Answers to Questions Following the ‘How Do I Get Paid for That?’ SAWC Fall 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.

The attendees at this SAWC Fall session learned that the answer to the question, “How do I get paid for that?” entails more than just knowing the pertinent code for the service, procedure, and/or product. They learned that reimbursement is comprised of 3 parts: coding, coverage, and payment.

In addition, they learned the answer could vary in different scenarios. These include: Payment changes depending on the exact work performed, who performed the work, the place of service where the work was performed, if the work was performed during the same encounter with another procedure, if the work was medically necessary, if the work was covered by a particular patient’s insurance, the relevant code and code description, global surgery indicators, the outpatient prospective payment system (OPPS) status indicators, the National Correct Coding Initiative Procedure-to-Procedure (PTP) edits, the allowable payment rates, consolidated billing payment systems, and much more.

This author/speaker used well-known procedures (applications of negative pressure wound therapy (NPWT); disposable and durable medical equipment (DME)) to explain  how payment performed in physician offices and in hospital-owned outpatient wound/ulcer management provider-based departments (PBDs) depends on more than using the correct code. At the end of this presentation, the attendees were challenged to use the same thought processes to determine how they will get paid for any service or procedure they perform, and/or product they manufacture.

Like all virtual SAWC Fall sessions, this author/speaker answered questions during the time allotted for Q&As and agreed to address any unanswered questions in this month’s Business Briefs column. Questions were submitted by wound/ulcer management professionals who work in various places of service, manufacturers, and wound management companies. Their questions are perfect examples of the scenario specificity that is required before we can answer “How do I get paid for that?”

Q:

Coding software does not always align with Medicare assigned codes. Is there a common process to inform all coding software companies about mistakes in their software? For example:

Cellular- and/or tissue-based products (CTPs) for skin wounds must be assigned a HCPCS code by the Centers for Medicare & Medicaid Services (CMS). Because CTPs are typically packaged (into the Medicare payment for the application of high cost or low cost CTPs) for hospital outpatient PBDs paid by the OPPS and for ambulatory surgery centers (ASC), the CMS specifies the high cost or low cost CTP package assignments in each year’s Final Rule. If the manufacturer of the product presents the CMS with cost information that changes the packaging assignment, that information is released via the quarterly OPPS and ASC updates. All the details in the Final Rules and quarterly updates are not always included in coding software and electronic health record (EHR) databases.   

A:

For many years, this author/speaker has been educating wound/ulcer management stakeholders that coding software and EHR databases are not always correct. Because digital tools impact claim submission, one would expect these companies to have teams of people who review and update their software with all the pertinent coding, payment, and coverage regulations, changes, additions, deletions, etc. to align the updates with the implementation dates determined by Medicare. As one can see from this attendee’s question and excellent example, the software companies do not always make these changes in a timely basis. In fact, some software companies only list products and make changes if manufacturers pay them to do so. Unfortunately, manufacturers cannot go to one software clearinghouse to get products listed or changes made to these digital tools: they must be handled one vendor at a time. Following are a few recommendations for providers, professionals, and/or manufacturers who learn about coding software and EHR database errors:

•    Gather the appropriate information needed to request database corrections, e.g. information from Final Rules, quarterly OPPS and ASC updates, communications from the CMS and from the Medicare Administrative Contractors (MACs) who process claims for the service, procedure, or product in question.

•    If you are a provider or professional who has purchased the software, identify the process for requesting database corrections, request immediate changes (with supporting reference) for issues that have already been implemented by Medicare, and follow up if the changes are not made in a timely manner—after all, you are paying to use software that is supposed to be correct and that should not lead to claims denial or false claims.

•    If you are a manufacturer, request that your reimbursement hotline team contacts the vendor to learn the person who oversees making database corrections and their process for making corrections, to request the corrections with supporting references, and to follow up until the corrections are made.

Q:

Many of our hospital-owned outpatient wound/ulcer management PBDs do not typically receive clinic visit reimbursement from their private payers. Is it acceptable for the PBD to report 97602 for clinic visit services when no professional service is rendered?

