Reimbursement Changes Enable Expansion into a Variety of Places of Service

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To celebrate the first digital issue of Today’s Wound Clinic, this author reflected on the many Medicare reimbursement changes that have occurred since the first print journal was published in April 2007.

Back then hospital-owned outpatient wound/ulcer management provider-based departments (PBDs) were rapidly opening throughout the country. Physicians and other qualified healthcare professionals (QHPs) had many reasons to send and/or see their patients with wounds/ulcers in the PBDs. For example, 1) Medicare payment rates were not adequate to cover the time and supplies required to manage these patients in their offices; 2) Medicare payment for procedures such as the application of cellular and/or tissue-based products for skin wounds (CTPs) [outdated term “skin substitutes”] was not adequate in office settings; 3) Medicare did not pay for hyperbaric oxygen therapy (HBOT) performed in physician/QHP offices; 4) Medicare only paid physicians/QHPs to perform limited wound/ulcer management in patients’ homes, and so forth. When physicians/QHPs conducted proformas to see if they could afford to specialize in wound/ulcer management based in their offices, in freestanding clinics, and/or in patients’ homes, most of them concluded that seeing those patients in PBDs was more cost effective.

For the past few years, Medicare reimbursement for PBDs and physicians/QHPs has been changing. In fact, this author continues to receive a plethora of questions from PBDs expressing concerns that physicians/QHPs are seeing wound/ulcer management patients in their own offices, in freestanding wound/ulcer management clinics, or in the patients’ homes. Simultaneously, physicians/QHPs are deluging this author with questions about both Medicare fee-for-service reimbursement and Medicare Advantage reimbursement for wound/ulcer management provided in a variety of places of service (including their offices). The answers to a few of the frequently asked questions (FAQs) should assist readers to understand how changes in Medicare reimbursement are enabling wound/ulcer management to be performed in PBDs, as well as other places of service.

NOTE: The FAQs pertaining to telehealth are not included because the February issue of Today’s Wound Clinic will focus on telehealth. Also, the FAQs do not pertain to work performed under the COVID-19 waivers.

FAQs From PBDs:

Q:     

Is it true that Medicare separately pays physician/QHP offices for the add-on codes to apply CTPs to wounds larger than 25 sq cm?

A:     

In PBDs paid by the Outpatient Prospective Payment System (OPPS), Medicare packages the payment for all add-on codes into the payment for the base codes. In addition, they package the payment for the CTPs into the payment for the application base codes. Therefore, the PBDs often cannot afford to purchase CTPs for wounds larger than 25 sq cm.

In physician/QHP offices paid by the Medicare Physician Fee Schedule (MPFS), Medicare pays separately for the CTP application base codes and add-on codes, as well as for total number of sq cm of the CTP purchased for the patient. Therefore, the physician/QHP office, unlike the PBD, can usually afford to apply CTPs to wounds greater than 25 sq cm.
    
Ever since Medicare implemented packaged payments for CTPs applied in PBDs, physicians/QHPs have consistently shifted patients who needed CTPs applied on their large wounds/ulcers to physician offices and/or physician-owned freestanding wound clinics.

Q:     

Some of the physicians who normally supervise HBOT in our PBD told us they were going to start performing HBOT in their offices. How can the physicians afford to do that in their office?

A:     

For many years Medicare paid PBDs to provide the HBOT (G0277) and paid the physicians to supervise the HBOT (99183). However, Medicare did not pay physician offices to provide HBOT. Therefore, physicians could not afford to perform HBOT in their offices. Several years ago, a Medicare payment rate for G0277 was added to the MPFS. Now physician offices and/or physician-owned freestanding wound clinics can receive payments for both the provision (G0277) and supervision (99183) of HBOT. In fact, the 2021 MPFS national average rate ($166.44) for G0277 is higher than the OPPS national average rate ($119.28). The 2021 national average Medicare payment rate ($109.91) to the physician for supervising the HBOT is the same in PBDs, physician offices, and physician-owned freestanding wound clinics.

