Reimbursement Pearls From Wound Clinic Business 2019

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.

To align with this month’s Today’s Wound Clinic theme, “How Medicare is Changing Wound Care,” this column will review some of the related topics that were discussed at the Wound Clinic Business (WCB) seminars throughout 2019.

Increasing Number of Beneficiaries Selecting Medicare Advantage Plans

In the past, many Medicare beneficiaries opted for traditional Medicare fee-for-service. Therefore, wound care professionals and providers focused their attention on the coding, coverage, and payment systems of traditional Medicare-fee-for-service. Conversely, a small percentage of Medicare beneficiaries selected one of the Medicare Advantage plans.

When the Centers for Medicare and Medicaid Services (CMS) embarked on a mission to improve the quality of care, enhance patient satisfaction, and reduce the total cost of care per beneficiary, CMS launched many demonstration projects to test which programs achieved their mission. The Medicare Advantage plans have benefited from this mission: the CMS has authorized these plans to offer benefits that are not normally covered by the Medicare fee-for-service program. In the early days, those benefits included eyeglasses, hearing aids, and dental care. Now the Medicare Advantage plans are permitted to offer many new benefits such as home health aides, transportation, and telehealth in the home. In 2020, greater than 40% of Medicare eligible beneficiaries are expected to opt for a Medicare Advantage plan.

What Does This Mean for Wound/Ulcer Management?

Wound/ulcer management professionals and providers should pay attention to their Medicare Advantage contracts and should reach out to the Medicare Advantage plans to identify if there are opportunities for managing their beneficiaries’ wounds and chronic ulcers in all sites of care. It may require taking wound/ulcer management to the patients, rather than seeing the patients in the office or hospital owned outpatient wound/ulcer management provider-based department (PBD). This might require managing the wounds/ulcers in the patients’ homes either in person or via telehealth.

When you communicate with the Medicare Advantage plans, be prepared to “think out of the box” because the plans are looking for innovative programs that will prevent chronic ulcers, catch wounds in the very early stages, and do everything possible to manage the wounds/ulcers in the shortest period of time. Medicare Advantage will not be anxious to support programs that are wasteful or that do repetitive procedures without improved quality, enhanced patient satisfaction, and reduction of total cost per beneficiary. This is a real opportunity for innovative wound/ulcer management professionals and providers.  

Increasing the Number of Entities Working Together to Manage Episodes of Care

In the past, hospitals and physicians were single business entities. Therefore, they focused on the Medicare coding, coverage, and payment systems that pertained to their business entity. That led to the United States being the highest cost health system in the world and 37th in quality.¹ Wound/ulcer management has often contributed to this problem due to 1) inconsistent clinical practice guidelines, plans of care, etc., 2) inconsistent orders, 3) duplicate diagnostic tests, 4) wasted supplies and drugs, 5) work often performed based on reimbursement rather than medical necessity, 6) work often unnecessarily performed in the highest cost sites of care, and so forth.  

Now a myriad of integrated health networks, accountable care organizations, demonstration projects, and so forth have formed to test different ways to better manage episodes of care, no matter where the patients are located. At this point in time, no one has the “magic bullet” that is going to accomplish the quality and cost mission overnight, but all forward-thinking individuals and entities know that our current health system is unsustainable and are willing to work together to create a healthcare system that delivers the highest quality, reduces the total cost per beneficiary, and achieves excellent patient satisfaction. Executives who are leading these organizations are moving beyond traditional cost cutting and are looking to create new business models with new and different revenue sources.

In addition, a variety of mergers, acquisitions, and partnerships are seeking to change the face of healthcare, including wound management. Not a day goes by without some news release about one or more innovative healthcare programs being launched and tested in large and small communities throughout our country. Some examples of unexpected entities working together are CVS and Aetna; Walmart and Humana; Kindred at Home (home health) and Humana; Amazon, JP Morgan, and Berkshire Hathaway in a joint venture to manage the three companies’ 1.5 million employees’ insurance; Express Scripts and CIGNA; and Anthem and CareMore Health.

