Is This Product Separately Payable By Medicare Part B?

  Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information accuracy. However, HMP Communications and the author 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 information accuracy lies with the reader.

  Each spring, most wound care professionals attend one or more wound care symposia that offer the opportunity to visit with those who manufacture the plethora of products used to manage wounds. This author has already been inundated with questions from wound care professionals who have seen new products and want to understand if these products are a cost of doing business or separately payable by Medicare Part B. Due to the repetitive nature of these questions, this month’s Business Briefs will share the most frequently asked questions and answers from two perspectives: wound care hospital-based outpatient departments (HOPDs) and qualified healthcare professional (QHP) office-based wound practices.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
RELATED CONTENT
Wound Clinic Business: Follow Your Revenue Cycle Through the Looking Glass
Use the Correct Payment File to Find Medicare Allowable Rates
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Wound Care Dressings

  Q: I saw an amazing new dressing at an annual wound symposium. It costs more than our normally stocked dressings. Can I ask Medicare Part B-covered patients to purchase these dressings and bring the dressings with them to their HOPD/QHP office visits?

  Answer to HOPDs & to QHP Offices
  No. HOPDs and QHP offices participating in Medicare Part B are required to purchase all wound care dressings used at each patient encounter.

  Q: Are wound care clinics (both HOPDs and QHP offices) required to provide dressings for Medicare Part B-covered patients’ use at home?

  Answer to HOPDs & QHP Offices
  No, HOPDs and QHP offices are not required to provide wound care dressings for Medicare Part B-covered patients’ use at home.

  Patients who have purchased Medicare Part B coverage and who are not currently receiving care by a home health agency should acquire their dressings for use at home from a durable medical equipment (DME) supplier: 1) if their condition meets the medical necessity requirements of the local coverage determination (LCD) for surgical dressings; 2) if the category of surgical dressing ordered meets the utilization guidelines of the LCD; and 3) if the specific product has been assigned covered Healthcare Common Procedure Coding System (HCPCS) code by Medicare’s pricing, data analysis, and coding contractor (PDAC).

  The four DME Medicare Administrative Contractors’ (MACs) surgical dressing LCDs are identical and can be found by entering the following LCD numbers into the search box at www.cms.gov:
    • Surgical Dressings (L11449) - CGS Administrators LLC
    • Surgical Dressings (L11460) - Noridian Healthcare Solutions LLC
    • Surgical Dressings (L11471) - NHIC Corp.
    • Surgical Dressings (L27222) - National Government Services Inc.

  VERY IMPORTANT: Wound care professionals should read their DME MAC’s surgical dressing LCD and attached article to learn all coverage and documentation requirements for wound care dressings ordered for patients’ use at home.

  If the order and medical record documentation do not align with the LCD/article, the wound care dressing will not be covered and the patients will be responsible for the full cost of their dressings. The major LCD medical necessity requirements for Medicare Part B coverage of wound care dressings used in the home setting (as long as a home health agency is not involved in the care) are:

   “Surgical Dressings are covered when either of the following criteria are met:
    1. They are required for the treatment of a wound caused by, or treated by, a surgical procedure, or
    2. They are required after debridement of a wound.”

  A few examples of LCD medical necessity requirements for specific categories of wound care dressings are:

Alginate or Other Fiber Gelling Dressing (A6196-A6199)
  “Alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full-thickness wounds (eg, stage III or IV ulcers); and alginate or other fiber gelling dressing fillers for moderately to highly exudative full-thickness wound cavities (eg, stage III or IV ulcers). They are not medically necessary on dry wounds or wounds covered with eschar. Usual dressing change is up to once per day. Once wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate or other fiber gelling dressing rope) is usually used at each dressing change. It is usually inappropriate to use alginates or other fiber gelling dressings in combination with hydrogels.”

Foam Dressing (A6209-A62510)
  “Foam dressings are covered when used on full-thickness wounds (eg, stage III or IV ulcers) with moderate to heavy exudate. Usual dressing change for a foam wound cover used as a primary dressing is up to 3 times per week. When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing change may be up to 3 times per week. Usual dressing change for foam wound fillers is up to once per day.”

Wound Filler, Not Elsewhere Classified (A6261-A6262)
  “Usual dressing change is up to once per day.” NOTE: See your DME MAC’s LCD for utilization guidelines for most of the other wound care dressing categories. If a specific wound care dressing is covered, the DME supplier will be paid 80% of its Medicare allowable rate from the DME MAC that processes the Medicare Part B claims. The patient will be responsible to pay the DME supplier for the remaining 20% of the Medicare allowable rate.

