Business Briefs: Potpourri of Reimbursement Facts & Reminders

Autumn brings with it a potpourri of flowers, colors, and aromas. As this author researched and prepared for this month’s Business Briefs column, it became apparent that there is too an assortment of reimbursement facts to share at this point of the year. Although the facts are disconnected from one another, together they should provide a healthy palette of reimbursement reminders to help wound care providers and program directors end 2016 on a compliant note and prepare everyone for a sound revenue cycle in 2017. So, let’s begin. 

Fact No. 1: Evaluation & Management (E&M) and Clinic Visits

Some qualified healthcare professionals (QHPs; eg, physicians, nurse practitioners, podiatrists, physician assistants, clinical nurse specialists) and wound care hospital-based outpatient departments (HOPDs) mistakenly believe they can code and bill Medicare for an E&M/clinic visit at each encounter regardless of whether or not a procedure is performed. Nothing can be further from the truth. 

To qualify for an E&M/clinic visit on the same day as a procedure, the QHP must address a significant, separately identifiable new service. Many QHPs and HOPDs report they are getting paid for both (E&M/clinic visit and procedure) even if they did not manage a new service; therefore, they intend to continue coding and billing for both at every encounter. What they do not realize is that to obtain this type of improper payment for an E&M/clinic visit and procedure during the same encounter, the claims are submitted with Modifier 25 appended to the E&M/clinic visit code. That modifier causes claims to be paid. However, Modifier 25 says to the payer “please audit me and read my documentation – you will clearly see that a significant, separately identifiable new service was provided.” If the medical record does not justify a separate E&M/clinic visit, repayments (sometimes triple damages) can be expected.

A recent Comprehensive Error Rate Testing improper payment report¹ showed E&M/clinic visits account for 10.2% of the overall Medicare fee-for-service improper error rate. This translates into about $4.6 billion. The biggest culprit is lack of documentation (eg, the documentation did not support a significant, separately identifiable new service; documentation did not support the level of E&M/clinic visit coded and billed; documentation did not include a physician signature; documentation from the HOPD and QHP were not maintained or did not align, etc.).

HOPD staff and QHPs should remember that nearly every wound care procedure has some E&M built into it. This time of year is a great time to 1) review the Medicare Learning Network’s E&M guidelines,¹ 2) review Medicare Administrative Contractor E&M local coverage determinations/handbooks/webinars, and 3) review the top 20 private-payer contracts and medical policies that pertain to E&M/clinic visits. After completing this review, make a resolution to only bill E&M/clinic visits during the same encounter as procedures when appropriate, according to the payer’s guidelines.

Fact No. 2: Smoking Cessation Counseling

Due to the detrimental effects of smoking on wound healing, many governmental and private payers are basing coverage for various procedures and products on the patient’s cessation of smoking. The May 2016 edition of Business Briefs provides a thorough review of coding, payment, and coverage for smoking cessation counseling.² This article also reviews two sets of codes: 99406/99407 for billing smoking and tobacco cessation counseling services to symptomatic individuals, and G0436/G0437 for billing tobacco cessation counseling services to prevent tobacco use by asymptomatic patients.

REMEMBER: Just as the season’s colors change, so do codes. Effective Sept. 30, 2016, CMS deleted G0436 and G0437. The services previously represented by these codes should be billed under existing codes 99406 and 99407. HOPDs should inactivate G0436/G0437 in their charge description masters for smoking cessation counseling provided on or after Oct. 1, 2016. 

Fact No. 3: National Correct Coding Initiative (NCCI) Edits for Debridement

When QHPs and HOPDs are considering new services, procedures, and technology, they frequently ask the sales representatives if they can code and bill it during the same encounter that debridement is performed. The first problem with that question is that QHPs and HOPDs should never ask sales representatives reimbursement questions. The sales representatives should be the “go to” professionals for clinical and technical knowledge about the services, procedures, and technology they represent. Sales representatives are not trained reimbursement specialists. The second problem with that question is that it indicates QHPs and HOPDs may not be regularly referring to the NCCI Policy Manual for Medicare Services (NCCI Policy Manual) and NCCI files on the CMS website (www.cms.gov) for their code pair answers. The NCCI files include three types of edits:

1) NCCI Procedure-to-Procedure (PTP) Edits

PTP edits prevent inappropriate payment of services that should not be reported together. Each edit has a Column 1 and Column 2 Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT^®) code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column 1 code is eligible for payment, but the Column 2 code is denied unless a clinically appropriate NCCI-associated modifier is also reported.

