austin attendees enjoyed working through the interactive reimbursement scenarios and submitted extremely high evaluation ratings for the seminar and the speakers.

As the speakers and the HMP Global team left Austin, we were fearful that we would not be able to offer any more WCB seminars in 2020. At first, some of the live seminars were rescheduled, but the pandemic just did not cooperate. Therefore, the HMP IT, marketing, and sales departments (along with the speakers) spent many long days and nights converting the live interactive format into a virtual interactive format. By the time that work was completed, HMP and the sponsors decided we could successfully deliver 6 virtual seminars (beginning on August 12 and ending on September 24) with 8:00 a.m. starting times in the various time zones throughout the country.

Therefore, we provided 6 virtual seminars that contained the exact same material, including the 44 interactive audience participation scenarios, as the live WCB in Austin. In addition, the attendees were able to speak directly to the speakers—they did not have to type their questions and comments. We were thrilled to receive extremely high evaluation ratings for all 6 seminars.

Like all past WCB seminars, both the live audience and the virtual audiences had many “aha!” moments when they 1) learned something new, 2) learned that they were doing something incorrectly, and 3) learned the “why” behind regulations and coding rules that they did not understand. Because many of the “aha” moments repeated over and over throughout the 7 WCB seminars, this author is sharing a few of them in this column.

Operational ‘Aha!’ Moments

Orders are required for every patient encounter in physician/qualified healthcare professional (QHP) offices and hospital owned outpatient wound/ulcer management provider-based departments (PBDs). Physicians/QHPs totally understood that orders are required for every patient encounter in their offices. Many PBDs did not realize that each patient encounter is a standalone event that requires an order. The PBDs were surprised to learn that both the Medicare coverage requirements and conditions of participation require signed and dated orders for each patient encounter, including hyperbaric oxygen therapy (HBOT) treatments, and for each change to the treatment regimen.  

“Nurse visits for dressing changes” in PBDs is not considered medically necessary by Medicare. Patients or their caregivers should be taught to change their dressings at home. If the patient insists on returning to the PBD for dressing changes, the PBD should charge the patient for this non-covered service.

Physicians/QHPs should not write “dressing change orders” if the patient really requires wound/ulcer assessment and reapplication of devices such as total contact casts, Unna boots, multi-layer compression bandages, negative pressure wound therapy (NPWT) durable medical equipment (DME), or disposable NPWT (dNPWT). Physicians/QHPs should write an order for wound/ulcer assessment and the name of the procedure that should be performed.

PBDs should not charge less for 100 sq cm of cellular- and/or tissue-based products (CTPs) for skin wounds applied to the foot than for the same 100 sq cm of the CTP applied to the leg. PBDs frequently complained that Medicare payment is less for 100 sq cm of CTPs applied to the foot than to the leg. Yet the PBDs are charging Medicare less to apply 100 sq cm of CTPs to the foot than they charge for application to the leg. When PBDs learned that claims submitted to Medicare this year are used to set Medicare payments for 2 years from now, they had an “aha” moment: they must immediately refine their Charge Description Masters to reflect the correct cost to apply 100 sq cm of CTPs to all anatomic locations.

Most PBDs and physicians/QHPs did not realize the importance of reading their contracts with private payers, and many said they do not have time to read payer contracts. Private payer contracts contain current payment rates, acceptable revenue codes, policies about QHPs, insurance benefit verification and prior authorization processes, etc. If the contracts do not align with the PBDs’/physicians’/QHPs’ needs, they should inform their contract manager to refine those sections of the contract at the next contract review period.

Most PBDs did not have contracts with skilled nursing facilities (SNF) and home health agencies (HHA). Most physicians did not have contracts with SNFs. The consolidated billing (CB) portion of the Medicare payment system for SNFs and HHAs requires that PBDs bill them for certain procedures that are on the CB list. Therefore, the PBD must negotiate contracts that state the SNFs and HHAs will pay the PBDs for the CB procedures. Similarly, physicians/QHPs must negotiate contracts with SNFs to pay them for CB procedures.  

Coding ‘Aha!’ Moments

Physicians/QHPs did not realize that the codes they report to Medicare for office/clinic visits are different than the code that PBDs report to Medicare for clinic visits. Physicians/QHPs report 99201–99215 on their Medicare claims for office/clinic visits. PBDs report G0463 on their Medicare claims for clinic visits. The PBDs have a mapping system, which is unique to their facility, that maps the resources used by the PBD to 99201–99215: each of these codes has a different charge in their Charge Description Master. When the billing department sees a PBD clinic visit code and charge for a Medicare patient, they change the code to G0463, but keep the charge that is affiliated to the 99201–99215 code.

PBDs and the physicians/QHPs, who work in PBDs, learned how to determine when their procedure codes reported to Medicare should/should not be the same.

o    When the physician/QHP performs a procedure, such as surgical debridement of subcutaneous tissue, the physician/QHP and the PBD should report the same procedure code. NOTE: The PBD should not report a clinic visit because they supported the physician/QHP to perform the procedure.

o    When the physician/QHP assesses the wound/ulcer and writes an order for the PBD staff to perform a procedure, such as application of an Unna boot, the physician/QHP should report the appropriate evaluation and management (E/M) code and the PBD should report the appropriate procedure code. NOTE: The physician/QHP should not report the procedure code because she/he did not perform the procedure.

