How Does Reimbursement Change With Wound Care Certification?

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information 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. 

Certified wound care professionals are one of the best-kept secrets in the medical industry. They simply do not receive enough credit and recognition that they deserve for the life- and limb-saving care they provide to chronic wound patients. Certification is important to obtaining the coveted positions that these individuals hold, not to mention the salary increases that they are certainly entitled to. Unfortunately, these professionals do not always receive adequate reimbursement education as part of their expert wound care training. As a result, there are many misperceptions about what wound care certification means to the payers. In fact, this author receives many reimbursement questions from professionals who have recently earned their wound care certification. As part of this careers edition of Today’s Wound Clinic, this Business Briefscolumn will share the most frequently asked questions (FAQs) about reimbursement that newly certified wound care professionals tend to have. 

CERTIFIED NURSE FAQs

I have received my certification and would like to open my own practice. Which codes can I use to bill Medicare and private payers for my wound care services?

Wound care certification is a wonderful milestone. Unfortunately, nurses (yes, even when they hold certification in wound care) are not a billable service in the Medicare program. Therefore, wound care nurses would not have a way to bill Medicare if they opened their own practice. However, certified nurses may be able to contract with private payers. In these cases, the private payers and the nurses will agree upon the codes that should be reported on their claims and the contracted payment rates for those codes.  

How much does an acute care hospital and a hospital-owned outpatient wound care provider-based department (PBD) get paid by Medicare for wound care services provided by nurses who are certified?

Acute care hospitals do not receive a separate Medicare payment for the services of their certified nurses. Medicare pays the hospital a flat rate based on the Medicare severity-diagnosis related group (MS-DRG) that aligns with the diagnosis(es) of each patient. That flat payment rate includes all hospital staff members, including certified wound care nurses, who are included on the hospital cost report. Likewise, PBDs do not receive a separate Medicare payment for the services of certified wound care nurses. Instead, Medicare pays the PBD a facility fee for the work performed during each patient’s PBD encounter. That fee includes the certified nurses and other PBD staff members who are included on the hospital’s cost report. 

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CERTIFIED PHYSICIAN FAQs

I am newly certified in wound care and would like to work in a hospital-owned outpatient wound care PBD. During my job interview, I was informed that patients will receive two bills when I provide care in the PBD. Is that correct, and, if so, can I prevent the patient from receiving two bills if I become an employee of the PBD?

Yes, that is correct. When a physician cares for a patient in a PBD, the patient and the payer receive two bills: one from the physician and one from the PBD. If a physician becomes an employee of the PBD, the physician will receive a contracted salary. In addition, the physician will give the PBD permission to use his/her National Provider Identification (NPI) number. The PBD will submit claims with the NPI for work the physician performs in the PBD and will keep that payment. The PBD will also submit facility claims for the same patient encounter and will keep that payment. Therefore, the physician cannot prevent the patient and the payer from receiving two bills by becoming an employee of the PBD. The only ways the physician can prevent the patient from receiving two bills are: 1) not personally see the patient in the PBD or 2) to see the patient in a physician office rather than a PBD.

I am a certified wound care physician who recently began providing wound care services in a hospital-owned outpatient wound care PBD. Because the PBD is staffed with certified wound care nurses, I often write orders for them to perform procedures such as application of an Unna’s boot or application of negative pressure wound therapy (NPWT) pumps and dressings. I have been informed that I cannot bill for those procedures that I ordered. Is that true?

Yes, that is true. When a certified physician performs work outside of his/her office, the physician should only bill for the procedures he/she performs. For example, in a PBD, if a certified physician examines a patient and writes an order for the certified nurse to apply an Unna’s boot, the physician should code and bill for the appropriate level of evaluation-and-management service. The PBD should code and bill for the application of the boot. Some PBDs and physicians mistakenly believe that their claims must be identical for each patient encounter. It is true that the patient’s diagnosis(es) on both claims should match, but the services/procedures are not required to match (and often do not match). In fact, when the Outpatient Prospective Payment System (OPPS) was released, the Centers for Medicare & Medicaid Services (CMS) told the PBDs that CMS does not expect the claims of the PBDs and physicians to always be identical.    

As a newly certified wound care physician, I am confused about hospital-owned outpatient wound care PBD coding and billing of Medicare for the work of certified wound care nurses. For example, when I write an order for certified nurses in an acute care hospital to apply an NPWT pump and dressing, they can implement the order even after I depart from the hospital premises. However, when I write the same order for a certified nurse in a PBD, I am told that the PBD cannot perform the work unless another physician or qualified healthcare professional (QHP) is immediately available in my absence to provide direct supervision. Please explain.

