Make These 5 Revenue Cycle Resolutions for 2020

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Happy New Year to all! By now you have most likely made your personal resolutions for the new year. Because 2020 is a big year for reimbursement changes, this month’s column will remind you about some 2020 reimbursement resolutions that you and your revenue cycle team should make. 

Resolution 1: Work with All Members of Your Clinical and Revenue Cycle Team

When this author conducts on-site consultations with wound/ulcer management professionals and providers, she always requests to have a meeting on the first day with the “key” members of the revenue cycle team who support the wound/ulcer management business. As the various team members enter the meeting room, this author observes that they are usually introducing themselves to each other for the first time. When the meeting begins, this author always invites each revenue cycle team member to describe their role in supporting the wound/ulcer management business. By the end of the meeting, the wound/ulcer management professionals and providers understand why this author requested this group meeting and they are usually surprised by the large number of revenue cycle professionals who work behind the scenes to ensure the financial success of the wound/ulcer management business. 

With the large number of coding, coverage, payment, and auditing changes that are occurring in 2020, wound/ulcer management professionals and providers should resolve to 1) know all the members of their revenue cycle team (chief financial officer, compliance officer, charge description master director, patient registration manager, insurance benefit verification manager, office manager, health information manager, coders, billers, process improvement specialists, revenue integrity audit specialists, etc.), 2) work with the team in implementing new 2020 changes at the beginning of the year, and 3) work with the team throughout the year to refine processes, review claims and remittance advices, conduct internal audits, and respond to requests for documentation during various external audits. 

When each member of the clinical team and the revenue cycle team does his or her part, insurance claims are submitted accurately, the payers pay correctly, and everyone (including the patients) benefits. Therefore, do not delay in taking steps to ensure that your clinical and revenue cycle team members work together. 

Resolution #2: Stay Updated with NCCI Edits

One of the most frequently asked questions by wound/ulcer management professionals and providers is, “If I perform XXXX procedure with XXXX procedure during the same encounter, will Medicare pay for both procedures?” This author is always surprised by this question because the answer to this question is public knowledge and readily available in the National Correct Coding Initiative (NCCI) section of the Centers for Medicare and Medicaid Services (CMS) website. Unfortunately, this author observes that most wound/ulcer management professionals and providers do not make a practice of reading the National Correct Coding Initiative Coding Policy Manual for Medicare Services, which is updated and effective every year on January 1.¹ 

This is a mistake that should be rectified starting in 2020 because this manual explains the rationale for the NCCI procedure-to-procedure (PTP) edits, which prevent improper payment when incorrect code combinations are reported for the same patient encounter. Wound/ulcer management professionals and providers do not need to read the entire NCCI manual. They only need to read the introduction, the table of contents, and the chapters that discuss the Current Procedural Terminology (CPT^®) codes for the services and procedures that they perform.² By reading the pertinent chapters of the NCCI manual, professionals and providers will have first-hand knowledge of the purpose for PTP edits that pertain to your work. Then by reviewing the PTP edit files, professionals and providers can easily identify code combinations that will not be paid if performed during the same encounter.  

Because the PTP edit files are updated every quarter, wound/ulcer management professionals and providers should mark their calendars to review the quarterly PTP edit updates every January 1, April 1, July 1, and October 1.³ Understanding these PTP edits helps everyone understand if/when a modifier should be reported on claims when more than one procedure is performed at the same patient encounter. If you do not know how to sort the PTP edit files for procedure code combinations that are pertinent to your business, download the excellent easy-to-read booklet entitled How to Use the Medicare National Correct Coding Initiative (NCCI) Tools.⁴ Once you read the pertinent portions of the NCCI manual and review the PTP edits that pertain to your work, you will understand why making this resolution is so important: you should never have to ask questions about PTP edits again. 

Resolution #3: Use the TPE Audits to Improve Your Clinical Documentation and Revenue Cycle Processes

The CMS designed the Targeted Probe and Educate (TPE) audit program to help providers and suppliers reduce claim denials and appeals through one-on-one assistance. Because everyone benefits when Medicare claims are submitted accurately, the CMS goal is to offer guidance for providers and professionals to quickly improve their clinical documentation and revenue cycle processes. 

Many common claim errors are simple and easily corrected, such as a physician’s missing signature. However, it is impossible to improve 1) if you are not aware that a TPE audit is occurring, 2) if you do not participate in gathering and packaging the requested documentation in a way that will “paint the picture” of each case that is under audit, 3) if the entire clinical and revenue cycle team does not participate in the education program provided by the TPE auditor, and 4) if you do not immediately refine clinical documentation and revenue cycle processes that were found to be deficient during the audit. 

Therefore, every wound/ulcer management business should verify that your Medicare Administrative Contractor (MAC) has the appropriate contact information for your company representative with whom the MAC should communicate regarding TPE audits. You should proactively contact your MAC to learn who they will contact if an audit is planned. If the company representative is not correct, proactively provide the correct contact information to your MAC. Then be sure the company representative knows the wound/ulcer management point person who should be contacted when a relevant TPE audit, or any other type of audit, is beginning. That point person should quickly discuss the audit with the wound/ulcer management professionals and identify the pertinent documentation that should be assembled and how it should be packaged for the audit. 

