Coding Challenge: Readers vs. Workshop Attendees

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.
 
This author/consultant recently had the honor of facilitating an in-person wound/ulcer management reimbursement workshop. The participants included physicians, podiatrists, nurse practitioners, physician assistants, and reimbursement specialists who work for manufacturers. One section of the workshop included scenarios that provided the participants with an opportunity to evaluate their knowledge of appropriate coding for hospital owned outpatient wound/ulcer management provider-based departments (PBDs) and the physicians/qualified healthcare professionals (QHPs) who work in the PBDs.

The scenarios were not meant to stump the participants, but they did! Very few of the participants were able to select the correct codes.

Therefore, this author/consultant is giving Business Briefs readers the opportunity to evaluate your own wound/ulcer management coding knowledge. Just like the workshop attendees, you should not use any coding references. Simply answer the questions from your coding knowledge. To take the test, simply scroll down to the end of this article. Once you submit your answers, you will receive your score and receive the correct answers.

Then you should return to this article to review some basic coding rules that you should have considered when you took the test. Today’s Wound Clinic will collate the readers’ answers. In next month’s Business Briefs, we will announce if the workshop attendees or the Business Briefs readers won the coding challenge.

Basic Coding Rules

When working in a hospital owned outpatient PBD, physicians/QHPs should only code and bill for work they perform.

Examples (not all-inclusive):
29445                         Application of total contact cast
29580                         Application of Unna boot
29581                         Application of multi-layer compression bandage
97605–97606            Application of NPWT durable medical equipment
97607–97608            Application of disposable NPWT
97610                         Low frequency non-thermal ultrasound
 
Report debridement codes based on the level of tissue removed and documented. Do not code by what you see; code by what you remove and document. Do not use the term “excision” when you perform this work; document the work as “debridement,” Do not describe the debridement as “sharp”; describe the level of tissue removed and the tool/implement used.

Examples (not all-inclusive)
11042/11045             Subcutaneous tissue removed
11043/11046             Muscle and/or fascia removed
11044/11047             Bone removed
97597/97598             Fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm removed from an open wound
97602                         Devitalized tissue removed with methods such as wet-to-moist dressings, enzymes, abrasion, larval therapy
 
Correctly report the application of cellular and/or tissue-based products (CTPs) for skin wounds.

• Select the application codes (15271–15278; C5271–C5278) based on the anatomic location and size of the wound/ulcer:

          §  Physicians/QHPs always report 15271–15278
          §  PBDs report 15271–15278 when the physician/QHP applies a CTP assigned to the high-cost CTP group
          §  PBDs report C5271–C5279 when the physician/QHP applies a CTP assigned to the low-cost CTP group

• Do not report the CTP application code based on the size of the product purchased; report it based on the size of the wound/ulcer.
• Do not report the CTP application code for every wound/ulcer unless the locations are described by different codes.
• For coding purposes, the ankle is part of the leg, and the wrist is part of the arm.
• Report the total number of sq cm of CTP purchased for each application: verify that your coders are not reporting the unit of “1.”
• PBDs should not report the wastage modifiers.
• Physicians/QHPs should verify if their Medicare Administrative Contractor (MAC) requires use of the wastage modifiers -JW and -JZ. 

          NOTE for physician/QHP offices: If a CTP does not have a published average sales price, physicians and QHPs should verify how their MAC expects them to report their actual acquisition cost.
 
Correctly report hyperbaric oxygen therapy performed in a PBD.

• Physicians/QHPs should report 99183 Physician supervision: 1 unit per session.
• PBDs should report G0277 Hyperbaric oxygen therapy: 1 unit for every 30 minutes increment.

          NOTE: Treatment time starts at the beginning of chamber pressurization and ends when chamber depressurization is finished
 
Only report an evaluation & management (E/M) or clinic visit on the same day as a minor procedure when a significant, separately identifiable service was performed by the same physician/QHP on the same day as the minor procedure. NOTE: A minor procedure is one that is assigned 0- or 10-global surgery days.
 
Do not report modifier -25:

• To all new patient visits
• When managing a condition related to the reason for the scheduled visit
• When documentation does not support that the physician’s/QHP’s E/M was beyond the normal preoperative and postoperative work of the minor procedure performed

Only use modifiers -59 or -XS to bypass a National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edit when the proper criteria are met and documented. For most wound/ulcer management procedures:

• Modifiers -59 and -XS are used to indicate that a distinct procedural service was performed on a different site or organ system and was clearly documented.
• Modifier -XS should be used instead of modifier -59 when the procedure was performed on a different site or organ system; only use modifier -59 when a more descriptive modifier is not available, and the use of modifier -59 best explains the circumstances.
• Modifiers -XS and -59 should only be appended to the procedure code, not to the E/M code.

          CAUTION: Do not use modifiers -XS and -59 to force payment for 2 procedures performed on the same site or organ system.
 
The Centers for Medicare & Medicaid Services (CMS) publish excellent NCCI resources:

• Medicare NCCI Policy Manual 
• Medicare NCCI Procedure-to-Procedure Edits: 1) Hospital and 2) Practitioner

         Example: 15275       11042

• Medicare NCCI Medically Unlikely Edits (MUEs) for: 1) DME supplier services; 2) Facility Outpatient Hospital Services; and 3) Practitioner Services

         Example: 97598       8 units

Summary

Now that you have taken the coding test pertaining to common wound/ulcer management services/procedures performed in PBDs, and have reviewed the basic coding rules above, you should take the time to verify that you and your colleagues are following these coding rules.

This author/consultant selected these 12 test questions because many PBDs, physicians, and QHPs are failing their pre-payment and post-payment audits due to noncompliance with these basic wound/ulcer management codes. You can prevent claim denials and repayments by simply assessing wounds/ulcers at every encounter, adjusting each plan of care as needed, documenting thoroughly, and reporting the correct codes to represent the work that was performed. Because wound/ulcer management professionals do not perform a wide variety of procedures, they only must learn the coding, coverage, and payment rules for a small number of services and procedures.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.