Business Briefs: Reimbursement Reminders for a Successful 2010 – Happy New Year!

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  The 2009 Sept/Oct business column provided wound care clinics with a Reimbursement Reminder Calendar to help program directors and medical directors maintain positive financial outcomes. That was followed by the 2009 Nov/Dec business column that reviewed the 2010 Final Outpatient Prospective Payment System (OPPS) Medicare Rule regarding supervision in hospital-owned outpatient wound care departments (HOPDs). Over the past four months program directors and medical directors should have been very busy accomplishing all of the September through January reimbursement tasks that were listed on the Reimbursement Reminder Calendar. Following is a checklist of major tasks that you should have accomplished by January 1, 2010:

    • Update charge sheet and/or electronic health record (EHR) with pertinent new ICD-9-CM codes and/or ICD-9-CM codes that are listed in relevant Local Coverage Determinations (LCDs).

    • Update charge sheet and/or EHR with pertinent new/changed CPT® codes (CPT® is a registered trademark of the American Medical Association). For example: if you apply multi-layer compression systems that are not Unna boots, you will want to add 29581 (Application of multi-layer venous wound compression system, below the knee) into your coding and billing systems. The new code is assigned to APC group 0058 and has a national average payment rate of $71.03.

  CAUTION: Prior to 2010 some Medicare contractors only covered zinc paste Unna boots. Therefore, providers should not assume that 29581 will be covered. HOPDs should contact their Medicare contractor and other major payers to verify if 29581 will be covered.

    • Remove deleted HCPCS codes from your Charge Description Master (CDM) and your EHR – if you use those products. For example, HCPCS codes deleted on December 31, 2009:
      ˚ A6200
      ˚ A6201
      ˚ A6202
      ˚ A6542
      ˚ A6543

    • Review new/changed HCPCS codes and add them to your Charge Description Master (CDM) and your EHR – if you plan to use those products. For example:
      ˚ A6549 Gradient compression stocking/sleeve, not otherwise specified
      ˚ C9358 Dermal substitute, native, non-denatured collagen, fetal bovine origin, (Surgimend collagen matrix), per 0.5 square centimeters
      ˚ C9360 Dermal substitute, native, non-denatured collagen, neonatal bovine origin (Surgimend Collagen Matrix), per 0.5 square centimeter
      ˚ C9363 Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter
      ˚ Q4115 Skin substitute, Alloskin, per square centimeter
      ˚ Q4116 Skin substitute, Alloderm, per square centimeter

    • Become aware of the 2010 first quarter’s Average Sales Prices (ASPs) for the separately covered and separately payable skin substitutes that you use. Table I outlines the difference between the 4th quarter 2009 and the 1st quarter 2010 ASPs. The quarterly updates to the ASPs for HOPDs can be found on the Centers for Medicare & Medicaid (CMS) Web site in the OPPS Addendum A and Addendum B.

    • Update CDM with 1) billable supplies (including HCPCS codes) that the HOPD purchases and 2) billable procedures and services (including CPT® codes). that the HOPD professionals perform. Be sure that the charges attached to each item in your CDM covers your HOPD’s costs. When you receive price changes from manufacturers, you should adjust your CDM charges. Do not assume that materials management automatically makes those changes. In most hospitals, the HOPD director is responsible for updating their department’s CDM.

    • Correctly report units for skin substitutes in multiples of the units included in the HCPCS code descriptor, e.g. “per sq cm” or “per cc”. For example: if the HCPCS code descriptor is per sq cm and 10 sq cm was applied, the units billed for the skin substitute should be 10. Many providers make the mistake of billing for one (1) unit of skin substitute because they applied one piece. Note that the HCPCS descriptors for the skin substitutes are not “per piece”. In the example, a billed unit of one (1) would derive a payment for only 1 sq cm.

  CAUTION: The HCPCS short descriptors are limited to 28 characters, including spaces. Therefore, short descriptors do not always capture the complete description of the HCPCS codes. Before setting up charge sheets and/or EHRs and before submitting claims for skin substitutes, providers should review the complete long descriptor of the HCPCS code. See Table I.

  Providers should also review the CPT® code descriptors for the skin substitute application procedures. The units in the CPT® code descriptors do not usually coordinate with the units in the HCPCS code descriptors. Most CPT® descriptors for skin substitutes are described as either “first 25 sq cm or less”, “each additional 25 sq cm or part thereof”, “first 100 sq cm or less”, or “each additional 100 sq cm “. In the example above, the coordinating CPT® code descriptor is “first 100 sq cm or less”. Therefore, the HCPCS code units would be reported on the claim as “10” and the CPT® code unit would be reported on the claim as “1” because no more than 100 sq cm was applied by the physician.

    • Review 2010 OPPS Final Rule and implement changes.