FAQs From Physicians/QHPs

Q:     

About 10 years ago we contemplated offering wound/ulcer management services in our office, but the limited services that we could offer and the Medicare reimbursement for those services did not make good business sense. With the Medicare Quality Payment Program placing so much emphasis on providing high quality service at a reduced cost, and with Medicare reimbursing for more services, we think we should begin offering wound/ulcer management services in our office. Will you please itemize some of the Medicare reimbursement changes that align with our thinking?

A:    

Several Medicare reimbursement changes make providing wound/ulcer management services in physician/QHP offices more realistic than it was 10 years ago. Following are a few of the changes.     

•    Because managing wounds/ulcers requires a thorough assessment and appropriate diagnostic tests to determine the primary and secondary diagnoses that prevent wounds/ulcers from healing, physicians/QHPs should focus on evaluation and management (E/M) services. In the past, the Medicare payment rate for E/M services was rather low, and if physicians/QHPs wanted to bill based on time, the time had to be spent coordinating care. Effective January 1, 2021 physicians/QHPs can now report E/M services provided in their office based on either the level of medical decision making, or the total time spent on E/M services that day (not just the face-to-face time with the patient). In addition, the national average MPFS rates have increased significantly for E/M services performed in 2021, and there is even a new prolonged service code (G2212).

•    Physician/QHP offices that have implemented patient portals and that have taken the time to educate patients on how to maximize the use of the portals can now offer communication technology-based services (CTBS), e.g.:

• Virtual check-ins (G2012) that are real-time, two-way audio and/or video conversations initiated by established patients, that do not originate from a related E/M service provided within the previous 7 days, and that do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment
• Technology-based remote evaluations (G2010) of recorded video and/or images that are submitted by established patients (e.g., store and forward), including interpretations with follow-up with the patient within 24 business hours
• Online non-face-to face digital E/M services (99421–99423) that are initiated by established patients and that include: review of initial inquiry, patient records or data pertinent to the assessment of the patient’s problem; development of management plans; generation of prescriptions; ordering of tests; and subsequent communications with patient via a HIPAA-compliant platform e.g., electronic health record portal, secure e-mail

•    Medicare now covers and pays for physicians/QHPs to provide home visits (99347–99348) to patients when the physicians/QHPs deem those visits to be medically necessary. CAUTION: Pay attention to the list of home health consolidated billing codes if the patient is also receiving care from a home health agency.

•    Medicare now covers and pays for physicians/QHPs to provide care to patients in skilled nursing facilities during their Medicare covered Part A stay and during their Medicare covered Part B stay. CAUTION: Pay attention to the specific list of consolidated billing codes during the Part A stay and the other specific list of consolidated billing codes during the Part B stay.

•    Remote physiologic monitoring (RPM) provides additional tools for physicians/QHPs to manage their patients’ in-between visits.

• Set-up of and patient education about Food and Drug Administration (FDA)-cleared medical device to remotely monitor physiologic parameters, e.g., weight, blood pressure, pulse oximetry, and respiratory rate (99453). NOTE: This code can only be reported once for each episode of care (begins when the remote physiologic monitoring service is initiated and ends when targeted treatment goals are attained).
• Supply of device for daily recording or programmed alert transmissions (99454). NOTE: This code can be reported once every 30 days but cannot be reported for monitoring of less than 16 days.
• Remote physiologic monitoring treatment management services (99457–99458) when clinical staff/physician/QHP use the results of remote physiological monitoring to manage a patient under a specific treatment plan and via a live, interactive communication with the patient/caregiver. NOTE: These codes cannot be reported for less than 20 minutes of services.

•    Telehealth services are also an option—watch for the February Business Briefs column!

Summary

This article should end physicians’/QHPs’ common belief that the only way they can get paid for managing wounds/ulcers is if they debride. The correct answer is to diagnose the underlying problem thoroughly, create a treatment plan, and manage the plan no matter where the patient is located. As an added benefit to doing the right thing, physicians/QHPs now have codes and Medicare reimbursement for this important work. Happy New Year!

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.