  Q: How can wound care professionals determine if the PDAC has assigned an HCPCS code to a specific brand existing/new wound care dressing?

  Answer to HOPDs & to QHP Offices
  Wound care professionals can verify if a specific brand of wound care dressing has been assigned a HCPCS code by visiting the PDAC’s website: www.dmepdac.com/dmecsapp/do/search

  While visiting this website, you can also identify the Medicare national average allowable rate or state-specific Medicare allowable rate for each wound care dressing category.

  Q: I am confused by the HCPCS code assignments for certain types of dressings. For example, even though collagen dressing categories exist, some dressings that contain collagen are not assigned to the collagen category: They are assigned to the category that defines the carrier of the collagen. Another example is the silver-impregnated dressings: They are assigned to the category that defines the carrier of silver or to a non-covered dressing category. A similar situation exists for the honey dressings: Some are assigned to the carrier of the honey while others are assigned to a non-covered dressing category.

  Answer to HOPDs & to QHP Offices

  Collagen Dressings:
  The surgical dressings LCD article states: “Products containing multiple materials are categorized according to the clinically predominant component (eg. alginate, collagen, foam, gauze, hydrocolloid, hydrogel). Other multi-component wound dressings not containing these specified components may be classified as composite or specialty absorptive dressings if the definition of these categories has been met. Multi-component products may not be unbundled and billed as the separate components of the dressing.

  “In the case of collagen dressings coded A6021, A6022, A6023, and A6024, the predominate component must be collagen.”

  For example, a hydrogel dressing that contains 10% collagen would be assigned to the hydrogel dressing category rather than to the collagen dressing category.

  See the PDAC’s website www.dmepdac.com/dmecsapp/do/search for the HCPCS code assignments for specific brands of collagen dressings.

  Silver-Impregnated Dressings:
  The surgical dressing LCD article also states: “Dressings containing silver are coded based on the other components of the dressing. For example, foam dressings that contain silver are billed using the foam dressing codes. Gauze dressings that contain silver are billed with the non-impregnated gauze dressing codes.”

  See the PDAC’s website (www.dmepdac.com/dmecsapp/do/search) for the HCPCS code assignments for specific brands of silver-impregnated dressings.

  Honey Dressings:
  A recent DME MAC joint publication was released that applies to all wound care dressings, including the honey-containing wound care dressings. “Historically, noncovered components have not been the majority constituent in multi-component products. Recently, dressings where the noncovered components comprise the majority of the dressing have been identified.

  The coding guideline for multi-component dressings states the clinically predominant component will determine classification. Following this guideline:
    • Dressings only containing non-covered components, with or without a substrate, are coded as A9270 (non-covered item or service).
    • Multi-component dressings are coded based upon the clinically predominant component. For dressings that contain non-covered elements:
      o If the non-covered components are < 50% of the dressing, coding is determined by the predominant covered component.
      o If the non-covered components comprise ≥ 50% of the dressing, the dressing is assigned to code A9270 (non-covered item or service).

  NOTE: You can read the two articles pertaining to this topic at: www.dmepdac.com/resources/articles/2015/01_27_15.html and www.dmepdac.com/resources/articles/2014/10_01_14.html

  See the PDAC’s website (www.dmepdac.com/dmecsapp/do/ search) for the HCPCS code assignments for specific brands of honey dressings.

  Q: I am a physician who manages chronic wounds in both HOPDs and in my office. Every time I write prescriptions for cadexomer iodinecontaining products, my patients tell me that their pharmacies say the product is not on the patients’ Medicare Part D drug plans. Are the pharmacies telling the truth or do they just not want to provide the product?

  Answer to HOPDs & to QHP Offices
  The pharmacies are telling the truth that the product is not on Medicare Part D drug plans. Both forms of the cadexomer iodine products are wound care dressings. Verify that by visiting the PDAC’s website and by searching for the HCPCS codes for each of the cadexomer iodine products: www.dmepdac.com/dmecsapp/do/search.

  When this author searched the website for both cadexomer iodine products, she learned that the PDAC assigned one of them to HCPCS code A6261 Wound filler, gel/paste, per fl. oz., not otherwise specified, and the other to A6222 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in or less, without adhesive border, each dressing.