2) Medically Unlikely Edits (MUEs)

MUEs prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances reportable by the same provider for the same beneficiary on the same date of service. (See the Reimbursement Update at right for more news about MUEs.) 

3) Add-on Code Edits

Add-on code edits consist of a listing of HCPCS and CPT add-on codes with their respective primary codes. An add-on code is eligible for payment if (and only if) one of its primary codes is also eligible for payment. Previous editions of Business Briefs and other Today’s Wound Clinic articles have included information about NCCI edits in numerous issues.^3-5 These articles should remind readers that CMS annually updates the NCCI Coding Policy Manual, which is a general reference tool that explains the rationale for NCCI edits. In addition, CMS updates the actual NCCI edit⁶ files on a quarterly basis (on Jan. 1, April 1, July 1, and Oct. 1).

Debridement Edits

If you’re asking yourself, “Why is it currently so important to discuss the NCCI edits again?” the answer is quite simple: The Oct.1, 2016, NCCI edits include more debridement edits! Many of the more than 42,000 new code pair edits bundle 14 debridement codes (11000-11001 — debridement of infected skin; 11004 — debridement of genitalia and perineum; 11005 — debridement of abdominal wall; 11006 — debridement of genitalia/perineum/abdominal wall; 11042-11047 — surgical debridement; and 97597-97598 — medical debridement) into many surgical and medical procedures. In these cases, CMS will not pay for debridement on the same anatomic location as the primary procedure in Column 1 of the NCCI edits. For example, surgical debridement of muscle and bone is bundled into the skin-replacement surgery codes (15271-15278), which are in Column 1 of the NCCI edits.  

In addition, numerous other new procedures are bundled into the debridement procedures. For example, additional casting and strapping procedures are new components of debridement procedures that are in Column 1 of the NCCI edits. These new edits align with the NCCI edits that have been in place for years and are described in the NCCI Policy Manual: “Debridement CPT codes (eg, 11042-11044, 97597) and grafting CPT codes (eg, 15040-15776) should not be reported with a casting/splinting/strapping CPT code (eg, 29445, 29580, and 29581) for the same anatomic area.” Since debridement is a major part of wound care, all QHPs and HOPDs should pay close attention to all NCCI edits in which debridement codes are the primary procedures listed in Column 1, and in which debridement codes are bundled into other procedures and are listed in Column 2 of the edits. 

Kathleen D. Schaum & Associates Inc., Lake Worth, FL; and director, medical products, reimbursement, biotherapeutics at Smith & Nephew.    

References

1. The Supplementary Appendices for the Medicare Fee-for-Service 2015 Improper Payments Report. U.S. Department of Health & Social Services. Accessed online: www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/cert/cert-reports-items/downloads/appendicesmedicarefee-for-service2015improperpaymentsreport.pdf

2. Schaum KD. Business briefs: smoking cessation counseling: coding, payment, & coverage. TWC. 2016;10(5):8-11.

3. Schaum KD. Business briefs: what happened to the outpatient prospective payment system status indicators this year? TWC. 2016;10(9):6-10. 

4. Schaum KD. Medicare payment trends & tips. TWC. 2015;9(2):7-11.

5. Schaum KD. Business briefs: E&M codes with procedures & NCCI edits dominated discussions at SAWC. TWC. 2013;7(8):6-8. 

6. Centers for Medicare & Medicaid Services. National Correct Coding Initiative Edits. Accessed online: www.cms.gov/medicare/coding/nationalcorrectcodinited/index.htm