CMS Continues to Educate Wound Care Providers: Are We Paying Attention?

HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   This author enjoys educating all the physicians, podiatrists, nurse practitioners, physical therapists, program directors, coders, billers, corporate compliance directors, and other wound care stakeholders who remain actively in contact through phone calls, e-mails, and regional and national wound care conventions. Often, one’s need for assistance and guidance is related to not receiving payment for a service/procedure/product or due to an audit that has resulted in a large repayment. When this author consults with these numerous stakeholders, we usually come to a conclusion that they were not originally aware of and/or did not understand the legislative/regulatory and/or coding/billing guidelines pertaining to the reimbursement issue in question.   For example, during a recent call a program director at a hospital-based outpatient wound care department (HOPD) nervously explained that her hospital administrator ordered that the HOPD code and bill for a clinic visit each time a patient was seen (even when the physician performed a scheduled “minor” surgical procedure) because the HOPD was “losing money.” Concerned that she could not justify this action, the program director did not know where to find the appropriate regulations and coding/billing rules pertaining to clinic visits and minor surgical procedures occurring on the same day.   Another example saw a program director reach out to ask how she could convince her HOPD coder that the facility was supposed to bill for the number of square centimeters (sq cm) of cellular- and/or tissue-based products for wounds (CTPs) [old term “skin substitutes”] that the physicians opened for each patient. The coder has reportedly been changing all units on the claim to “1” to match the number of units reported for the Current Procedural Terminology® (CPT) code pertaining to the application of the CTP. These examples may be tough to believe, but such is a day in the life of a wound care reimbursement consultant.   The Centers for Medicare & Medicaid Services (CMS), which write the regulations and billing guidelines and the Medicare Administrative Contractors (MACs) who process wound care claims, continue to educate us about the regulations, the problems they find with submitted claims, the issues that are being audited, and the list goes on. Today, we have to ask ourselves whether or not we are paying close-enough attention to the information being provided. During the summer months, CMS and the MACs released many educational documents, newsletters, webinars, etc. This column is not large enough to discuss everything that pertains to wound care, but it will cover a few important topics that you may have missed while you were on summer vacation. It would be wise to share this information with your entire team, including your coders and billers.

Skin Substitute List Additions

  Effective July 1, the following products have been added to CMS’s skin substitute product list:     • Q4126 MemoDerm, Dermaspan, TranZgraft, or InteguPLY, per sq cm   CMS assigned Q4126 to a new ambulatory payment classification (APC) group: 01452.     • Q4134 hMatrix, per sq cm   CMS assigned Q4134 to APC group 01453.   Also effective July 1, CMS has assigned the following APC status indicator (SI) to both of these APC groups:     K Paid under OPPS; separate APC payment.   Effective July 1, CMS also has changed the SI for APC group 01419 (Q4122 DermACELL, per sq cm). The new APC SI is:     G Pass-through drugs and biologicals.   Effective Oct. 1, 2013, the following products will be added to the list:     • Q4135 Mediskin, per sq cm   CMS assigned Q4135 to APC group 01461     • Q4136 EZ Derm, per sq cm   CMS assigned Q4136 to APC group 01462   Also effective Oct.1, 2013, CMS assigned APC SI to both of these APC groups:     K Paid under OPPS; separate APC payment.   NOTE: The existence of a Healthcare Common Procedure Coding System (HCPCS) code and a payment rate does not mean the product(s) are covered. As we have discussed many times before in this column, qualified wound care professionals must read their Medicare Local Coverage Determination (LCD), if one exists, to determine whether or not the product is covered by their MAC. If an LCD does not exist, the product may be covered based on medical necessity. Before applying any CTPs on patients insured by private payers, managed Medicare payers, Medicaid, Worker’s Compensation, etc., verify the coverage and obtain prior authorization, when required.

Add-On HCPCS/CPT Codes

  An add-on code is an HCPCS code or CPT code that describes a service that is always performed in conjunction with another primary service. An add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner on the same date of service. CMS has learned from recovery-audit reports that some providers are billing only add-on HCPCS/CPT codes without their respective primary codes, which has resulted in overpayments. Because HOPDs and physicians surgically and medically debride many large wounds that require the use of add-on codes, be sure to review claims to ensure the coder has used a primary code and the appropriate number of add-on codes. The same is true for the application of CTPs (aka “skin substitutes”).