In fact, Humana Inc. recently announced that it will transition from “an insurance company with elements of health care to a health care company with elements of insurance.” Several years ago, it was unthinkable that a drug store chain and a payer would merge, or that a large distribution organization would join with financial organizations to manage health care, or that a payer would become a health care provider. All these entities, as well as existing health systems and organizations, will use “data” to create business models that will allow them to quickly elect to participate in innovative health care programs that deliver value.

Because wound/ulcer management professionals are highly skilled in managing wounds/chronic ulcers from start to finish, now is the time for them to seek out the individuals and entities who have been delegated to create organizational structures that may not look anything like the place where they now work. They should let these innovative thinkers know that patients with wounds/ulcers cross all disease states and all sites of care and that they can guide their new organizational structures to prevent wounds/ulcers, to manage them when they are small problems, and to aggressively manage those ulcers that are big problems. When wound/ulcer management professionals start to investigate the activity, to better manage episodes of healthcare in their community, they will be pleasantly surprised.   

Increasing Number of Ways to Share Wound/Ulcer Management Expertise

In the past, wound/ulcer management professionals typically managed wounds/chronic ulcers in their offices, in hospitals, and in PBDs because that was the easiest way to get paid by Medicare. Some wound/ulcer management professionals spread their wings and provided services to skilled nursing facilities, but they were still dependent on getting paid fee-for-service by the Medicare program. Very few did home visits because those visits were very hard to justify to Medicare and other payers.

Then the hospitals and physician organizations began participating in the various bundled payment programs that often included wound/ulcer management. That was when wound/ulcer management professionals started to focus on quality across the continuum of care, the total cost of the episode, and patient satisfaction, rather than on the number of visits, the number of debridements performed, the number of hyperbaric oxygen therapy treatments, etc. In fact, executives in those programs stopped asking “How many did you perform this week?” and began asking “Did you only perform services that were medically necessary this week?”

Although wound/ulcer management professionals could easily act as consultants for other physicians and qualified healthcare professionals (QHPs), they faced numerous hurdles. For example, they could not bill Medicare for consultations to other physicians, they could not provide telehealth services to patients in their homes, they could not do home visits without a major justification to the payer, etc.

Beginning Jan. 1, 2019 wound/ulcer management professionals can now provide technology-based communications and remote evaluation services. Physicians who need consultations from wound/ulcer management professionals can now receive payment by Medicare to prepare the referral and to communicate with the wound/ulcer management professionals via telephone, internet, or an electronic health record referral service. Likewise, the wound/ulcer management professionals can also receive payment for providing the consultation and for writing their report. Of course, wound/ulcer management professionals should read and learn the coding and coverage regulations pertinent to these services. The most important part of the regulations is that the patient must provide verbal consent before the consultation occurs, the consent must be documented, and the patient must be told that she/he may incur a copayment for the consultation.

Also, beginning Jan. 1, 2019 physicians can offer remote evaluations of pre-recorded patient information for established patients. If the patient did not have a related evaluation and management (E/M) service within the previous 7 days and wants to send a recorded video and/or image for the wound/ulcer management physician to evaluate, the physician can bill for the remote evaluation, interpretation and follow-up with the patient within 24 business hours. The follow-up may be via the phone, an audio/video conference, secure text messaging, e-mail, or patient portal—if the communication method complies with the Health Insurance Portability and Accountability Act (HIPAA). Once again there are coding and coverage regulations surrounding this service, including the requirement for documented verbal consent.

To make this more exciting, wound/ulcer management physicians can now take patient-initiated virtual check-ins from their established patients. The virtual check-in must be a real-time, two-way audio and/or video conversation; a voice message is not acceptable. Again, there are coding and coverage regulations surrounding this service and it requires documented verbal consent.  

Finally, effective Jan. 1, 2019 the CMS removed the need to justify providing a home visit instead of an office visit. In addition to a private residence, “home” may also include temporary lodging or short-term accommodations such as hotels, campgrounds, hostels, and the author’s favorite place—cruise ships! The home visit must be face-to-face and must be billed as place of service 12 (home).

