Business Briefs: Understanding Medicare Payment Changes for HOPDs and Physicians in 2013

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. 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 coding, coverage, and payment information accuracy lies with the reader.   In March 2012, we described the physician as an “orchestra leader” and the staff of the hospital-based outpatient wound care department (HOPD) as an “orchestra” that work together to implement a unique plan of care for each patient living with a chronic wound.¹ In fact, the staff of the HOPD cannot care for patients if a physician is not immediately available to provide direct supervision in the HOPD. Last month, we discussed the new 2013 codes that should be integrated into encounter forms, Charge Description Masters, and billing systems (if the physician orders those services, procedures, and/or products for their patients).²   The next logical 2013 topic is the 2013 Medicare payment rates for codes that are relevant to wound care professionals. When a physician provides care to wound patients in the HOPD, the patients receive two bills — one from the physician and one from the HOPD.   This article will review the 2013 Medicare payment rates for both physicians and HOPDs. NOTE: Medicare payment rates in tables 1, 2, and 3 are national average payment rates. HOPDs and physicians should verify their own unique Medicare payment rates.

E&M Services/Clinic Visits

  If the physician provides evaluation and management (E&M) services in the HOPD, the physician selects the appropriate code based on the 1995 OR the 1997 E&M guidelines that are published by the American Medical Association.   The Medicare payment rates for E&M services and all other services and procedures are released each year in the Medicare Physician Fee Schedule (MPFS) Final Rule: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1590-FC.html.   For the past few years, the Centers for Medicare & Medicaid Services (CMS) has been increasing the payment rates for E&M services provided by physicians. Table 1 shows a blend of payment increases and decreases for physicians when they perform E&M services in the HOPD.   The payment increases for new patient E&M levels III, IV, and V continue to provide additional financial incentives for physicians to take the time to carefully diagnose new patients. HOPDs borrow the 10 new and established patient E&M codes, but are required by CMS to create their own mapping system as well as policy and procedure for affiliating resources used in the HOPD during a clinic visit with the new patient and established patient clinic-visit codes.   The Medicare payment rates for these and all other services, procedures, and separately billable products are determined by CMS: They assign the HOPD clinic visit codes to ambulatory payment classification (APC) groups with services that require similar HOPD resources. Medicare releases APC group assignments and their affiliated Outpatient Prospective Payment System (OPPS) rates every year in the OPPS Final Rule: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1589-FC.html.   As Table 1 reveals, CMS pays the HOPD more for a clinic visit than it pays the physician because the HOPD incurs the practice expenses such as the cost of surgical dressings.   The 2013 OPPS payment rates for E&M services have very slight increases and decreases.

Debridements: Surgical, Selective, and Non-selective

  The 2013 MPFS payment rates for debridements performed by physicians in HOPDs increased/decreased ever so slightly. (See Table 2.)   Physicians should continue to select the appropriate debridement codes based on the depth of tissue removed and the size of the wound surface area that was debrided.   The 2013 OPPS payment rates for debridements increased for all debridement codes except for the add-on code for surgical debridement of bone. This decrease occurred because CMS moved 11047 from APC Group 20 to lower-paying APC Group 19. (See Table 2.)   Like physicians, HOPDs should continue to select the appropriate debridement codes based on the depth of tissue removed and the size of the wound surface area debrided.

Advanced Technology Procedures

  Cellular- and/or Tissue-based Products for Wounds (CTPs): The 2013 Medicare payment rates for the application of CTPs codes increased/decreased slightly for physicians, but increased for HOPDs. (See Table 3.)   Compression: Similarly, 2013 MPFS rates for the application of various forms of compression nearly mirror 2012 payment rates. The 2013 HOPD payment rates increased for the application of rigid leg casts, Unna’s boots, and multilayer compression to the lower leg, but decreased for the application of multilayer compression to the upper leg, upper arm, and arm/hand because CMS moved these three codes to a lower-paying APC group that requires fewer resources. (See Table 3.)   Negative Pressure Wound Therapy (NPWT): The 2013 MPFS payment rates for physicians who apply NPWT pumps decreased by pennies while the Medicare payment to HOPDs increased for that work. A Medicare payment rate for the new code (NPWT using a mechanically powered device) has been posted for HOPDs, but is carrier priced for physicians. (See Table 3.)   Hyperbaric Oxygen Therapy (HBO): Physicians who supervise HBO received a very slight increase in Medicare payment while HOPDs received about $20 more for every 120 minutes of HBO therapy provided. (See Table 3.)   Wound Ultrasound: MPFS payment for wound ultrasound is carrier priced in 2013, just as it was in 2012. HOPDs received a sizeable Medicare payment decrease for this procedure because CMS moved the code to a lower-paying APC Group. (See Table 3.)   Now that we have reviewed the major changes that will affect wound care’s “orchestra leaders” and “orchestras” in 2013, physicians and HOPDs should make any necessary adjustments to their charges and billing systems.   All wound care professionals should pay close attention to any Medicare payment changes that may be implemented due to the across-the-board government spending cuts known as “sequestration” that took effect March 1. Kathleen Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She can be reached for questions and consultations at 561-964-2470 and kathleendschaum@bellsouth.net.

References

1. Schaum, K. The business of wound care: the physician’s perspective. Today’s Wound Clinic. 2012;6(2):6-8. 2. Schaum, K. Integrating new/updated codes into your business for 2013. Today’s Wound Clinic. 2013; 7(1):6-8.