When Wound Care Marketing & Reimbursement Payments Collide

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.

Based on this author’s interactions with wound care stakeholders, there is a disconnect among many clinicians and program directors between the marketing of their outpatient services and the payment rules for those services. Consider:

• Hospital outpatient wound care provider-based departments (PBDs) allot a portion of their time each month toward marketing their services to surrounding medical practices, with the goal being to gain referrals of patients who are living with chronic wounds. 
• Wound care physicians and podiatrists market their wound care services to skilled nursing facilities (SNFs), with the goal being to increase their wound care business beyond their offices.

Let’s review several problematic marketing scenarios that have caused many reimbursement denials and/or repayments among stakeholders who have recently sought appropriate guidance and solutions to better align their marketing efforts and payers’ reimbursement policies. Examples will be provided through actual scenarios that have been reported, however identities will not be revealed. 

Scenario No. 1: PBDs provide and apply surgical dressings for patients sent from medical offices.

Numerous PBD program directors have reported that many community physicians/podiatrists manage their patients’ chronic wounds in their offices, but do not apply dressings to the wounds. Instead, they immediately send patients to the PBDs with an order to apply the appropriate surgical dressing. The PBDs may enjoy the increased business; however, during audits these “dressing change” visits were denied as “not medically necessary,” and the PBDs experienced significant repayments. Of course, the PBD stakeholders have two concerns: 1) the marketers do not know how to communicate to the providers that they cannot continue the “dressing changes” that they said they could do and 2) the loss of business in the PBD.  

Years ago, one of this author’s most influential mentors shared his favorite motto: “Bad business is worse than no business.” That motto rings true in this scenario. The marketers did not realize that the payment for office visits and procedures includes the application/reapplication of surgical dressings. Therefore, patients who receive wound care management in medical offices should not be sent to PBDs for surgical dressing applications. Additionally, PBDs do not have a way to correctly charge for the surgical dressings and their application if the patients were not evaluated by a PBD physician or other qualified healthcare professional (QHP), and if a plan of care is not written and signed by the physician or other QHP who directly supervised the PBD. In fact, PBDs can only bill for medically necessary visits. They cannot bill for services that should have been performed by another provider or by the patient.

Solution: Wound care PBD program directors should educate marketing staff members about the type of services, procedures, and products that can be offered in a PBD. Then, the PBD program directors, medical directors, and marketing staff should educate their referring provider(s) about the type of referrals that the PBD can legitimately accept, as well as the reasons why the PBD cannot provide and apply dressings for patients who just received wound care in their medical offices. 

Scenario No. 2: PBDs change negative pressure wound therapy (NPWT) durable medical equipment (DME) dressings/canisters and disposable NPWT equipment and dressings for patients receiving care from home health agencies (HHAs). 

Those on staff with HHAs often complain that responding to NPWT DME alarms and changing NPWT DME dressings require too many visits. Although disposable NPWT does not typically require as many visits, some HHAs have not taken advantage of the opportunity to purchase and bill (separate from the bill for 60-day episode of care) for the disposable NPWT equipment. When marketing personnel from PBDs hear the HHAs’ complaints about excessive NPWT visits, they typically recognize an opportunity to make the agency members happy and to increase business for the PBD: They tell agency representatives to send patients requiring NPWT DME or disposable NPWT to the wound care PBD. An increasing number of PBD program directors are reporting that their claims for NPWT services are typically paid when they are first submitted. However, when the HHAs’ 60-day claims are processed, the PBDs then experience repayments. The explanation for these repayments is simple: Both the NPWT DME codes (97605/97606) and the disposable NPWT codes (97607/97608) are on the HHA consolidated billing list. Therefore, HHAs are expected to provide these services or to pay the PBDs for providing these services to their patients. 

Solution: The PBD program director should educate the marketing staff about the wound care services that are on the HHA consolidated billing list. Then, the PBD program director, a hospital executive, and the marketing staff should meet with the administrator and director of nursing from the HHAs that send patients to the PBD. Together, they should review the wound care services that are on the HHA consolidated billing list and discuss why the PBD must charge the HHAs, rather than Medicare, for those services. If the HHAs still want the PBDs to provide one or more of these services, the wound care PBDs should contract with the HHAs to provide the wound care services on the HHA consolidated billing list and bill the HHA for those services. The Centers for Medicare & Medicaid Services (CMS) offers a master list of the products and procedures on the HHA consolidated billing list.¹ 

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Scenario No. 3: Physicians experience repayments for performing follow-up wound care on patients in a global surgery period following a major procedure.

