Best Practices for Receiving and Keeping Your Payment

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Good afternoon. My name is Kathleen Schaum, and I'm the president of Kathleen D. Schaum and Associates, Inc. And it is a consulting company that does reimbursement strategy and education for wound and ulcer management professionals And provider based departments like wound care clinics and manufacturers and sales representatives. And I'm honored to be here, speaking at SAWC. It's always an honor to be here at this particular meeting. And last spring when I spoke, one of the, things that was written in the evaluations was that the attendees would like to have some real life scenarios.
 
What are the best practices to connect the dots between payment guidelines?
 
Well, the best practices start with 4 questions. Number 1, who's going to perform the work? Two, where will the work be performed? Three, why will they be performing it? And, of course, 4, what work will be performed? And those answers to those questions change as the person moves around, sees patients in a different place of service, or even a different provider See some. So it's really important to consider those 4 questions. And then it's always important to report the codes that That represent that exact work that you did, by that particular, physician or practitioner and in that place of service. Then they also have to follow the coverage guidelines, because the guidelines then will tell them whether or not they are going to get paid for the work they do, and, of course, That everyone needs to be paid for the work that they perform.
 
And wound and ulcer management professionals are miracle workers. And, you know, sometimes, they don't get paid correctly. And very often, it could be something that they didn't follow a guideline that they could have been paid if they only had followed it better. And the 4th thing is to actually know the payment regulation that pertains to them in the place of service they're going to do the work. And they not only need to know the guideline and the regulation for the year, but they have to follow some of the other things like the National Correct Coding Initiative, edits as well as the correct use of modifiers. So lot of dots that they have to connect in order for them to get paid correctly.
 
What are some payment pitfalls to avoid?
 
The biggest problem we have is that we fail to justify what we did. And you have to prove there's medical necessity for any, procedure or product or service that you provide to a patient because the payer, of course, wants to know, why should I pay for this? So we really have to, do a much better job of justifying and documenting what we do. Another pitfall is they frequently will use a diagnosis code that's considered unspecified.
 
There are literally thousands of diagnosis codes, and they're very and there's many of them for wound and ulcer management. But for some reason, I think sometimes maybe we get a little lazy. And there's codes that are called unspecified codes and they will just use those codes. And when they do, the payer says, well, if you don't know what's wrong with the patient and you put unspecified diagnosis, why should I pay for it? The other thing is that they fail to sometimes document their surgical procedure that they performed.
 
They'll say they did it. They might say, I did a surgical debridement of subcutaneous tissue, but they don't really give the entire procedure. How did they do it? And if you don't document the entire surgical procedure, then you can't get paid for it. And then that would lead to failure to report the codes based on the code description.
 
For example, some codes will say per each. Some will say per 25 square centimeters. Another might say per 50 square centimeters. Another might say, 3 per month. So clearly, we have to follow the code description so that we select the right code and the right units for the code. We also have to report the correct modifiers, and we tend to in the wound and ulcer space, we tend to overuse the modifier 25 when we do a minor procedures, and what happens then is that causes the provider to get paid For a an evaluation in management and the procedure. And then, later, if they are audited, they find out that they really did a minor procedure at that same time and that the modifier 25 wasn't correct. So that's a big issue for, all of our providers. We also, fail to consider if a patient is also in a nursing home. Because in a nursing home, there are certain things the nursing home has to pay for, And we call that skilled nursing facility, consolidated billing.
 
And, if we don't consider whether or not the patient, was in a is in a nursing home, we might bill Medicare for a service that we really should have billed to the nursing home. We also make a mistake of, reporting the incorrect place of service. For example, a physician may be seeing a patient in a home, and they report that they saw him in the office. And then, that is considered a fraudulent claim. So, we have to be really, really sure that if as the physician moves around in his day, If he goes to a hospital, he bills the place of service of a hospital.
 
If he then moves to an outpatient department, the place says that he is in an outpatient department. So the place of service is really important. And last, there's this concept of incident-to billing, and, we tend not to follow the incident 2 billing correctly, And that causes us to have a lot of repayments or denied claims.
 
Considering coding, payment, coverage, and documentation.
 
They really need to consider to the coding, the payment, And the coverage, plus the answers to those 4 questions. And it that has to all be wrapped together because as they move from scenario to scenario, place to place, do a different type of service, you have to think about what's the correct code, the correct payment in this scenario? What is the correct, coverage guidelines? Then they have to use all of those Guidelines in their medical decision making and in their documentation and in their coding. And, by the way, did I mention documentation? Documentation. Documentation.
 
I would say to you that clearly, I hope that everyone who is listening today will rethink how clearly we are painting the picture of what we do in our documentation of wound and ulcer management. Because if we paint the picture, we should get paid correctly.