A:

Before we discuss codes, we must address the underlying problem. PBDs must work with the contract manager of their hospital system to make contract revisions during the designated time periods when revisions are permitted. Keep two things in mind: 1) when a health system opens new departments/services, they can usually amend their private payer contracts, and 2) all outpatient departments/services should not have the same contract terms, e.g. the coding and payment terms for emergency departments, wound/ulcer management departments, and diabetic education departments should not be the same because they offer very different services.

Now let us discuss the coding issue. First, the portion of the question that stands out is “when no professional service is rendered.” If a professional did not assess the patient during that encounter and there was no order for the staff to perform a procedure during that encounter, then the PBD staff may have been seeing the patient for a “dressing change.” Remember, that dressing changes are not deemed medically necessary services by Medicare or private payers. If patients and/or their caregivers do not wish to change their dressings at home, then the PBD should charge them for this non-covered service. Second, 97602 should only be reported when the physician or other qualified healthcare professional wrote an order for the PBD staff to perform removal of devitalized tissue from the wound(s), non-selective debridement, wound assessment, and instructions for ongoing care. The code 97602 is not for dressing changes. Therefore, 97602 is not interchangeable with 99201–99215 and G0463.

Conclusion: Using an inappropriate code is not the solution to this problem. The only solution is to amend the contract between the private payer and the health system.

Q:

Does Medicare review regional utilization of disposable negative pressure wound therapy (dNPWT) to identify where the wage index of the hospital owned outpatient wound/ulcer management PBDs is so low that the PBDs cannot afford to provide dNPWT?

A:

Medicare does not conduct such a review. However, keep in mind that each PBD’s allowable Medicare payment rates are unique to that one hospital. You cannot assume that PBDs in the same region, even those across the street from each other, have the same Medicare allowable rates. Also keep in mind that physician offices and home health agencies can also receive Medicare payment for the application of dNPWT; their rates may be adequate to cover the cost of the application of dNPWT.

Q:

Can a continuing care retirement community bill Medicare for the work of their employed wound care nurse who recently received certified wound specialist (CWS) certification?

A:

No, the work of wound care nurses, even if they are CWSs, is not a billable service to Medicare. Nursing services are included in the services and procedures billed by their employer/entity under the Medicare program. For example: Medicare pays skilled nursing facilities (SNFs) a patient-driven payment model consolidated rate that includes the wound care nurse; and Medicare pays physician/nurse practitioner offices/clinics a Medicare Physician Fee Schedule allowable rate for the work performed by the wound care nurse that is “incident to” to the work and billed under the NPI number of the physician/nurse practitioner. NOTE: If the work is performed for a resident of a SNF, Medicare will not pay the physician/nurse practitioner if they perform services that are included on the list of consolidated billing services, e.g. selective debridement (97597), application of an Unna boot, (29580) or application of multi-layer compression bandages (29581). The physician/nurse practitioner must have a contract with the SNF and must bill the SNF for services on that list.

Q:

Will Medicare pay a hospital owned outpatient wound/ulcer management PBD to provide care to a patient during a 90-day global surgery period?

A:

The global surgery period only pertains to physicians and other qualified health care professionals who are paid by the Medicare Physician Fee Schedule. Because Medicare typically pays the hospital-owned outpatient wound/ulcer management PBD by the OPPS regulations, the global surgery period does not pertain to the PBD.

Q:

If a patient is in a 90-day global surgery period and develops a complication of the surgery, is the surgeon who performed the surgery responsible for that complication? Can the surgeon transfer the care of the complication to another physician?

A:

During the 90 days following the surgical procedure, the surgeon owns the responsibility to manage all medical or surgical services required of her/him because of complications.

The surgeon can transfer care of the postoperative complication to another physician, if both professionals agree to the transfer of care, and if there is a written transfer agreement (e.g. letter or annotation in discharge summary). On the surgeon’s claim for the surgical procedure, she/he appends modifier 54 to the CPT^® code that represents the surgical procedure performed.¹ Modifier 54 indicates the surgeon is turning over all or part of the postoperative care to another physician/QHP. The physician/QHP who agrees to assume the postoperative care appends modifier 55 to the CPT code that represents the surgical procedure that was performed by the surgeon and the date on which the postoperative care was assumed (in Item 19 of the CMS -1500 paper claim or the 2300 NTE Loop and Segment on the ANSI 837 electronic claim) after she/he provides one postoperative service.

