Revealing Mid-Year Updates for QHPs & HOPDs

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The calendar year 2015 is nearly half over at the time of this column’s publication. Before long, the draft of 2016 Medicare rules will be released and preparation for the New Year will be underway. However, wound care professionals must keep their eyes on the current year to ensure coding, documentation, and billing are aligning with this year’s regulations. To assist in this effort, this month’s column will provide some mid-year updates that may apply to one’s business.

Updates for QHPs

Medicare Physician Fee Schedule
As reported in last month’s Business Briefs, qualified healthcare professionals (QHPs) who are paid by the Medicare Physician Fee Schedule will receive a 0.5% increase in their Medicare allowable rates effective July 1. 

Medicare Average Sales Price
QHPs who purchase and apply cellular and/or tissue-based products for wounds (CTPs) [old term “skin substitute”] in their office practices should review the July 1 release of the Medicare average sales price (ASP) file (visit www.cms.gov). This release shows the Medicare allowable rates for some of the CTPs. If an office uses a CTP that does not appear on the July ASP file, the office can expect to be paid the lesser of the wholesale acquisition cost or 106% of the office’s invoice price. TIP: The office should include the following items on Medicare claim forms (in Field No. 19 of paper claims or in the narrative field of an electronic claim):

• product name,

• product size,

• product number, and

• invoice price, per piece.

QHPs should audit their claims because many physician offices have complained that their Medicare payment for CTPs was very small. Upon reviewing their claims, in most cases, the QHPs were paid exactly what they incorrectly requested on their claims: the Medicare allowable for “1” sq cm, because the claim reported “1” in the units field rather than the total number of sq cm purchased for the patient. Believe it or not, many offices were incorrectly paid because someone did not know how to correctly calculate the number of sq cm purchased for the patient. This calculation is a simple math problem: multiply the length of the CTP in cm by the width of the CTP in cm to calculate the number of sq cm purchased for the patient.

Example: The QHP purchased a CTP that was 4 cm long and 2 cm wide: 8 sq cm should be reported in the unit’s column on the claim.

MAC Audit Findings
Speaking of coding and claim submissions, Medicare Administrative Contractors (MACs) continue to share their audit findings. QHPs should pay close attention to these findings and should conduct internal audits to prevent these common errors:

• insufficient documentation,

• up-coding,

• missing physician signature,

• missing physician order,

• missing progress notes, and

• missing dates of service.

The most surprising error was due to down-coded claims. This author interviewed some of the QHPs who down-coded their claims and learned that QHPs purposefully down-coded their claims because they did not want to trigger audits. However, their coding practices were below the norm for similar practices and actually were the cause for the audits: The auditors assumed that the providers were coding improperly!

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Place-of-Service Codes
The mid-year update to the Work Plan for fiscal year 2015 by the Office of Inspector General (OIG) was issued in May. The plan re-emphasizes the OIG’s concern about QHPs reporting work performed in facilities such as wound care hospital-based outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) with place-of-service code 11 when, in fact, the HOPD place-of-service code is 22 and the ASC place-of-service code is 24. Place-of-service code 11 should only be used when the QHP actually performs work in his/her office.

This author frequently finds QHPs do not know that the incorrect place-of-service code is on their claims. Very often the QHPs have not established a process for indicating the place of service on each encounter form/super bill/charge sheet, etc. In addition, the QHPs’ billers often do not realize the importance of reporting the correct place-of-service code on the claim: They are often unaware that Medicare payment in the office setting is higher than it is in any facility. Billing software that is incorrectly programmed with the place-of-service code can also perpetuate these overpayment situations. 

QHPs should remember that no matter who prepares their claims, the name of the QHP who performed the work is at the bottom of the claim: The QHP is ultimately responsible for everything that is reported on each claim. Therefore, QHPs should be highly motivated to establish a process for reporting the correct place of service for each patient encounter, to educate their staff about the importance of assigning the correct code to each claim, to check their billing software to be sure it is not the cause of incorrect codes, and to regularly audit their claims to double-check that each claim has the correct code. The OIG has made it perfectly clear that MACs should focus on this problem and should recover all overpayments due to incorrect place-of-service codes on QHP claims.

Medicare “Two-Midnight Rule”
Wound care clinicians should generally order an inpatient admission when it’s determined that:

1. The beneficiary requires hospital care that is expected to transcend at least two midnights, or

2. The beneficiary’s care involves a procedure designated by the Outpatient Prospective Payment System (OPPS) as an inpatient-only procedure. NOTE: The inpatient-only procedure list contains little to no wound care procedures.

3. Physicians must write, sign, and date their hospital admission orders, which must include:

• the reason for inpatient admission,

• the estimated duration of stay, and

• the tentative post-discharge plan.

Inpatient admissions that do not meet the two-midnight rule or the inpatient-only procedure rule will not be paid under the Medicare Part A diagnosis-related group (DRG) payment system.  Instead, they will be paid by OPPS. Out of that payment, the hospital will have to pay for:

• room and board

• hospital staff

• operating room (OR) use

• instruments and supplies

• drugs and biologicals

• primary and secondary dressings

• offloading devices, etc.