    ˚ Note services and procedures with increased payment rates:

    • Excisional debridement: 11040-11044

    • Surgical preparation or creation or recipient site: 15002-15005

    • Skin substitute applications: 15150-15152; 15155-15157; 15170-15176; 15300-15336; 15400-15431

    • Selective debridement: 97597-97598

    • Non-selective debridement: 97602

    • Negative pressure wound therapy: 97605-97606

    • Clinic visits: 99201-99202; 99205; 99211-99213

    • Hyperbaric oxygen under pressure: C1300

    ˚ Note services and procedures with decreased payment rates:

    • Low frequency, non-contact, non-thermal ultrasound: 0183T

    • Skin substitute applications: 15340-15366

    • Unna boot application: 29580

    • Clinic visits: 99203-99204; 99214-99215

    ˚ Note product that now has pass-through status:

    • C9363 Skin substitute, INTEGRA Meshed Bilayer Wound Matrix, per square centimeter

    ˚ Note product that no longer has pass-through status:

    • C9354 Acellular pericardial tissue matrix of non-human origin (VERITAS), per square centimeter

    ˚ Note new procedure with new payment rate:

    • 29581 Application of multi-layer venous wound compression system; below knee.

    ˚ Ask your hospital administration if your hospital submitted the hospital outpatient quality data for OPPS services furnished on or after January 1, 2009. The hospital should have submitted data for eleven (11) quality measures: 5 emergency department related measures; 2 perioperative care measures; and 4 imaging measures. If your hospital submitted the required quality data, your HOPD will receive its full 2010 APC payment rate. If your hospital did not submit the required quality data, your HOPD will receive a 2% reduction in 2010 payment rates. The reduction also applies to beneficiaries and will also affect secondary payers

    ˚ Note that CMS did not create national E/M coding guidelines for 2010. HOPDs should continue using their own internally developed clinic visit level mapping system based on the 11 principles released by CMS. Review and update your E/M mapping system and policy to reflect resources actually used and to comply with the 11 principles.

    ˚ Effective January 1, 2010 Medicare will no longer reimburse physicians for consultation codes 99241-99255. CMS has instructed physicians and other providers to use other applicable E/M codes to report the services that formerly were coded as consultations.

  HOPDs have not been able to use consultation codes to bill Medicare for several years. However, many HOPDs provide a charge sheet for their physicians either via paper or via their EHR. Physicians should contact the other major payers such as Medicare Advantage, Medicaid, and other commercial payers to learn if any of them still accept and pay for consultations. If the answer is “yes”, HOPDs should maintain those codes in their system for the physicians who work there. If the answer is “no” and the other payers follow the Medicare guidelines and do not accept and pay for consultants, HOPDs may wish to remove the consultation codes from their systems.

    ˚ If the HOPD multi-disciplinary team includes physical therapists, be sure to bill for “sometimes therapy” and “always therapy” services correctly. This is particularly important now that nearly all of the Medicare contractors have reminded physicians to use the selective debridement codes (97597-97598) when appropriate. Six (6) wound care related codes are listed by Medicare as “sometimes therapy” codes. See Table II.

   “Always Therapy” services must be performed by a qualified therapist under a certified therapy plan of care. “Sometimes Therapy” services may be performed by 1) a qualified therapist or by 2) an individual outside of a certified plan of care.

    • When “sometimes therapy” services are performed by a qualified therapist under a certified plan of care, providers should attach the appropriate therapy modifier (GP, GO, or GN) and should report the charges under the appropriate therapy revenue code (042x, 043x, or 044x) – be sure to account for this coding in your charge sheets, EHR, and CDM.

    • When “sometimes therapy” services are furnished to hospital outpatients as a non-therapy service without a certified plan of care, HOPDs should not attach the therapy modifiers and should report the charges under the appropriate HOPD revenue code, e.g. 051x, etc.

    • Review the latest version of the Outpatient Code Editor which is updated each quarter. For example: New CPT® code 29581 has been added to column 2 of all column 1 CPT® codes for the application of skin substitutes and for excisional debridements with a modifier indicator of “1”. If the clinical circumstance warrants separate reimbursement and your documentation supports attaching a modifier (such as 59 Distinct procedural service), the HOPD may be paid for 29581 in addition to the application of the skin substitute or the excisional debridement.

    • Research and review all of the wound care related local coverage determinations (LCDs) that your Medicare contractor has posted on its Web site. In the CR#6751 January 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS) that was effective on January 1, 2010, CMS reminded HOPDs: “The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. Fiscal Intermediaries(FIs)/Medicare Administrative Contractors (MACs) determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, FIs/MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”

  Assign someone from your HOPD to review your Medicare contractor’s active, future, draft, and retired LCDs and their attachments and articles on a monthly basis. All changes should be thoroughly discussed with the team to be sure the physicians, clinicians, billers, coders, and chargemaster personnel make the appropriate changes to comply with the LCD guidelines. Remember: auditors will use the LCD that was in existence when you provided a drug, biological, device, procedure, or service to determine if you coded, billed, and were paid correctly. Therefore, you must always know and follow the most current LCD guidelines.

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.