Consultation Corner

Pay Attention to Code Descriptions or Lose/Repay Money!

October 2021

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.

During the COVID-19 public health emergency (PHE), I received numerous requests for teleconsultations from physicians who decided to manage their patients with wounds/ulcers in their offices because the local hospital-owned outpatient wound/ulcer management provider-based departments (PBDs) were closed. Unfortunately, none of the teleconsultation requests came before the physicians began to document and the coders and billers began to submit claims. The following scenario is just one of many teleconsultations that I conducted for these physician offices. Read it carefully to prevent the same things from happening to you.

Scenario

The physician contacted me because she was 1) surprised that she actually lost money on many of her wound/ulcer management encounters and 2) upset that she faced a sizeable repayment after a post-payment audit.

Facts to Consider

While interviewing the physician and her coders and billers, I gathered the following facts:

• The physician is a family practice physician who typically reports her office practice work with evaluation & management (E/M) codes. Prior to the PHE, she worked one day per week in the PBD. The PBD provided a scribe for the physician and provided the physician with the codes to bill for each encounter. The physician simply brought those codes back to her office and her coders and billers prepared her Medicare claims with those codes.

• When the PBD closed, the physician asked the PBD for a list of all the codes that were used by the PBD. The physician gave that list of codes to her office coders and billers.

• The coders and billers recognized most of the codes on the list as codes they were directed to report on the Medicare claims for the work the physician performed in the PBD. However, they did not know the coding rules for each code and did not know the nuances between codes.

• The physician, coders, and billers did not have any wound/ulcer management coding training before the physician began registering patients in the office. The physician simply documented just like she did for her family practice patients. The coders and billers selected the codes off the list that they received.

• Because the coders and billers were accustomed to billing an E/M code for every family practice visit, they billed an E/M code for every wound/ulcer management visit, even when the physician performed a minor procedure.

• The coders and billers did not review the full description for each of the skin substitute application procedure codes and for the cellular and/or tissue-based product (CTP) for skin wounds codes [outdated term skin substitute].

• Neither the physician nor the coders and billers read the Current Procedural Manual (CPT^®)¹ instructions about the codes they reported and the pertinent Local Coverage Determinations (LCDs) and Articles (LCAs) released by the Medicare Administrative Contractor (MAC) who processes the physician’s claims.

Consultation

When our teleconsultation began, I advised the physician, coders, and billers that I would teach them 1) about the wound/ulcer management codes that pertained to the work the physician performed, and 2) how their lack of knowledge about the codes and coding guidelines caused them to lose money and to repay money during the recent post-payment audit.

First, we discussed the main reasons they lost money:

• They did not thoroughly read the procedure code descriptions to understand that many of the codes were based on the wound surface in sq cm. Therefore, they did not report any of the add-on debridement codes, add-on application of skin substitute codes, etc., when the wound/ulcer surface size exceeded the size in the description of the base procedure codes. Because the physician managed many large wounds, this caused a sizable financial loss to the office.

• They did not carefully read the application of skin substitute code descriptions to see that 4 of the codes align with the trunk, arms, and legs and 4 other codes align with the smaller anatomic locations, such as the feet. Therefore, every time the physician applied a CTP to a large ulcer that extended from the heel up into the ankle, the coders only reported the application code for the feet. However, for coding purposes, the heel is part of the foot and the ankle is part of the leg. Therefore, the physician should have measured the portion of the ulcer that was on the heel and reported the correct application code for the feet. In addition, the physician should have measured the portion of the ulcer that was on the ankle and reported the correct application for the legs. Because the physician managed many wounds that extended from the feet to the legs, the office once again incurred payment losses.

• They did not carefully read that the descriptions of the CTP product codes are “per sq cm.” Therefore, they did not report the total number of sq cm of the CTP that the physician purchased for each patient. Instead they reported the unit of “1” for each CTP applied. You guessed it: Medicare paid the office for “1” sq cm, which caused the office to incur huge losses.

Then we discussed the main reasons they incurred repayments after their post-payment audit. Once again, the main culprits were 1) not reading code descriptions carefully and 2) not understanding the unique wound/ulcer management coding guidelines,

• Every time the physician surgically debrided more than one ulcer during an encounter, the coders reported multiple surgical debridement codes and forced their payment by appending modifiers that did not accurately define the work that was performed. The coders did not understand that they were supposed to sum the surface area of the ulcers that were debrided at the same depth. This consistent error resulted in a large repayment to the Medicare program.

• Similarly, every time the physician applied a CTP to the same anatomic location on both feet or both legs, the coders reported multiple application of skin substitute codes and forced their payment by appending modifiers that did not accurately define the work that was performed. The coders did not understand that they were supposed to sum wounds from the same code description. For example, if the physician applied a CTP to ulcers on both feet, the physician should document the size of both ulcers. Then the coders should sum the sq cm of both ulcers together and report the code(s) for the application to the feet based on the total number of sq cm of ulcer size that received the CTP. Because many of the patients had non-healing ulcers on the same anatomic location, the office incurred a sizable Medicare repayment for this error.

• Reading and understanding the descriptions and guidelines for modifiers is as important as understanding code descriptions and guidelines. The two scenarios described above were perfect examples of using modifiers when they should not have been used. However, the modifier that caused the largest repayment was Modifier 25. As mentioned above, the coders were used to billing an E/M code for every family practice visit. Therefore, when the physician performed a minor procedure, the coders thought they should apply Modifier 25 to the E/M code. However, they failed to read the definition of Modifier 25 carefully and to learn the guidelines for its use. Because minor procedures include the E/M procedures performed, and because Modifier 25 should only be used when the physician identified and managed a separate new problem during the same encounter when a minor procedure was performed, the post-payment audit identified that the coders incorrectly billed an E/M with Modifier 25 on nearly every visit. That repayment was significant.

By the end of the teleconsultation, the physician, coders, and billers learned that they should spend more time reading the code definitions and learning the coding guidelines. The physician also learned the importance of thoroughly documenting her work. Because she is performing excellent work and achieving excellent outcomes, she can have a successful business if she and her coders and billers pay attention to code descriptions and guidelines. The entire team was thankful for the education and only wished they had requested the teleconsultation before they began seeing wound/ulcer patients in the office.

Summary

When I finished this teleconsultation, I felt sad because the physician’s financial loss and Medicare repayment could have been prevented. Therefore, here are 2 learning lessons for all readers:

1. If you are starting a new wound/ulcer management business, or if you are adding a new procedure to your existing business, read all the code descriptions and coding guidelines for the work you intend to perform—before you perform the work.

2. If you are unsure about the unique wound/ulcer management coding, coverage, and payment details, seek appropriate training. There is no shame in admitting that you need assistance, and the cost of training is small compared to financial losses and repayments that can occur.

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@bellsouth.net.