PBD marketers routinely solicit referrals from surgeons by telling them to send their patients experiencing postoperative wound complications to the PBD. When the PBD physician or other QHP evaluates the complication(s), creates a plan of care, and manages the complication(s), Medicare and the patient receive two bills: one from the physician or other QHP and one from the PBD. Medicare Part B typically pays both bills. However, upon Medicare audits, physicians and QHPs often experience repayments if the patient was in a 90-day global surgery period for major surgery performed by a different surgeon. The PBDs do not experience Medicare repayments because global surgery periods do not apply to outpatient departments paid by the Medicare Outpatient Prospective Payment System. 

Solution: PBD marketers should be careful when marketing wound care services to surgeons.  The PBD marketers, as well as the physicians and other QHPs who work in the PBD, should review which services are included in the surgeon’s global surgery Medicare payment (see Table 1) and which services are not included in the global surgery Medicare payment (see Table 2). PBD marketers should clearly explain to surgeons that the physicians or other QHPs in the PBD cannot manage postoperative wound complications for the surgeon’s patients who are in a 90-day global surgery period because surgeons are typically responsible for managing complications of their surgery during that global period. If the surgeons do not want to manage their own complications, they can formally transfer care to the physician or other QHP. For more information about the global surgery period, refer to the Global Surgery Booklet offered by CMS.² 

Scenario No. 4: Physicians and other QHPs experience repayments for not charging SNFs for some wound care services provided to patients during their Medicare-covered Part A and Part B stay.

SNFs often have a need for a physician or other QHP to manage their patients who are living with chronic wounds. Therefore, some physicians or other QHPs with wound care expertise often market their services to these SNFs. They usually explain to the SNF administrator that the SNF will not incur any costs for their wound care services. However, these physicians or other QHPs may not realize that payment for most of the services provided to beneficiaries in a Medicare-covered Part A SNF stay, including most services provided by entities other than the SNF, are included in a bundled prospective payment through a Medicare Administrative Contractor (MAC) to the SNF. The SNF must bill these bundled services to the MAC in a consolidated bill. For services subject to consolidated billing and provided by entities other than the SNF, the entity must look to the SNF for payment and must not bill Medicare separately for those services. Therefore, all is well when the physicians or other QHPs bill Medicare for services (eg, surgical debridement, application of multilayer compression bandages) that are not included on the SNF consolidated billing list. These services are represented by the codes in File 1 on the SNF consolidated billing website³ and are not subject to SNF consolidated billing for Medicare beneficiaries in an SNF Part A covered stay. The physicians or other QHPs should submit codes for this work to the Part B MAC for payment consideration. When the physicians or other QHPs perform services (eg, selective debridement, NPWT) that are not included in File 1, the Part B MAC denies payment during the Part A covered stay. In addition, codes included in File 4 are subject to SNF consolidated billing for Medicare beneficiaries in SNF Part B stays.³ The Part B MAC will always deny these codes for Medicare beneficiaries in an SNF Part B stay. These services must be provided and billed under arrangement with the SNF. Six common wound care services are included in File 4: 97597, 97598, 97602, 97605, 97606, and 97610. 

Solution: Physicians and other QHPs who provide services in SNFs should review the Medicare payment regulations for SNFs and should pay attention to the consolidated billing rules and files. Then, they should schedule a meeting with the SNF administrator and provide an explanation about the few wound care services that must be billed to the SNF due to the consolidated billing rules. The SNF administrator may choose to: 1) have those wound care services performed by either the facility’s physical therapists or wound care nurses; or 2) pay the physicians and other QHPs for that work. If the administrator chooses the second option, the physicians and QHPs should negotiate a contract with the SNF to perform the work on the consolidated billing list and to bill the SNF. 

SUMMARY

These real-life scenarios should motivate wound care stakeholders to examine their marketing messages and adjust them to prevent collisions of marketing and reimbursement. Remember, “bad business is worse than no business.” Be careful of what you market because the increased business could cost you money! 

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. 

References

1. Coding and Billing Information. CMS. 2018. Accessed online: www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/coding_billing.html

2. Global Surgery Booklet. CMS. 2017. Accessed online: www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf

3. 2018 Part B MAC Update. CMS. 2018. Accessed online: www.cms.gov/medicare/billing/snfconsolidatedbilling/2018-part-b-mac-update.htm