Is Medicare’s Reimbursement Timeline Incorporated Into Your Calendar?

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP 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.

If you are like this author, you are probably amazed at how quickly 2019 is coming to an end. As you wind down this last quarter of the year, you are probably attending the Symposium on Advanced Wound Care (SAWC) Fall, creating a great Halloween costume, planning a Thanksgiving get-together with your family and friends, making a holiday gift list, and deciding how you will celebrate New Year’s Eve. Before you know it, you will arrive at work and it will be 2020! Therefore, this author is hoping that you are incorporating the implementation of pertinent Medicare coding, payment, and coverage changes into your 2020 calendar.

Throughout 2019 the Centers for Medicare and Medicaid Services (CMS) were very busy reviewing applications for new Healthcare Procedure Coding System (HCPCS) codes and refining both the volume-based and value-based payment systems. New and revised ICD-10-CM diagnosis codes, new HCPCS codes, and new Current Procedural Terminology (CPT®) codes necessitated revisions to National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), the National Correct Coding Initiative (NCCI) Edit manual, and the NCCI and Medically Unlikely Edits (MUEs) files.1

Because the CMS has a strict implementation calendar, wound management stakeholders had to remain vigilant when the public meetings were announced and when the draft rules were released: we had to act swiftly to review the preliminary information and create/submit meaningful comments.   

Therefore, wound management stakeholders had many opportunities to participate in these CMS processes by submitting written comments about any issue that matters to them and their patients. For example: The CMS held public meetings to review their preliminary decisions pertaining to new HCPCS code requests and released draft payment system regulations for all sites of care.

Many of the 2020 Medicare reimbursement changes will affect wound management provided by physicians, podiatrists, non-physician practitioners (NPPs), therapists, and wound certified nurses who work in various sites of care such as acute care hospitals, skilled nursing facilities (SNFs), home health agencies (HHAs), physician offices, and hospital owned outpatient wound management provider-based departments (PBDs). Therefore, as Medicare releases the new final reimbursement changes, all wound management professionals should review the ones that pertain to them, mark the implementation dates on their calendars, and make appropriate adjustments in their processes before the announced implementation date. Let’s review some of those important implementation dates that should be on your calendar.  

October 1, 2019

•    2020 ICD-10-CM Updates
The 2020 ICD-10-CM codes are to be used for discharges occurring from October 1, 2019 through September 30, 2020 and for patient encounters occurring from October 1, 2019 through September 30, 2020.¹ Read Donna Cartwright’s article on page 10 to learn about the new and revised diagnosis codes that are most important to wound management professionals and begin to use the codes effective October 1, 2019.  
•    2020 Inpatient Prospective Payment System (IPPS)
The IPPS Final Rule, which will affect approximately 3,300 acute care hospitals, applies to discharges occurring on or after October 1, 2019.² The rule has many interesting changes such as improvements in payment to low wage index hospitals which tend to be in rural areas, increases in new technology add-on payments, and much more.
•    2020 Skilled Nursing Facility (SNF) Prospective Payment System (PPS)
The 2020 SNF PPS Final Rule implements a new Patient Driven Payment Model (PDPM), which replaces the Resource Utilization Group (RUG) payment system.³ Under the RUG payment system, most patients were classified into a therapy payment group, which primarily used the volume of therapy services provided to the patients as the basis for payment classification. This created an incentive for SNF providers to furnish therapy to SNF patients regardless of each patient’s unique characteristics, goals, or needs. PDPM eliminates this incentive and improves the overall accuracy and appropriateness of SNF payments by using clinically relevant factors, rather than volume-based service, for determining Medicare payment. Under the PDPM, patient characteristics are used to assign patients into case mix groups across 6 payment components from which payment is derived. Additionally, the PDPM adjusts per diem payments to reflect varying costs throughout the patient’s stay.

Wound management professionals who provide care to SNF patients should have already studied the new SNF PDPM payment system and should now be specifically diagnosing their patients and documenting their wound-related goals and needs so that the SNF will receive appropriate payment that includes the wound management services provided.