What Does This Mean for Wound/Ulcer Management?

Wound/ulcer management professionals can now share their expertise with other physicians who are managing patients—without delaying care, without incurring transportation costs, and with the right care for the patient. In addition, wound/ulcer management professionals can evaluate their existing patients’ recorded videos or images and can follow up with the patient—and the patient receives the evaluation without an office visit. Similarly, wound/ulcer management professionals can make themselves accessible to their existing patients for virtual real-time check-ins. Think how many more patients you can manage in a day and how many small problems you can catch before they become large problems.

And then for some patients, it is simply easier for the professionals and the patients to see the patients in their homes. Now that is possible and may be a very marketable wound/ulcer management service.

All these services have the potential for improving quality, reducing total cost of care, and improving patient satisfaction.

Increasing Emphasis on Primary and Secondary Diagnoses, and Comorbidities

In the past, wound/ulcer management professionals complained that the payers did not give them credit for taking care of patients with many comorbidities. Then Medicare Advantage plans began using the CMS Hierarchical Condition Category (HCC) Risk Adjustment Factor (RAF) Scores to determine their contracted rates.

Now each physician/QHP has a cumulative CMS-HCC risk adjustment score based on the RAF scores of all the beneficiaries attributed to him/her by the CMS. Higher HCC scores can bring higher Medicare Advantage payments and can influence Merit-Based Incentive Payment System (MIPS) scores in the Quality Payment Programs. Many other payers either use or are planning to use the CMS-HCCs in their payment calculations. The CMS-HCC scores of patients can also impact the capitated payment rates of hospital-based outpatient wound/ulcer management PBDs.

Because many patients with wounds and chronic ulcers receive care in skilled nursing facilities (SNFs) or from home health agencies (HHAs), wound/ulcer management professionals should carefully document and diagnose the primary and secondary diagnoses, as well as the comorbidities, that they must consider when managing the wound/ulcer. Effective Oct. 1, 2019 the SNFs have a new Medicare payment system, and effective Jan. 1, 2020 the HHAs will have a new Medicare payment system. Although both payment systems are different, patients with wounds/ulcers may bring SNFs and HHAs higher reimbursement rates even if the wounds/ulcers are not the primary reason for the patients’ admissions.   

What Does This Mean for Wound/Ulcer Management?

Wound/ulcer management professionals can now receive credit for the complexity of their work by describing each patient’s comorbidities in addition to their primary and secondary diagnoses. Too many wound/ulcer management professionals make the mistake of only coding the ICD-10-CM diagnosis code that will provide coverage for their service. By taking that shortcut and by using unspecified diagnosis codes, wound/ulcer management professionals are shortchanging themselves.

Throughout this year at Wound Clinic Business, many clinicians shared the fact that their electronic health record system always listed the unspecified diagnosis codes first in their drop-down screens. To save time, they always select the first codes in the list. We discussed the importance of taking the time to find and select the specific diagnosis codes. In addition, we discussed either having their software vendor move the unspecified diagnosis codes to the bottom of the list or removing them from the list.

Now that primary and secondary diagnoses and comorbidities also play such an important role in the new SNF and HHA Medicare payment systems, wound/ulcer management professionals owe it to their patients and the SNFs and HHAs to document and diagnose the patients correctly.

Increasing Impact of Quality Measures

In the past, physicians/QHPs, as well as all sites of care, were driven by their volume-based payment systems. As discussed above, the U.S. became the highest cost healthcare system in the world and did not fare so well in quality. Therefore, the CMS slowly but surely introduced quality-related payment incentives to all sites of care. Until recently, the CMS has not focused on the quality of wound/ulcer management in most sites of care.

Because physicians’ orders drive a very large percentage of healthcare costs, quality is a major component of their new Medicare Quality Payment Program. The general quality measures included in the MIPS do not focus on specialties such as wound/ulcer management. In fact, wound/ulcer management physicians/QHPs (as well as many other medical specialties) had a difficult time showing the quality of their work to Medicare.  