Physicians/QHPs were surprised to learn they could perform, and receive Medicare payment for, 2 advanced wound/ulcer management therapies in their offices.

o    Physician/QHP offices can receive Medicare payment for the medically necessary application of CTPs, as well as the CTP product. This is unlike the PBD where the payment for the CTP is packaged into the payment for its application. Another major difference is that Medicare pays offices separately for the add-on application codes for larger wounds/ulcers: Medicare packages the add-on application codes into the base codes in PBDs.

o    Physician/QHP offices can receive Medicare payment for medically necessary HBOT. The office should code 99183 for the HBOT supervision and G0277 for the use of the HBOT chamber. NOTE: When the physician/QHP supervises HBOT in a PBD, she/he only reports 99183 on their Medicare claim.

Physicians/QHPs and PBDs were surprised to learn they should not routinely code for E/M or clinic visits during the same encounter when selective and non-selective debridement, application of negative pressure wound therapy (durable medical equipment and disposable), or low frequency non-contact non-thermal ultrasound is performed. The code descriptions for all active wound care management codes (97597, 97598, 97602, 97605, 97606, 97607, 97608, and 97610) include “wound assessment.” Therefore, a separate E/M or clinic visit should not routinely be reported during the same encounter as an active wound care management code unless a significant, separately identifiable service is performed.

Confusion reigned regarding coding for wastage of CTPs applied in PBDs vs. physician/QHP offices.

o    Medicare requires physician/QHP offices to report the number of sq cm of CTPs applied and the amount wasted on separate claim lines.

o    Because PBD payment for CTPs is packaged into the application payment, Medicare allows the total number of sq cm purchased for the application to be reported on one claim line. However, some Medicare Administrative Contractors (MACs) still require the PBDs to report the amount applied and the amount wasted on separate claim lines. CAUTION: Check your MAC’s local coverage determination (LCD) and local coverage article (LCA) for direction about reporting wastage. If your MAC does not have an LCD and LCA pertaining to the application of CTPS, PBDs should follow Medicare’s guidelines.

Payment ‘Aha!’ Moments

If physicians/QHPs perform work in PBDs, they must verify if the PBD is considered on-campus or off-campus. Physicians are required to correctly report (on their Medicare claims) the place of service where they provided care to Medicare patients. Because it is not always easy to determine the if the PBD is on-campus or off-campus, the physician/QHP should always ask the hospital administration.

Many grandfathered/excepted off-campus PBDs did not realize they incurred a 60% Medicare payment reduction for G0463 Hospital outpatient clinic visit for assessment and management of a patient. As of January 1, 2020, all off-campus PBD clinic visits are paid 40% of the Medicare APC fee schedule allowable rate. This is Medicare’s attempt to have site-neutral payments between off-campus PBDs and physician/QHP offices.

All minor procedures include evaluation of the patient, unless a significant, separately identifiable service is performed. Because most of the wound/ulcer management procedures performed in PBDs and by physicians/QHPs are considered minor procedures by Medicare, the PBDs and physicians/QHPs should not routinely bill for a clinic visit or E/M and minor procedure during the same encounter. The biggest “aha” moment came when the attendees realized that this applies to both “new” and “established” patients.
Patients who receive services from a physician/QHP in a PBD are billed by both the professional and the facility.

Some billing scenarios surprised many attendees:

o    When the physician/QHP performs a procedure (e.g., debridement of a wound/ulcer), both the professional and the PBD report the procedure code on their claims.

o    When the physician/QHP assesses the wound/ulcer and writes an order for the PBD staff to perform a procedures (e.g., apply a multi-layer compression bandage), the professional reports the appropriate E/M code and the PBD reports the procedure code on their claims.

Physician/QHP offices and PBDs are paid differently by Medicare for medically necessary applications of CTPs.

o    PBDs report 1) the “Q” code for the CTP, the JC modifier (and the JW modifier if required by the payer to separately report wastage), the total number of sq cm purchased, and the appropriate charge, and 2) the appropriate application code and charge. Medicare pays the PBDs one packaged payment for the CTP and its application.

o    Physician/QHP offices report 1) the “Q” code for the CTP, the JC modifier and the total number of sq cm applied along with the appropriate charge for the amount applied, the JW modifier and the total number of sq cm wasted along with the appropriate charge for the amount wasted, and 2) the appropriate application code and charge. Medicare pays the office a separate payment for the CTP and for its application.

Summary

The “aha!” moments described above are only a few of this year’s WCB attendees’ revelations. In fact, this author could have filled this entire journal with the attendees’ WCB learnings.

Now this author has received many e-mails and calls asking about the dates and plans for the 2021 WCB. Jo Devers and this author are already working on WCB 2021, which HMP and the sponsors are planning to offer, starting in April 2020, in 8 cities throughout the US. The 13th year of WCB promises to be “lucky” seminars because Jo and this author have many new coding, payment, coverage, and auditing regulations and rules to share with the attendees. In fact, there are so many new 2021 changes that we will have to work hard to fit them into a 1-day seminar. If you and your wound/ulcer management team want to participate in the 2021 WCB, visit www.woundclinicbusiness.com for the list of cities and dates where the seminars will be offered next year.

Be prepared to have many “aha!” moments when you attend.

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.