If the submitted documentation supports the claims under audit and the claims pass the TPE audit, the entire clinical and revenue cycle team should celebrate. If the claims do not pass the TPE audit, the TPE auditor will offer an education program. The clinical and revenue cycle team should carefully select the day and time for the education program to allow all members of the clinical team and the revenue cycle team to participate in the TPE audit findings and recommendations. As soon as the education program is over, that same group of people should meet and decide the processes that must be refined. Then each team member should do his or her part to implement the new processes immediately so the business can pass the next step of the TPE audit.  

If your wound/ulcer management business has not yet been audited, the clinical team and revenue cycle team should do their best to follow all coding, coverage, and payment regulations in order to be paid fairly and to keep their payments if audited. In addition, they should pay attention to the topics that are on their MAC’s audit list. Most of the MACs have already scheduled teleconferences throughout 2020 to discuss the TPE audit process and the topics that are currently on their audit lists. As part of your 2020 New Year’s resolution, frequently visit your MAC’s website for reimbursement guidance, for audit topic information, and for a schedule of their 2020 TPE audit review teleconference. 

Resolution #4: Pay Attention to Consolidated Billing Updates for SNFs and HHAs

For many years, the consolidated billing regulations pertinent to skilled nursing facilities (SNFs) and home health agencies (HHAs) have been important for wound/ulcer management providers and professionals. Now that new Medicare payment programs for SNFs and HHAs have raised the importance of wound/ulcer management, hospital-owned outpatient provider-based departments (PBDs), physicians and qualified healthcare professionals (QHPs) should verify that they have a process in place to identify (before patient encounters) if the patients are receiving Medicare Part A benefits from a SNF or a HHA. The PBDs, physicians, and QHPs should have contracts in place with SNFs and HHA to bill them for procedures that are on their respective consolidated billing lists.

In addition, the PBDs, physicians, and QHPs should monitor updates to the consolidated billing lists of both SNFs and HHAs. For example, the October 2019 quarterly update to the SNF consolidated billing announced that the application of Unna Boots (29580) and the application of multi-layer compression bandages (29580, 29581, and 29584) were incorrectly listed in File 1, which meant the procedures were not included in the SNF consolidated billing. Effective October 1, 2019 these 3 codes were removed from File 1 and added to File 4, which means they are now subject to SNF consolidated billing. Therefore, wound/ulcer management professionals and providers who provide these compression procedures for Medicare Part A-covered SNF patients must now have a contract with the SNF that allows them to bill the SNF and be paid by the SNF for these procedures. That contract should also include the other procedures that are in the SNF consolidated billing, e.g. selective debridement (97597) and negative pressure wound therapy with durable medical equipment (97605/97606). 

Wound/ulcer management providers and professionals should resolve to review the 2020 SNF and the 2020 HHA consolidated billing files as soon as they are posted and should watch for updates throughout the year. Then they should resolve to write contracts (if they have not already done so) or refine contracts to include procedures they perform that are on the respective consolidated billing lists. 

Resolution #5: Proactively Share Your Expertise with Programs and Payers That Are Focused
on Managing Episodes of Care

This author often tells wound/ulcer management professionals and providers that they are among the best kept medical secrets in the country because they often perform “miracles” for patients with wounds/ulcers. In 2020 these specialists should proactively investigate the various programs that are incentivized to manage episodes of care and offer to work with them to manage their patients with wounds/ulcers across the continuum of care. Keep in mind that you may have to establish innovative models of care in which you may have to take wound/ulcer management to the patients, rather than having the patients come to you. 

To align with the theme of this month’s Today’s Wound Clinic, this author is reminding wound/ulcer management providers and professionals to proactively work with Medicare Advantage plans. As discussed in the November 2019 Business Briefs column, Medicare Advantage plans are now permitted to offer benefits that are not normally covered by the Medicare Fee-For-Service program.⁵ Therefore, they are looking to offer innovative services to their beneficiaries. Because of these innovative services and programs, greater than 40% of Medicare eligible beneficiaries are expected to opt for a Medicare Advantage plan in 2020. 

Conclusion

In previous years wound/ulcer management providers and professionals often had adversarial relationships with Medicare Advantage plans. This new year could bring new opportunities for everyone. Wound/ulcer management specialists know how to prevent, assess, and manage wounds/ulcers from start to finish. Medicare Advantage plans need your expertise, but they need you to work with their beneficiaries in creative ways, such as telehealth, virtual visits, and so forth. Reach out to the Medicare Advantage plans and offer to create innovative wound/ulcer management programs that provide high quality care throughout the continuum of care, at the lowest cost of care, and with excellent patient satisfaction.

By resolving to proactively share your expertise with programs and payers that are focused on managing episodes of care, wound/ulcer management professionals and providers have the opportunity to expand out of their silos and become active throughout the continuum of care. 

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

1. Centers for Medicare and Medicaid Services. National Correct Coding Initiative Coding Policy Manual for Medicare Services. Available at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html . Last accessed November 3, 2019.

2. CPT is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT^®) is copyright 2019 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply

3. Centers for Medicare and Medicaid Services. Quarterly PTP Update Changes. Available at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html . Last accessed November 3, 2019. 

4. Centers for Medicare and Medicaid Services. How to Use the Medicare National Correct Coding Initiative (NCCI) Tools. Available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf . Last accessed November 3, 2019. 

5. Schaum K. Reimbursement pearls from Wound Clinic Business 2019. Today’s Wound Clinic. 2019; 13(11):4–8.