Business Briefs: Application of Compression: Medicare Coding, Payment, & Coverage

Information regarding coding, coverage, and payment is provided as a service to our readers. HMP Communications and the authors 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 information accuracy lies with the reader.   One of the most confusing wound care reimbursement subjects pertains to the application of compression devices such as Unna Boots, multilayer high compression bandage systems, and total contact casts. Let’s take a look at the coding, Medicare payment, and Medicare coverage rules and try to make some sense out of this complicated subject. After reading this article, readers should clearly understand the correct code to use for application of the various forms of compression, understand the importance of identifying whether a National Correct Coding Initiative (NCCI) edit exists when compression is applied on the same anatomic location where another procedure was performed, and understand the importance of checking to see if the patient’s payer has a coverage policy that pertains to the application of compression.

Application Coding

  As more clinical evidence (surrounding use of compression to manage ulcers caused by venous insufficiency and lymphedema) has been published, the American Medical Association has responded by creating new codes and by refining existing codes for the application of the various forms of compression. Table 1 (page 8) presents an overview of the Current Procedural Terminology (CPT®) code changes for these procedures. Wound care professionals and revenue cycle personnel, should use correct codes and definitions of these procedures in documentation, electronic medical records, coding, super bills/charge description masters, billing, etc. Now is a good time for providers to conduct an audit that verifies correct use of these compression codes.

Application Payment By Medicare

  Table 2 (page 9) presents a comparison of the 2012 national average Medicare payment rates for the application of the various forms of compression when performed by physicians in their offices and in facilities. Table 3 (page 9) presents the 2012 national average Medicare payment rates for hospital-based outpatient wound care departments (HOPDs) when one of the application procedures is performed in their facilities. Wound care professionals and wound care revenue cycle teams should adjust their charges to represent the true cost of performing these procedures.   During tele-consultations with wound care physicians and HOPDs, this author is often asked the two following questions that pertain to billing for compression procedures:   Q: Should the physician bill Medicare for the application of compression if the physician ordered it, but the wound care nurse applied it?   A: “Yes,” if:     • The physician is physically present in his/her own office suite;     • The physician purchased the compression device;     • The work is in the scope of practice of the professional who is applying the compression device and that person is working “incident” to the physician; and     • The compression procedure is not in Column 2 of the Center for Medicare & Medicaid Services’ NCCI edit table. (See “Explaining NCCI Edits” on page 9.)   A: “No,” if:     • The physician orders the work to be performed by the HOPD staff. In this case, the HOPD should bill for the application of the compression and the physician should bill for the service or procedure that he/she performed during that visit.   Q: Can the HOPD bill Medicare for the application of compression on the same day that it bills for a clinic visit or for another procedure, such as surgical debridement, selective debridement, non-selective debridement, skin substitute graft, or hyperbaric oxygen?   A: Let’s begin with a CAUTION: Do not ask this question to sales representatives. They are product experts, not reimbursement experts. Instead, wound care professionals should obtain the answers to Medicare coding and billing questions from the:     1. Current year’s CPT Current Procedural Terminology manual     2. Current year’s CPT Changes: An Insider’s View book     3. Current quarter’s NCCI edits for physicians     4. Current quarter’s NCCI edits for HOPDs that are imbedded in the Outpatient Code Editor     5. Medicare Administrative Contractor (MAC) that processes your Medicare claims: via Local Coverage Determinations (LCDs) and/or articles, or via an e-mail question to the MAC medical director     6. Other third-party payers, (eg, Medicaid, worker’s compensation, AETNA, CIGNA, etc.) via their medical policies and/or via insurance benefit verification/prior authorization.

