Business Briefs: Top 10 Concerns: Challenges to Consider as You're Getting Started

  Several times a week, wound care professionals call with questions about their wound clinics. Following are the top 10 questions that were asked in 2006 — common concerns among wound care centers. We present these questions as reassurance: if you have these dilemmas, you are not alone.

  ■ I am a wound care nurse/physical therapist/nurse practitioner in an acute care hospital. The physicians are encouraging the hospital administrator to open a hospital-owned outpatient wound care center (a hospital-owned outpatient department — HOPD). I have been assigned to open the HOPD in 1 month.The 1-month deadline is a nearly impossible goal, even if I only have to establish the clinical processes for the HOPD. I do not believe that I can accomplish that part of the assignment by myself because I have not been trained in the business side of wound care.Will you please advise me if the 1-month deadline is realistic? Can you guide me in setting up the business processes for the HOPD?

  ■ I am the program director of an HOPD that opened 9 months ago. Last week, the vice president to whom I report announced that the HOPD has lost money every month since it opened. I do not receive any financial reports that keep me informed about revenue collected, denied claims, or other financial pitfalls. Will you help me evaluate if we are coding appropriately and why we are not receiving adequate payment for our work?

  ■ Medicare has denied nearly all of our billed clinic visits ever since we opened the HOPD 3 years ago. Unfortunately, I just learned about this situation. Will you help us identify why?

  ■ I am the medical director of an HOPD that provides care to patients from three surrounding states. Their wounds often have been managed with a multitude of simple dressings, such as saline-moistened gauze. Many of the patients now require advanced wound care procedures and products. Unfortunately, the HOPD program director is resistant to purchasing advanced wound care products. She claims that the patient will have co-payments for these products and their accompanying procedures. I thought Medicare patients were charged co-payments for all visits and procedures, not just advanced procedures and products. Will you please explain the Medicare co-payment regulations to me?

  ■ We use numerous advanced wound care drugs, dressings, biologics, and procedures in our HOPD. However, our compliance officer, who is responsible for the chargemaster, will only allow us to include clinic visits on our chargemaster. Will you verify if this is correct?

  ■ An outside durable medical equipment (DME) supplier provides and bills Medicare Part B for the surgical dressings patients use at home between HOPD visits. The supplier tells the patients to bring the dressings to our HOPD for us to use on the day of their clinic visit. Our program director is pleased with the arrangement because she is always under pressure to reduce expenses. I recently read that departments paid by Medicare under the Ambulatory Payment Classification (APC) system are expected to purchase and supply surgical dressings used on the day of the clinic visit. Will you please clarify whether the HOPD should be purchasing the surgical dressings used on the day of the patient’s HOPD visit or if we can continue using the dressings that patients bring from home?

  ■ The physicians who practice at our HOPD nearly always bill for 11042 Debridement; skin, and subcutaneous tissue even if they simply remove some fibrin with forceps. The staff of the HOPD believe the facility should bill either 97597 Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure water jet/without suction, sharp selective debridement with scissors, scalpel, and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 cm2 or 97598 for total wound(s) surface greater than 20 cm2, depending on the size of all the wounds treated during the clinic visit. The problem could become that the procedure billed by the physician and by the HOPD will differ.Will you please verify if that is acceptable?

  ■After a Medicare audit, our HOPD had to repay Medicare for all of the claims where 29580 Strapping; Unna boot was coded and billed for the application of a multilayer, sustained high-compression bandage system. Our Medicare contractor released a Local Coverage Determination (LCD) disallowing 29580 for compression bandage systems that do not contain zinc paste. Our HOPD had no idea that the LCD existed. Will you help us identify other LCDs that apply to our wound care business?

  ■ When our physicians write orders for surgical dressings and for negative pressure wound therapy pumps, the DME suppliers frequently call and say the physician did not supply adequate information to prove medical necessity for the ordered product(s). Will you help us find and learn the guidelines for justifying the medical need for the various products we order for our patient's use at home?

  ■ Our HOPD opened 6 months ago. We were told to bill the same clinic visit level as the physician bills, which we have done for the past 6 months. Recently, we were audited and told that we need to write our own clinic visit level mapping system. Will you please verify if this is really an HOPD requirement?

 Whether you are contemplating development of, just launching, or working in a mature HOPD, correct coding, coverage, and payment are paramount to your business success. These top 10 questions are an indication that proper attention to “getting started” is vital to the success of your wound business. As the HOPD matures and coding, coverage, and payment rules change, you must continually update your business as if you were getting started anew each year.

 “In Business” will cover these and other timely real-life coding, coverage, and payment scenarios that are pertinent to HOPDs at all levels of maturity. Guest authors will be invited to offer guidance in their areas of expertise. If you or your co-workers have any coding, coverage, and payment questions or topics that you would like to see covered in the column, please e-mail them to: kathleendschaum@bellsouth.net. We will include the most requested questions and topics in future columns.

  For now, please see Table I for some important tips to help you get started with developing or improving your HOPD.

  Kathleen D. Schaum, MS, is President of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net.

  Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.