FAQs from the 2021 SAWC Spring Reimbursement Session

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.

Last month this author was honored to share reimbursement insights for offices and outpatient departments at the virtual 2021 Symposium on Advanced Wound Care (SAWC) Spring. During that 1-hour session, we reviewed a total of 21 insights: 5 Medicare coverage insights, 10 coding insights, 3 Medicare payment insights, 2 audit insights, and 1 insight that pertains to contracting with skilled nursing facilities.

By the time the presentation ended, the virtual attendees had submitted more questions than could be answered in the time allotted for Q&As. Therefore, this author promised to publish the questions and answers in this month’s column. To be concise, this author has taken the liberty of grouping similar questions into one global question.

Q:     

I am a physician who works exclusively in a hospital-owned outpatient wound/ulcer management provider-based department (PBD). When the application of cellular- and/or tissue-based products (CTPs) for skin wounds is medically necessary for wounds/ulcers larger than 25 sq. cm., the PBD says it cannot afford to purchase the products for those larger wounds. However, other physicians who manage wounds/ulcers in their offices have no problem affording to purchase CTPs for large wounds. What is the difference between the Medicare reimbursement in the PBD and in the office?

A:     

The PBD and the physician office are paid by totally different Medicare payment systems. The PBD receives a packaged payment for the application procedure that includes the CTP. That payment is the same no matter if the wound/ulcer is 1 sq. cm. or 99 sq. cm. The PBD also receives a packaged payment for a wound/ulcer that is 100 sq. cm., but if the wound/ulcer is 101, 150, 200, 300 or more sq. cm., the PBD’s payment is the same as the payment for 100 sq. cm. Because the cost to purchase CTPs increases as the wound/ulcer size increases, the PBDs cannot afford to apply CTPs to larger wounds.

The physician’s office receives separate Medicare payments for the application procedure and for the CTP. In fact, the office receives an increased procedure payment for every 25 sq. cm. applied between 1 and 99 sq. cm., and for every 100 sq. cm. applied above 100 sq. cm. In addition, the physician office is paid for each sq. cm. of the CTP that is purchased for every application. Therefore, the physician’s office can afford to apply CTPs to larger wounds.

Q:   

You mentioned that the Medicare payment rate is higher when a physician performs work in her/his office than work performed outside the office, such as in a PBD. Because my office billers submit the claims to Medicare, we always report the place of service as my office, even when I perform the work in a PBD. Is that correct?

A:    

Unfortunately, that is not correct. Your claims are most likely paid at the Medicare office allowable rate because the payer believes you performed the work in your office. However, if you are audited and/or if you have a “whistle-blower” in your office, you can expect some large repayments and possibly some large fines. You must report the correct Place-of-Service code on every claim.

Q:     

Because applying an Unna Boot takes a significant amount of time, can we bill Medicare for an evaluation and management (E/M) service along with the application of an Unna Boot?

A:     

The National Correct Coding Initiative (NCCI) edits do not allow separate Medicare payment for an E/M during the same encounter that a minor procedure (0-day or 10-day global period) is performed, unless the physician/qualified healthcare professional (QHP) provided the E/M service for a significant, separately identifiable problem.

Q:     

If a surgical debridement (11042–11047) or selective debridement (97597–97598) is performed during the same encounter that a CTP is applied to the same wound/ulcer, should the PBD and/or physician bill Medicare for both procedures?

A:     

The NCCI edits do not permit Medicare payment for both procedures performed on the same anatomic location during the same encounter.

Q:     

Will Medicare pay for debridement of extensive eczematous or infected skin (11000) during the same encounter when a CTP is applied to the same wound/ulcer?

A:     

The NCCI edits do not permit Medicare payment for both procedures performed on the same anatomic location during the same encounter.

Q:     

Does Medicare cover and pay for surgical preparation or creation of a recipient site by excision of open wounds, burn eschar, or scar (15002–15005) during the same encounter when a CTP is applied to the same wound/ulcer?

A:     

To answer this question correctly, one must consider 3 things.

1.    Consider the CPT^®1 book guidelines for 15002–15005. The guidelines clearly state that these codes should only be used to remove appreciable nonviable tissue from a burn, a traumatic wound, or from necrotizing infections, and should not be used for removal of nonviable tissue/debris in a chronic wound (e.g., venous or diabetic) when the wound is left to heal by secondary intention.