Therefore, the CMS now allows medical specialties to develop Qualified Clinical Data Registries (QCDRs) that include quality measures relevant to their patients and their specialty practices. Even though wound/ulcer management is not a recognized medical specialty, the CMS agreed that the Alliance of Wound Care Stakeholders could act in lieu of a specialty society in order to launch the Chronic Disease Registry (CDR), which is also called the U.S. Wound Registry. Now physicians/QHPs can report quality measures that are relevant to wound/ulcer management.  

Not only does the CMS use the quality measures to determine if individual physicians/QHPs will receive a MIPS bonus or payment reduction, but they also publish, on the Physician Compare website, some of the quality performance scores on the profile page of each physician/QHP. When the Physician Compare website was recently updated, the CMS only printed quality performance scores reported via 6 QCDRs—even though more than 40 QCDRs exist. From those 6 QCDRs, only 11 quality measures were selected for publication on the profile pages. The wound/ulcer management specialists who reported via their quality measures via the U.S. Wound Registry were excited to learn that 3 of the quality measures reported via that registry were included on their Physician Compare profile pages.² These quality measures are:

•    Adequate offloading of diabetic foot ulcer at each treatment visit
•    Adequate compression of venous leg ulcers at each treatment visit
•    Vascular assessment of patients with chronic leg ulcers

True wound/ulcer management performance information is finally available to assist patients select wound management specialists who provide high-quality care.  
 

What Does This Mean for Wound/Ulcer Management?

Wound/ulcer management professionals and providers should work to have wound/ulcer management-related quality measures in all relevant quality programs. Once the CMS approves wound/ulcer management-related quality measures, professionals and providers should use them to report their performance. Otherwise, the CMS will delete the very measures that your specialty worked so hard to get approved. For example: The CMS requires enough physicians/QHPs to report QCDR quality measures for 3 years in order to set national benchmark rates. Then the measures are eligible to be reported on Physician Compare. If benchmarks cannot be set, the measures are deleted and will no longer appear on Physician Compare. Therefore, if wound/ulcer management physicians/QHPs wish to maintain eligible quality measures specific to their work, they should report their quality measures through a pertinent QCDR.

The Increasing Impact of Accurate Coding and Billing on Bundled Payments

In the past, when wound/ulcer management professionals or facilities did not report correct codes and the correct number of units, and did not set their charges appropriately, they suffered the consequences of incorrect payments. Recently Medicare has been using claims data (no matter if the data is correct or incorrect) to set a variety of bundled payments. If sizable numbers of claims data are incorrect, the bundled payments for all providers will be impacted.  

What Does This Mean for Wound/Ulcer Management?

All wound/ulcer management professionals and providers should conduct self-audits to be sure that the correct codes, correct number of units, and correct marked-up charges appear on the submitted claims. They should not assume that the information reported via their charging system appeared on their claims.

For example: A large percentage of claims from PBDs report the unit of 1 for a cellular and/or tissue-based product (CTP) for skin wounds even though the PBD should have reported the total number of sq cm opened for the procedure. Therefore, the PBD only bills and receives payment for 1 sq cm. Because the CMS uses claims data information to set packaged CTP payment rates, that explains why the device offset amounts included in the packaged payments for the CTPs is so low. This problem will compound itself immensely if the CMS decides to pay an episodic payment when CTPs are applied. Therefore, PBDs should take the time to review their actual submitted claims to ensure the CMS receives accurate information.  

Although this example is about the application of CTPs in PBDs, wound/ulcer management professionals and providers should take the time to review their actual submitted claims for all services and procedures. This will guarantee that the CMS has accurate claims data if they choose to move wound/ulcer management to some type of bundled payment system.

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. World Health Organization. The World Health Report 2000. Available at https://www.who.int/whr/2000/en/ .
2. Centers for Medicare and Medicaid Services. Physician Compare. Available at https://www.medicare.gov/physiciancompare/.