The acute care hospital and the PBD receive their Medicare payments based on different payment systems. The acute care hospital MS-DRG payment system assumes that the hospital always has a physician or other QHP available to provide direct supervision when needed.  Therefore, the wound care nurses can implement your orders after you leave the hospital premises. The PBD’s OPPS, which is also the Medicare payment system for the emergency department (ED), requires direct supervision for all services/procedures, except those that have been specifically reviewed and moved to general-supervision requirements. The application of NPWT pumps and dressings is not one of the general-supervision exceptions. Therefore, another physician or QHP must be immediately available when a nurse applies and bills for the application of NPWT. The only wound care-related exceptions to the direct-supervision requirement are the application of an Unna’s boot, the application of high-compression bandage systems, and smoking cessation sessions.  

The outpatient wound care PBD where I work is very strict about posting a schedule for the wound care-certified physicians/QHPs who work in the department. If a physician/QHP does not show up for work, the PBD program director cancels all the patients for that period, unless the reason for their appointment is to have an Unna’s boot or high-compression bandage applied, or to have a smoking cessation counseling session. I am surprised at the program director’s stance on this issue. With all those certified nurses in the PBD, why does she reschedule the patients’ care?

Hospital PBDs, like EDs, are always required to have direct supervision when patients receive wound care (except for the services mentioned in the question at hand). When the physician/QHP who is scheduled to provide the direct supervision does not show up for work, and when no other physician/QHP is available to provide the direct supervision, the program director has no choice but to reschedule the patients. This direct-supervision rule is the reason the ED must be staffed by a physician 24/7.

CERTIFIED NURSE PRACTITIONER FAQs

I am a newly credentialed nurse practitioner (NP) who is also certified in wound care. Because we did not receive much reimbursement education in either program, I have several questions: 1. Can an NP provide and receive Medicare payment for the same wound care services as physicians? 2) Is it true that the Medicare Physician Fee Schedule (PFS) allowable rates for NPs are 85% of the allowable rates for physicians? 3) If an NP is employed by a physician office, whose NPI number should be submitted on the Medicare claim? 4) If an NP is employed by a physician office and provides wound care services to patients in wound care PBDs, can the office use the physician’s NPI number on the Medicare claims? 5) Can an NP provide direct supervision in a hospital PBD?

An entire book could be written about NP coding, payment, and coverage! Because these questions contain many moving parts, we will discuss each separately: 

1. Wound care-certified NPs must consider several other requirements, including the respective state’s practice act, the respective facility’s bylaws, one’s hospital privileges (remember that some wound care procedures are considered “surgical” procedures), the Medicare Administrative Contractor’s local coverage determinations and articles, and any private-payer contracts (to name a few examples). Before providing and billing for any wound care services, NPs should research the pertinent guidelines and obtain the appropriate facility privileges, etc. 
2. Yes, if NPs bill under their own NPI number, their Medicare allowable rate is 85% of the physician’s allowable rate. However, in appropriate circumstances, when the NP’s work is reported under the physician’s NPI, the office practice’s Medicare allowable rate will be 100% of the Medicare PFS. 
3. Several options exist when an NP is employed by a physician office.
   • If the physician personally performed the initial service and remains actively involved in the course of treatment, and the NP conducts follow-up examinations while the physician is in the office suite (but does not perform a service for the patient), the office should include the physician’s NPI on the original examination claim and has a choice of using either the physician’s NPI or the NP’s NPI on the follow-up examination claim.
   • If the NP conducts the original examination, the office should include the NP’s NPI on the claim.
4. “Incident to” billing by NPs employed by physician offices is not acceptable in PBDs. Therefore, for those patient encounters, the office must use the NP’s NPI and place-of-service code 22 on the Medicare claim. 
5. In general, NPs can provide direct supervision in hospital PBDs. However, NPs should review all the references and guidelines itemized in answer No. 1 of this question. For example, some states may not allow an NP to perform certain wound care services/procedures (eg, hyperbaric oxygen therapy supervision). In these cases, NPs cannot provide direct supervision for services/procedures that they cannot perform. 

CERTIFIED PHYSICAL THERAPIST FAQs

Our hospital does not have an outpatient wound care PBD. Therefore, our wound care-certified physical therapists (PTs) provide some wound care when it is part of a therapy plan of care. Can our outpatient rehabilitation department bill Medicare a separate facility fee when those PTs provide wound care?

No, outpatient rehabilitation services are paid by the Medicare PFS at the non-facility rate. Therefore, the rehabilitation department cannot bill a separate facility fee. Only hospital-owned outpatient departments paid by the OPPS can bill a separate facility fee. 

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