2.    Consider if the payer will cover both procedures during the same encounter. Some Medicare Administrative Contractors (MACs) will cover, and other MACs will not cover both procedures during the same encounter. The MACs that provide positive coverage usually only allow it before the first application of the CTP. Refer to your MAC’s local coverage determination (LCD).

3.    Consider if NCCI edits permit or prevent both procedures during the same encounter. Currently NCCI edits do not exist for these code pairs if performed on the appropriate type of wound and if covered by the MAC. However, just because an NCCI edit does not exist, that does not mean both procedures are performed on appropriate wounds/ulcers and are covered by your MAC.

Q:     

If the physician performs a surgical debridement (11042–11047) or a selective debridement (97597–97598) of a venous leg ulcer and applies either an Unna Boot (29580) or a multi-layer compression bandage system (29581) to the same ulcer for management of edema, will Medicare pay for both procedures?

A:     

The NCCI edits do not permit Medicare payment for both procedures performed on the same anatomic location during the same encounter, even if the procedures are for different diagnoses.

Q:     

What should we do if our MAC retired an important LCD that pertains to procedures we perform routinely?

A:     

When an LCD is retired, the physician’s and QHP’s documentation increases in importance. The documentation must thoroughly explain why the procedure and/or product is necessary. If the physician/QHP had choices, the documentation should explain why that procedure and/or product was selected.

Even though the LCD was retired, physicians and QHPs should use it as a reference because your MAC will still use the retired LCD as a reference for pre-payment and post-payment audits.

In summary, the short answer is to use the retired LCD as a reference, and document, document, document!

Q:     

We ask patients to sign a blank Advance Beneficiary Notice of Noncoverage (ABN) prior to their first visit. After listening to your presentation, I think that is not the correct process. Is it OK to continue our ABN process?

A:     

Unfortunately, your current process is not compliant with Medicare regulations. ABNs should be provided when Medicare normally covers a service, procedures, and/or product, but the physician/QHP does not believe that a particular patient’s condition will be covered. The physician/QHP should discuss the procedure with the patient and give the patient the option of proceeding or not proceeding. The ABN should identify the service, procedures, and/or product in question, why it will most likely not be covered, and the cost to the patient—if the patient decides to proceed. The ABNs should be readily available to the physician/QHP to discuss and provide to the patient during that encounter—not before the patient’s first encounter.

To help your team understand why your current ABN process is non-compliant, visit this link where you will find instructions for using the ABN.

Q:     

Why do you call RPM, remote physiologic monitoring, rather than remote patient monitoring?

A:     

That is a great question. Remember that words matter in documentation and coding.

There are many remote patient monitoring devices that do not qualify for coding and Medicare payment because they do not monitor and collect physiologic data. For example: wristbands or lavalieres that patients wear to monitor if they leave their dwelling or facility.

If you open your CPT book to this section, you will see that the codes for monitoring and collecting physiologic data are clearly defined as remote physiologic monitoring. Therefore, that is the terminology that physicians and QHPs should use in their documentation and discussions with patients and payers.

Q:     

Will you please provide a few examples of procedures that are in the skilled nursing facility (SNF) consolidated billing file #1 and that should be billed to the SNF rather than to Medicare?

A:     

A few of the most common wound care procedure codes, which should be billed to the SNF during a patient’s Medicare covered part A stay, are:

29580                   application of an Unna boot
29581                   application of a multi-layer compression bandage system
97597/97598        selective debridement
97605–97606       application of negative pressure durable medical equipment
97607–97608       application of disposable negative pressure

Q:      

Please provide a good use of communication technology-based services (CTBS) for wound/ulcer management.

A:   

I can think of many uses; here is one that should resonate with most wound/ulcer management professional. I often hear wound/ulcer management professionals express concerns about patients who miss their assessment visits for a variety of reasons, and about patients who develop new wounds and do not make appointments until the wounds are out of control. By educating those patients about virtual check-ins, online non-face-to face digital E/M services, and/or remote assessment of recorded video and/or images, wound/ulcer management professionals may be able to have more consistent assessment visits, and may be able to triage patients in the early stages of wound development.

Although CTBS services will never take the place of in-person visits when procedures must be performed, they should assist in seeing your patients regularly and/or before new wounds get out of control.

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.

Reference

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