January 1, 2020

•    2020 HCPCS Codes
The CMS official update of the HCPCS code system, which includes the new HCPCS codes, is effective on January 1 and is available as a public use file.⁴ All wound management professionals who use HCPCS codes should update their coding and billing tools with the pertinent new codes. 

•    First 2020 Quarterly Update of HCPCS Codes
The CMS releases some new HCPCS codes (such as C-codes, G-codes, and codes for new drugs and biologics) on a quarterly basis.⁵ Wound management professionals should pay attention to cellular and/or tissue-based products (CTPs) for skin wounds that may receive new codes during the quarterly updates and should update their coding and billing tools if they use those CTPs.    

•    2020 New, Revised, and Deleted CPT^® Codes
The American Medical Association’s (AMA) official update of the CPT^® code system is effective on January 1 and is available in various formats from the AMA.⁶ All wound management professionals who use CPT^® codes should update their coding and billing tools with the pertinent new, revised, and deleted codes.

•    NCD and LCD Coding Updates
The CMS updates NCDs and the Medicare Administrative Contractors (MACs) update LCDs to include ICD-10-CM, HCPCS, and CPT^® code changes.⁷ Wound management professionals should carefully review these coverage changes and incorporate them into their medical decision making.

NOTE: In addition to the annual coding updates, new draft NCDs and new draft LCDs can be released for public comment at any time. Wound management professionals should assign someone in their practices to 1) sign-up for the CMS Listserv and for the Listserv of the MAC that processes their Medicare claims, 2) monitor the Listserv for notices of draft NCDs and LCDs, 3) review pertinent draft NCDs and LCDs, and 4) share all pertinent draft NCDs and LCDs with the wound management professionals, who should never miss an opportunity to submit evidence-based comments during the open comment periods.

•    2020 Home Health Agency (HHA) Prospective Payment System (PPS)
The 2020 HHA PPS Final Rule implements a new case-mix classification model, the Patient-Driven Groupings Model (PDGM).⁸ The PDGM relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service thresholds. In conjunction with the implementation of the PDGM, there will be a change in the unit of home health payment from a 60-day episode to a 30-day period.

Wound management professionals, who provide care to HHA patients, should have already studied the new HHA PDGM payment system and should now be preparing to specifically diagnose their patients and document each patient’s specific wound-related goals and needs so that the HHA will receive appropriate payment that includes the wound management services provided.

•    2020 Hospital Outpatient Prospective Payment System (OPPS)
The 2020 OPPS Final Rule has not yet been released.⁹ The decisions about several issues, that were proposed in the Draft Rule, should be very interesting to wound management professionals: direct vs. general supervision, reduced payment for clinic visits (G0463-PO) in off-campus excepted provider-based departments (PBDs), prior authorization for select services such as vein ablation, requirements to post standard charge information including payer-specific negotiated charges for all items and services, and much more.

When the 2020 OPPS Final Rule is released in early November 2019, wound management professionals who provide care to patients in PBDs should review the ambulatory classification group (APC) assignments, allowable rates, and status indicators of the codes for the work they perform. In addition, they should review Medicare’s decisions about the issues that pertain to their wound management work.

•    2020 Medicare Physician Fee Schedule (MPFS)
The 2020 MPFS Final Rule has not yet been released.¹⁰ The decisions about several issues that were proposed in the Draft Rule should be very interesting to wound management professionals: changes to outpatient office and outpatient hospital evaluation and management (E&M) documentation guidelines, liberalization of billing requirements for transitional care management services, review and verification (rather than re-document) of medical record notes of other members of the medical team, changes to the Merit-based Incentive Payment System (MIPS), alignment of physician supervision for physician assistant services with state law and scope of practice rules, and much more.

When the 2020 MPFS Final Rule is released in early November, wound management physicians and other qualified healthcare professionals who are paid by the MPFS should review the 2020 facility and non-facility allowable rates of the work they perform. In addition, they should review Medicare’s decisions about the issues that pertain to their wound management work.  

•    2020 National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Update

The revised annual version of the NCCI Policy Manual for Medicare Services should be posted in December 2019 and will become effective on January 1, 2020.¹¹ The additions/revisions to the manual are usually italicized in red font.