Q:

What should be charged when the physician ordered the application of negative pressure wound therapy (NPWT) durable medical equipment (DME) on an ulcer on the left leg and the application of a surgical dressing to an ulcer on the right leg?

A:

This is an example of a question that needs additional information before it can be answered:
•    What was the place of service?
•    Who performed the work?
•    Was any other procedure performed during the encounter?
•    Was this a new or established patient?
•    Was the patient also receiving care in a SNF? If yes, was the patient in a Medicare covered Part A stay or in a non-covered Part B stay?
•    Was the patient also receiving care from a home health agency (HHA)?
•    Do you have contracts with the SNFs and HHAs that sent patients to you?

Because none of that information was provided in the submitted question, this author/speaker contacted the SAWC attendee who submitted the question and was surprised to learn that this work was performed by a physical therapist in an outpatient therapy department. The patient was new to the outpatient therapy department and was also a resident in a Medicare covered Part A SNF stay. The patient brought the NPWT DME and a new canister and dressing from the SNF. Once the physical therapist evaluated the patient and developed a therapy plan of care, the therapist cleaned the 30 sq cm ulcer on the left leg and reapplied the NPWT DME and the new canister and dressing. The correct code for that work is 97605. The physical therapist also selectively debrided devitalized epidermis and dermis (which was not disclosed in the original question) from an open 15 sq cm ulcer on the right leg and dressed the ulcer with a bordered foam dressing. The correct code for that work is 97597. Please note that 97597 also includes the assessment, the application of the surgical dressings, and any instructions given to the patient.

Believe it or not, there is more to consider about this scenario. Because the patient was in a Medicare covered Part A SNF stay, the therapist must also determine if 97605 and 97597 are included in the SNF consolidated billing, which can be determined by researching File 1 at this website: https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index. This file lists codes that can be separately billed by providers directly to their Part B Medicare Administrative Contractor (MAC) because the codes fall outside SNF consolidated billing. If the code for a service/procedure is not found in File 1, providers must bill the SNF under the terms of their contract, because their MAC will not pay separately for the codes. Neither 97605 nor 97597 are listed on the SNF consolidated billing File 1. Therefore, the outpatient therapy department should bill the SNF according to their contract. As luck would have it, this therapy department does not have a contract with the SNF. Therefore, they do not have any way to get paid for the work they already performed.

Q:

In a hospital owned outpatient wound/ulcer management PBD, when a physician performs surgical debridement (11042–11044) on an ulcer and applies a total contact cast (29445) to the same ulcer, will Medicare pay for both procedures?

A:

Medicare will only pay the PBD for the surgical debridement because the National Correct Coding Initiative edits consider the total contact cast as a dressing in this case, and dressings are always considered part of the procedure.

Q:

If a physician applies a multilayer compression bandage, will Medicare separately pay for a surgical dressing applied underneath the compression bandage?

A:

Similar to the previous question, Medicare will only pay the physician for the application of the multilayer compression bandage (29581). Any other surgical dressings applied underneath the compression bandage are considered part of the procedure and are not separately payable to the physician.

SUMMARY

By now you should understand that Medicare payment depends on more than submitting the correct code. Because these attendees’ questions focused on coding and payment, we did not have the opportunity to consider the coverage ramifications. But remember that reimbursement has 3 components: coding, coverage, and payment. All wound/ulcer management stakeholders must also determine the coverage criteria of the patient’s payer. A service, procedure, and/or product can only receive payment if it has a relevant code and if the patient’s condition meets the medical necessity coverage requirements.

Stay safe and be well during this holiday season. Let us hope we can meet in person at the 2021 Spring SAWC where this author/speaker will be honored if you attend the information-packed reimbursement session and reimbursement post-conference.

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.