Explaining NCCI Edits

  The purpose of the automated prepayment NCCI edits is to prevent improper Medicare payment when incorrect code combinations are submitted together for Medicare Part B-covered services.   NCCI edits are updated quarterly (Jan. 1, April 1, July 1, and Oct. 1) and can be found online by visiting www.cms.gov/nationalcorrectcodinited. See the links “Quarterly NCCI and MUE (Medically Unlikely Edits) Version Update Changes” and “NCCI Coding Edits.” NOTE: If you do not find an edit listed, both procedures/services performed at the same visit may be billed to Medicare if both procedures/services are medically necessary.   For each service type or code range, you will find 2 tables of edit pairs:     1. Column 1/2 NCCI edits     2. Mutually exclusive code edits   In either case, both tables are comprised of code pairs labeled as Column 1 and Column 2. If a provider submits the 2 codes of an edit pair to Medicare, the Column 1 code is eligible for Medicare payment and the Column 2 code is denied. However, if both codes are clinically appropriate and an NCCI-associated modifier is used, the codes in both columns are eligible for Medicare payment. Supporting documentation must be in the beneficiary’s medical record. NOTE: In the case of compression, in Medicare’s opinion, “clinically appropriate” is defined as “was performed on a separate anatomic location.”   The second step, to determine whether a certain compression CPT code is eligible for payment on the same date as another service or procedure, is to simply search Column 1 for the CPT code of the major service or procedure, then scroll down to see if the compression code is in Column 2.     • Column 1 indicates the payable code.     • Column 2 contains the code that is not payable with this particular Column 1 code, unless a modifier is permitted and submitted.     • Column 3 indicates if the edit was in existence prior to 1996.     • Column 4 indicates the effective date of the edit (year, month, day).     • Column 5 indicates the deletion date of the edit (year, month, day).     • Column 6 indicates if use of a modifier is permitted to override the edit:         0 (Not Allowed): No modifiers associated with NCCI are allowed to be used with this code pair; there are no circumstances in which both procedures of the code pair should be paid for the same beneficiary on the same day by the same provider.         1 (Allowed): The modifiers associated with NCCI are allowed with this code pair when appropriate.         9 (Not Applicable): This indicator means that an NCCI edit does not apply to this code pair. The edit for this code pair was deleted retroactively.   See Table 4 (page 9) to view the actual 4th quarter 2012 NCCI edits for the following example: The physician wants to know if the application of a multilayer compression bandage system (29581) is eligible for Medicare payment on the same date that the physician surgically debrides subcutaneous tissue (11042) from a venous stasis ulcer on the same anatomic location. NOTE: The physician will be eligible for payment for both procedures, if the NCCI edit table does not show an edit. Therefore, the physician should go to the NCCI edit table and search 11042 in Column 1 and 29581 in Column 2. Unfortunately, the NCCI edit table does include an NCCI edit for this code pair. The edit has a modifier of “1,” which means the procedures can only be reported together if they are performed on different anatomical locations. Because the example is for procedures performed on the same venous ulcer, the physician and/or HOPD can only bill Medicare for 11042. NOTE: The NCCI edits are unique to the Medicare program. Therefore, private payers may pay for these two procedures when performed together. For example, the CPT Assistant dated May 2011 states that 29581 should be reported separately from 97597 and 97598 when performed at the same visit on the same anatomic location. Providers should verify this during insurance benefit verification/prior authorization.   CAUTION: NCCI edits do not include all possible combinations of correct coding edits or types of bundling that exist. Wound care professionals are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination.

Application Coverage By Medicare

  As discussed many times by this author:     • The existence of a code does not guarantee Medicare payment and Medicare coverage.     • The existence of a code and a separately payable Medicare payment rate do not guarantee Medicare coverage. Therefore, we must now turn our attention to the MAC LCDs and articles that pertain to compression.   Table 5 provides an overview of the LCDs and/or articles (in existence on Nov. 1, 2012) that provide coverage guidelines for 29445, 29580, and 29581-29584. As you can see, the MACs have not chosen to provide many coverage guidelines for these procedures. If your MAC has written an LCD and/or article, all members of your clinical and financial team should read the document(s). If your MAC has not written an LCD and/or article, their coverage will be based upon medical necessity. In that case, coverage will be based entirely on the clarity of the physician’s diagnosis and documentation. Although Medicare does not provide prior authorization, your MAC medical director may answer physicians’ questions (via e-mail) about specific scenarios: the physician should clearly describe the scenario, then e-mail it to the MAC medical director.   Private payers may also write medical policies regarding compression coverage. Many private payers display their medical policies on their websites. Others may provide their medical policies upon request. In addition, providers should inquire about coverage for the application of compression when conducting insurance benefit verification. If the private payer requires prior authorization, providers should complete the process before performing the compression procedure. Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She may be reached for questions and consultations by calling 561-964-2470 or at kathleendschaum@bellsouth.net.