The NCCI Policy Manual for Medicare Services, the NCCI procedure-to-procedure (PTP) edits, the medically unlikely edits (MUEs), and the add-on code (AOC) edits were developed for application to Medicare services billed by a single provider for a single patient on the same date of service. The NCCI PTP edits prevent inappropriate payment of services that should not be reported together. The MUEs prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT^® code is the maximum number of units of service (UOS) under most circumstances reportable by the same provider for the same beneficiary on the same date of service. The AOC edits consist of a listing of HCPCS and CPT^® add-on codes with their respective primary codes. An add-on code is eligible for payment if and only if one of its primary codes is also eligible for payment.

Wound management professionals should take the time to review the table of contents of the 2020 manual and should identify the chapter(s) that pertain to the codes that represent their work. Then they should read the introduction chapter, as well as the chapter(s) that discuss the edits for the codes they report to Medicare.

•    First 2020 Quarterly Update of the NCCI Edits
The first quarter NCCI edit updates are effective on January 1. Wound management professionals should review the PTP, MUE, and AOC files for new edits of code pairs they typically perform.^12,13
 

April 1, July 1, and October 1, 2020

•    Quarterly Updates of HCPCS Codes

The CMS releases some new HCPCS codes (such as C-codes, G-codes, and codes for new drugs and biologics) on a quarterly basis.¹⁴ Wound management professionals should pay attention to cellular and/or CTPs for skin wounds that may receive new codes during the quarterly update and should update their coding and billing tools if they use those CTPs.    

•    Quarterly Updates of NCCI Edits
The CMS releases NCCI edit updates on a quarterly basis. Wound management professionals should review the PTP, MUE, and AOC files for new edits of code pairs they typically perform.

Summary

Now that we have reviewed the coding, coverage, and payment information that must be implemented every year, this author hopes you will mark your calendars to review and incorporate the pertinent changes into your wound management processes. You should plan to fit this work into your busy wound symposium and holiday preparation schedule. Whether you are ready or not, the reimbursement changes will be implemented by Medicare like clockwork!

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. CPT is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT^®) is copyright 2018 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.
2. Centers for Medicare and Medicaid Services. 2020 ICD-10-CM Updates: https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM.html. Last accessed September 2, 2019.
3. Centers for Medicare and Medicaid Services. 2020 IPPS Final Rule: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2020-IPPS-Final-Rule-Home-Page.html. Last accessed September 2, 2019.
4. Centers for Medicare and Medicaid Services. 2020 SNF PDPM: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html#fact. Last accessed September 2, 2019.
5. Centers for Medicare and Medicaid Services. 2020 HCPCS Information: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html. Last accessed September 2, 2019.
6. Centers for Medicare and Medicaid Services. Quarterly Update of HCPCS Codes: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.html. Last accessed September 2, 2019.
7. American Academy of Professional Coders. 2020 CPT® Codes: https://www.aapc.com/medical-coding-books/2020/cpt-book.aspx. Last accessed September 2, 2019.
8. Centers for Medicare and Medicaid Services. Medicare Coverage Database: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Last accessed September 2, 2019.
9. Centers for Medicare and Medicaid Services. 2020 HHA PDGM: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.html. Last accessed September 2, 2019.
10. Centers for Medicare and Medicaid Services. 2020 OPPS: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html. Last accessed September 2, 2019.
11. Centers for Medicare and Medicaid Services. 2020 MPFS: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html. Last accessed September 2, 2019.
12. Centers for Medicare and Medicaid Services. 2020 NCCI Manual Update: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. Last accessed September 2, 2019.
13. Centers for Medicare and Medicaid Services. NCCI PTP Quarterly Edits: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. Last accessed September 2, 2019.
14. Centers for Medicare and Medicaid Services. NCCI MUE Quarterly Edits: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html. Last accessed September 2, 2019.
15. Centers for Medicare and Medicaid Services. Quarterly Update of HCPCS Codes: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.html. Last accessed September 2, 2019.