Resubmission of Rejected Debridement Claims

  CMS was recently made aware of erroneous rejections (based on skilled nursing facility [SNF] consolidated billing) of HOPD claims containing CPT surgical debridement codes 11042, 11043, and/or 11044. These rejections are occurring because the codes were not removed from the minor surgery inclusion list in the 2013 SNF Consolidated Billing File for fiscal intermediary (FI) billing. Medicare contractors have now been instructed to bypass the SNF Consolidated Billing Common Working File edits for outpatient hospital bill types 13x and 85x with dates of service on or after Jan. 1, 2013, when one or more of these CPT codes is/are present on the HOPD claim. HOPDs need to adjust/resubmit any claims that may be affected by this change. Because many HOPDs provide wound care services for SNF patients, providers should advise their billing departments to investigate if there are any claims with these surgical debridement codes that were erroneously rejected and that need to be resubmitted.

I/OCE Changes

  The Integrated Outpatient Code Editor (I/OCE) is used by MACs to edit Outpatient Prospective Payment System (OPPS) Claims and non-OPPS claims for HOPDs, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness. It can be found online at www.cms.gov/OutpatientCodeEdit/.   The I/OCE identifies individual errors and indicates which actions should be taken (and the reasons these actions are necessary). In order to accommodate this functionality, the I/OCE is structured to return lists of edit numbers. Currently, there are 86 different edits in the I/OCE. The structure of the I/OCE facilitates the linkage between the actions being taken, the reasons for the actions, and the information on the claim (eg, a specific diagnosis) that caused the action. See Table 1 on page 7 for a list of the edits.   One of the recent edits pertained to autologous platelet rich plasma:     G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment is subject to edit No. 68 - service provided prior to date of National Coverage Determination approval, retroactive to July 1, 2012.   The occurrence of an edit can result in one of six claim dispositions. See Table 2 at right for a list of claim dispositions.   CMS typically releases I/OCE specification updates quarterly, about two months before their implementation. This gives providers time to make any adjustments to their charge description masters and to their claims processing system. Several I/OCE special processing conditions are very important to HOPDs:     • One reminds us that certain wound care services may be paid an APC rate or from the Medicare Physician Fee Schedule (MPFS), depending on the circumstances under which the service was provided. The I/OCE will change the SI and remove the APC assignment when these codes are submitted with therapy revenue codes or therapy modifiers.     • Another reminder tells us if a “sometimes therapy” code such as 97597/97598, 97602, and/or 97605/97606 is performed by a therapist, a therapy revenue code and a therapy modifier should be used on the claim. In that case, the claim will not be paid by the APC system. Instead, it should be submitted on a CMS 1500 claim form and paid according to the MPFS.     • Another reminds us that certain CTPs will be separately paid based on their standard SI/APC assignments, only when billed with specified CTP (aka “skin substitute”) application procedure codes. If one of the specified application procedure codes is not present on the same date as the CTP, the CTP will be packaged (will have its SI changed to “N”).     • Another states that certain claims will be returned to the provider if a specified add-on code is submitted without a code for a required primary procedure on the same date of service.   The I/OCE also generates National Correct Coding Initiative (NCCI) Edits. All applicable NCCI edits are incorporated into the I/OCE. Modifiers and coding pairs in the I/OCE may differ from those in the NCCI because of differences between facility and professional services. The NCCI edits are applied to services submitted on a single claim, and on lines with the same date of service. NCCI edits address unacceptable code combinations based on coding rules, standards of medical practice, two services being mutually exclusive, or a variety of other reasons. In some cases, the edit is set to pay the higher-priced service, in other cases the lesser-priced service. In some instances, both codes in an NCCI code pair may be allowed if an appropriate modifier is used that describes the circumstances when both services may be allowed. The code pairs that may be allowed with a modifier are identified with a modifier indicator of “1”; code pairs that are never allowed, whether or not a modifier is present, are identified with a modifier of “0.” (Modifiers that are recognized/used to describe allowable circumstances are: 24, 25, 27, 57, 58, 59, 78, 79, 91, E1-E4, F1-F9, FA, LC, LD, LM, RI, RC, RT, T1-T9, and TA). NOTE: If you have not been reading the quarterly updates to the I/OCE, you should add this to your list of things to do. Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She may be reached at 561-964-2470 or kathleendschaum@bellsouth.net.