  Therefore, HOPDs and QHPs should send orders for these wound care dressings to DME suppliers, just as they do for any other category of wound care dressings. Cadexomer iodine dressings should not be ordered as a drug.

Negative Pressure Wound Therapy

  Q: When QHPs write orders for traditional negative wound pressure therapy (NPWT) pumps/supplies to be delivered by DME suppliers to Medicare Part B covered patients for use at home, can the patients bring their new NPWT supplies to their HOPD visits/QHP office visits for the wound care staff to apply after assessing the wound?

  Answer to HOPDs & to QHP Offices
  Yes, Medicare Part B-covered patients may bring their DME-supplied traditional NPWT supplies to the HOPD/QHP office visits for application after the wound is assessed. This may sound confusing because these same patients cannot bring home-use wound care dressings acquired from DME suppliers to the HOPD/QHP office. The difference is due to the fact that DME and surgical dressings are provided through different Medicare Part B benefits.

    • HOPDs and QHP offices are required to provide these beneficiaries with wound care dressings needed during each encounter. Therefore, patients cannot take their home-use dressings to the HOPDs and QHP offices.
    • HOPDs and QHP offices are not required to provide DME and the accompanying supplies during each encounter. Therefore, the patients can take their traditional NPWT pumps and replacement supplies to their HOPD visits and/or QHP office visits.

  Q: Why can’t Medicare Part B-covered patients acquire their disposable NPWT equipment and supplies from their DME supplier — similar to the way they acquire their traditional NPWT equipment and supplies?

  Answer to HOPDs & to QHP Offices
  Disposable NPWT equipment and supplies are not part of the Medicare Part B DME benefit, as is traditional NPWT. Therefore, DME suppliers cannot bill Medicare Part B for disposable NPWT. Instead, HOPDs and QHP offices should purchase disposable NPWT equipment and supplies, and bill Medicare Part B for Current Procedural Terminology (CPT®) procedure codes 97607/97608 for disposable, non-durable medical equipment, which include the provision of the exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care.

Cellular and/or Tissue Based Products (CTPs)

  Q: Is there a way that HOPDs and QHP offices can require the Medicare Part B-covered patients to purchase CTPs (outdated term “skin substitute”) from a DME supplier and take them to the HOPDs/QHP offices for application?

  Answer to HOPDs
  Disposable NPWT equipment and supplies are not part of the Medicare Part B DME benefit, as is traditional NPWT. Therefore, DME suppliers cannot bill Medicare Part B for disposable NPWT. Instead, HOPDs and QHP offices should purchase disposable NPWT equipment and supplies, and bill Medicare Part B for Current ProceduralTerminology (CPT®) procedure codes 97607/97608 for disposable, non-durable medical equipment, which include the provision of the exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care.

  Answer to QHP Offices
  No, CTPs are not included in the Medicare Part B-covered DME benefits. Additionally, per the Medicare Part B drug and biologic benefit, the CTPs are paid in QHP offices based on the average sales price posted by CMS on a quarterly basis. The application of the products is paid in QHP offices via the Medicare Physician Fee Schedule. In fact, CMS requires the HCPCS code for the CTP to appear on the same QHP office claim with the CPT code for the application of the product. Therefore, QHP offices should purchase CTPs in order to appropriately code and bill Medicare Part B.

  Q: Because the cost of CTPs is not inconsequential, can HOPDs and QHP offices request prior authorization from their MACs for the application of specific CTPs before they are purchased and applied?

  Answer to HOPD & to QHP Offices
  No, MACs are not permitted by law to provide prior authorization for CTPs and their application. Instead, the MACs are authorized to develop LCDs to determine coverage of items and services covered by Medicare. LCDs specify under what conditions an item or service is considered to be “reasonable and necessary.” MACs develop LCDs by considering medical literature, the advice of local medical societies and medical consultants, and public comments (including comments from the provider community).

  Therefore, HOPDs and QHP offices should verify if their MAC has published an LCD pertaining to the application of CTPs. If the answer is “yes,” HOPDs and QHP offices should print the LCD and any attached article(s) and share copies with all the QHPs who order, apply, and document in the medical record. If the answer is “no,” that MAC will determine coverage based on medical necessity and may ask for HOPD and or QHP medical record documentation before paying claims and/or during post-payment audits.

  Both HOPDs and QHP offices are required to purchase CTPs applied to Medicare Part B-covered patients’ wounds.