In most cases, OPPS payments for inpatient stays will not be economically feasible for hospitals. Therefore, hospitals will engage their medical staff utilization review committee to control these short-stay hospital admissions. The Centers for Medicare & Medicaid Services (CMS) conducts medical reviews if there’s evidence of systemic gaming, abuse, or delays in provision of care in an attempt to qualify for the full DRG payment rather than OPPS payment. The review of the proper implementation of the two-midnight rule is also on the OIG’s 2015 Work Plan. In addition, recovery auditors (RAs) will be allowed to conduct audits regarding the two-midnight rule effective Oct. 1. Therefore, wound care clinicians should carefully discern between patients who can receive wound care in outpatient settings and those who require at least two-midnight care as a hospital inpatient.

Updates for HOPDs
From the HOPD perspective, we did not see many changes during the first half of 2015.  Following are a few CTP changes that HOPD staff should know:

•Two products were reclassified from the “low cost” category to the “high cost” packaged category:

- Q4150 AlloWrap^® DS or Dry, per sq cm

- Q4153 Dermavest, per sq cm.

Therefore, HOPDs that use these products must update their data entry systems, charge description masters, coding systems, etc. with the correct application code (15271-15278) for these products. Effective July 1, both the description of Healthcare Common Procedure Coding System (HCPCS) code C9349 and the ambulatory classification group 01657 will change from Fortaderm, Fortaderm Antimic to PuraPly, PuraPly Antimic.

Updates for QHPs & HOPDs

Medicare Auditors Can Adjust Codes on Claims
On May 4, CMS issued Transmittal 585, which allows auditors to adjust the level of codes (up or down) billed on claims and still pay the claim rather than denying the claim. The transmittal grants this authority to the following entities:

• MACs,

• RAs,

• zone program integrity contractors,

•supplemental medical review contractors, and

•comprehensive error-rate testing contractors.

The “upside” of this new regulation is that providers will receive some payment for the product/procedure/service without having to appeal the claim. This is yet another reason for wound care professionals to sharpen their documentation and to take caution not to use templates and/or electronic health record systems that document details that are not pertinent to each specific patient encounter. When Medicare contractors request documentation to determine medical necessity, wound care professionals should provide specific documentation that is relevant to the encounter in question.

NCCI Edits
The National Correct Coding Initiative (NCCI) edits were developed by CMS to prevent inappropriate payment of services that should not be reported together. Many of the policies described in the NCCI manual use the term “physician.” However, NCCI policies apply to all practitioners, hospitals, providers, and suppliers eligible to bill the relevant HCPCS/Current Procedural Terminology (CPT)^® codes.

QHPs and HOPDs who continue to bill Medicare for the debridement of chronic wounds at the same encounter when CTPs are applied should be aware that the 2015 NCCI manual clearly states: “Simple debridement of a skin wound (CPT codes 11000, 11042-11045, 97597-97598) prior to a graft/skin substitute is included in the skin graft/skin substitute procedure (CPT codes 15050-15431) and should not be reported separately. If the recipient site requires excision of open wounds, burn eschar, or scar or incisional release of scar contracture, CPT codes 15002-15005 may be separately reportable for certain types of skin grafts/skin substitutes.”

The 2015 NCCI manual provides some other important directives that QHPs and HOPDs should also heed:

•“Physicians should avoid down-coding. If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less-comprehensive code.”

•“Physicians must avoid up-coding. A HCPCS/CPT code may be reported only if all services described by that code have been performed.”

•“Physicians must report units of service correctly. Each HCPCS/CPT code has a defined unit of service for reporting purposes. A physician should not report units of service for a HCPCS/CPT code using a criterion that differs from the code’s defined unit of service.”

Example: QHPs should report attendance and supervision of hyperbaric oxygen therapy (HBOT [99183]) per session.  HOPDs should report hyperbaric oxygen under pressure, full-body chamber (G0277) per 30-minute intervals.

•“If a definitive surgical procedure requires access through diseased tissue (eg, necrotic skin, abscess, hematoma, seroma), a separate service for the access (eg, debridement, incision, and drainage) is not separately reportable.”

•“Treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intraoperative services that are normally a usual and necessary part of the procedure. Additionally, the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the OR.”

Covered ICD-10 Diagnosis Codes for HBOT
CMS has posted future effective national coverage determinations (NCDs) and MACs have posted future effective local coverage determinations (LCDs) that list the diagnosis codes that will be considered medically necessary for many wound care services/procedures/products.  Wound care professionals should take time to download NCDs and LCDs that are pertinent to their work: visit www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

In addition, wound care professionals should keep an “eagle’s eye” on CMS and MAC announcements of updates to those future effective NCDs and LCDs. For example, CMS released the first future effective NCD for HBOT on Jan. 1, 2013. Since then, wound care professionals have provided clinical evidence for refinement to the list of covered diagnoses. On May 22, CMS released a change request (CR9087) that included 10 spreadsheets with ICD-10 codes for 10 NCDs. One of those spreadsheets pertains to NCD 20.29 HBOT.

The HBOT spreadsheet is listed 8^th (OTN8) in the zip file found at  www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/R1478OTN.zip. The HBOT spreadsheet clearly itemizes the covered ICD-10 diagnoses that can stand alone as well as the ICD-10 diagnoses that must be reported together to justify medical necessity for HBOT.

Of particular interest to this author is the side-by-side listing of covered ICD-9 codes and ICD-10 codes.  Don’t miss the opportunity to preview all the future effective NCDs and LCDs. They should help QHPs refine documentation before the ICD-10 implementation deadline of Oct. 1, 2015. n

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