Reimbursement Tips for Launching Your New Wound Care Clinic

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 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.

When Today’s Wound Clinic published its first edition 10 years ago, wound care hospital-based outpatient departments (HOPDs) — now referred to as provider-based departments (PBDs) in this column — focused on obtaining reimbursement for services, procedures, and products from volume-based payment systems. At that time, when those new wound care PBDs were preparing to open their doors, the program directors, medical directors, physicians, and other qualified healthcare professionals (QHPs) often asked their colleagues who were already working in existing wound care PBDs about the best codes to use to obtain payment. They rarely asked about payer coverage. Additionally, oftentimes these colleagues were not located in the same state or reimbursed by the same payer. Because many of these individuals were also not experts in coding, billing, and/or reimbursement strategy, many misperceptions about proper reimbursement were shared from one practice to another. Some of the misperceptions at that time included: 

• “Wound care PBDs and physicians/QHPs do not have to purchase and read new coding books each year — that is the coding and billing departments’ responsibility.”
• “Wound care PBDs should only charge for services, procedures, and products that receive line item reimbursement.”
• “Wound care PBDs should not markup their costs to include their overhead because it will increase patients’ coinsurance.” 
• “Wound care PBDs should not use advanced wound care procedures and products because they cost too much and will increase patients’ coinsurance.”
• “Wound care PBDs should request that patients bring their surgical dressings that they acquired for use at home from durable medical equipment suppliers into the PBD for use during wound care management.” 
• “Wound care PBDs should follow the same rules and report the same clinic visit code as the evaluation and management (E&M) code reported by the physician/QHP.”
• “Physicians/QHPs should report procedures (even if they did not perform the procedures) that they ordered the wound care PBD staff to perform.” 
• “Wound care PBDs and physicians/QHPs do not need to read Medicare national coverage determinations (NCDs), local coverage determinations (LCDs), private payer medical policies, Medicaid medical policies, etc. because they only pertain to coders and billers.”
• “Wound care PBDs can implement a charge description master (CDM) from a friend’s wound care PBD because creating and updating a new CDM is nothing but busy work.”
• “Wound care PBDs should only submit claims to the payers once a month for each patient.”
• “Wound care PBDs and physicians/QHPs have no reason to audit the claims that are submitted on their behalf.”

Throughout the past decade, Business Briefs and the seminar Wound Clinic Business have educated wound care PBDs and physicians/QHPs on correct coding, payment regulations, and medical coverage policies that were/are applicable in the volume-driven and value-driven payment systems. Today, when new PBDs open, program directors, medical directors, and physicians/QHPs are more knowledgeable and understand that:

• They should purchase new ICD-10-CM, Healthcare Common Procedure Coding System (HCPCS), and Current Procedural Terminology codebooks each year.
• The wound care PBD should charge for all services, procedures, and “non-routine” supplies, even though some of the items are packaged into the payment for another item.
• The charges on claims do not determine a patient’s coinsurance: The payer’s allowable rate determines the patient’s coinsurance.
• Advanced procedures and products may require a higher patient coinsurance, but may cost the patient less if the procedures and products shorten the episode of care. 
• Wound care PBDs are required to purchase and provide all dressings, drugs, and biologics used during each patient encounter.
• Wound care PBDs are responsible for establishing a mapping tool that maps to the “new” and “established” patient clinic visit codes 99201-99215. Physicians and other QHPs must follow the 1995 or 1997 E&M guidelines for the same codes. Therefore, the payers do not expect that the wound care PBD’s clinic visit code will align with the physician’s/QHP’s E&M codes.
• Physicians/QHPs should not submit claims for procedures they order, but do not perform (eg, application of multilayer high-compression bandage systems, disposable negative pressure wound therapy, nonselective debridement).
• Medicare NCDs/LCDs, private payer medical policies, Medicaid medical policies, etc. are pertinent to the wound care PBD staff, the physicians/QHPs, and the coders/billers/members of the revenue cycle team: They provide guidelines for medical necessity, utilization, coding, documentation, etc. 
• CDMs are the “heartbeat” of the wound care PBD revenue cycle. Because PBDs are staffed by different physicians/QHPs, provide services/procedures/products unique to that medical team, and incur different acquisition costs for products, each PBD’s CDM should be unique. In addition, CDMs should be updated every time codes change, new services/procedures/products are implemented, prices change, etc. 
• PBDs, like emergency departments, should submit their claims for each patient after each encounter, not on a “series” or “monthly” claim.
• Wound care PBDs and physicians/QHPs should audit a sampling of their claims monthly to confirm compliance with coding, payment, and coverage regulations/guidelines, as well as submission of the correct number of units and accurate charges.  

These volume-based coding, payment, coverage, and auditing tips still pertain to existing and new wound PBDs alike, as well as to the physicians/QHPs who direct and manage patient care. Due to the volume-based payment systems’ spiraling costs over the past 10 years, payers have implemented many new coding, payment, and coverage regulations. Table 1 outlines some of the additional reimbursement tips that apply to both existing and new wound care PBDs and their physicians/QHPs. After reviewing these additional tips, readers will surely agree that it was much easier to open a new wound care PBD 10 years ago! Much has been written about the costly United States healthcare system, which ranks low on quality and patient satisfaction. Both payers and patients want the U.S. healthcare system to produce better outcomes, reduce the total cost of care, and earn higher patient satisfaction scores. Therefore, a growing number of payers are focusing on value-based payment systems. Existing wound care PBDs and their physicians/QHPs are working hard to meet the reimbursement requirements of both the ever-changing volume-based payment systems and to simultaneously adjust their business models and processes to meet the value-based payment systems. Table 2 outlines some reimbursement tips that apply to both existing and new wound care PBDs, as well as their physicians/QHPs. After reviewing the value-based reimbursement tips, wound care professionals should clearly understand that launching a new wound care PBD today requires more than clinical knowledge and is not for the faint of heart.

Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL.