Wound Care Professionals Influence Medicare Payment & Coverage for Advanced Treatment

This author is compelled to remind wound care professionals that they have the ability to influence Medicare payment and coverage for current and new advanced wound care products, procedures, and services. You may be saying to yourself, “Gaining payment and coverage for new technology is the job of the manufacturer.” In reality, however, the manufacturers can (and most often do) introduce their technology to the payers. However, the Medicare Administrative Contractors (MACs) that process your claims also value your insights about the medical need for coverage and payment of current and new advanced wound care technology. They want to hear from you, the wound care professionals. Following are a few examples of how wound care professionals can positively influence Medicare payment and coverage. 

MEDICARE LOCAL COVERAGE DETERMINATIONS (LCDs) 
LCD Reconsideration Process 
If your MAC has published an LCD that pertains to a current or new wound care technology, verify that the LCD: 

1. appropriately describes the technology, 

2. outlines clinically correct medical necessity and utilization guidelines, 

3. lists all pertinent ICD-10-CM diagnosis codes (if the LCD includes diagnosis codes), 

4. lists all the relevant Current Procedural Terminology (CPT^®) and Healthcare Common Procedure Coding System (HCPCS) codes, and 

5. includes documentation guidelines that are reasonable for the technology. 

LCDs can be found online: www. cms.gov/medicare-coverage-database/ overview-and-quick-search.aspx. If an LCD needs additions, deletions, and/ or refinements to correctly represent the advanced wound care technology, the following persons may use the LCD Reconsideration Process to request revisions: 

• beneficiaries residing or receiving care in a contractor’s jurisdiction, 

• providers doing business in a contractor’s jurisdiction, and 

• any interested party doing business in a contractor’s jurisdiction. 

Information about a MAC’s LCD Reconsideration Process can be found on their respective websites (see Table 1 on page 7). That information includes: 

• a description of the LCD Reconsideration Process and 

• instructions for submitting LCD reconsideration requests, including postal, email, and fax addresses where requests may be submitted. 

LCD reconsideration requests should be submitted in writing and should identify the specific language the requestor wants added to or deleted from an LCD. Requests should include a justification supported by new evidence, which may materially affect the LCD’s content or basis. Copies of published evidence should be included. The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development (Medicare Program Integrity Manual, Chapter 13, Section 13.7.1). Any request for LCD reconsideration that, in the judgment of the MAC, does not meet these criteria is invalid. In addition, MACs have the discretion to consolidate valid requests if similar requests are received. Within 30 days of the day the LCD Reconsideration Process request is received, the MAC will determine whether the request is valid or invalid. 

• If the request is invalid, the MAC will respond (in writing) to the requestor and will explain why the request is invalid. 

• If the request is valid, the MAC should follow these requirements: 

o Within 90 days of the day the request was received, the MAC shall make a final LCD reconsideration decision on the valid request and notify the requestor of the decision with the MAC’s rationale for the decision. The MAC’s decision options include: retire the LCD, make no revision to the LCD, revise to a more restrictive LCD, or revise to a less restrictive LCD. 

o If the decision is either to retire the LCD or to make no revision to the LCD, then (within 90 days of the day the request was received) the MAC will inform the requestor of that decision, along with the rationale for the decision. 

o If the decision is to revise the LCD, the MAC will follow the normal process for LCD development. 

o All MACs will keep an internal list of the LCD reconsideration requests received and the dates, subject, and disposition of each one. 

Comments to New or Revised LCDs 
Wound care professionals also have the ability to comment on drafts of new or revised LCDs. The MACs post drafts of LCDs to their websites, clearly indicating the beginning and ending dates of the comment periods while listing email and postal addresses to which comments can be submitted. MACs provide a minimum comment period of 45 calendar days on the draft LCDs. The MACs also provide open meetings for the purpose of discussing draft LCDs. To accommodate those who cannot be physically present at the meetings, the MACs provide other means for attendance (eg, telephone conference) and accept written or email comments. Written and email comments are given full and equal consideration as if presented in the meeting. Interested parties (generally those who would be affected by the LCD, including providers, physicians, vendors, manufacturers, beneficiaries, and caregivers) can make presentations of information related to draft policies. After the MAC considers all comments and revises the LCD as needed, the MAC provides a minimum notice period of 45 calendar days before the final LCD becomes effective. 

MEDICARE PAYMENT RATES 
Now that we’ve taken into consideration the power that wound care professionals hold for voicing their opinions on Medicare coverage, let’s discuss some ways they can help the Centers for Medicare & Medicaid Services (CMS) and the MACs determine adequate Medicare payment rates for advanced wound care services, procedures, and products. Although CMS has many sophisticated formal processes in place for determining payment rates for each site of service and for each payable service, product, and procedure, wound care professionals have the ability to educate Medicare about their costs for certain new advanced wound care technology. As an example, let’s take a look at how wound care professionals can influence: 1) the Hospital Outpatient Prospective Payment System (OPPS) rates for wound care hospital-based outpatient departments (HOPDs) and 2) the payment rates for carrier-priced products and procedures performed in qualified healthcare professionals’ (QHPs’ [medical doctors, doctors of osteopathic medicine, doctors of podiatric medicine, nurse practitioners, physician’s assistants, clinical nurse specialists]) offices. 

OPPS PAYMENT RATES 
CMS uses charges submitted on claims by HOPDs to set future OPPS allowable rates. For example, CMS used charges submitted on HOPD claims in 2014 to set the current 2016 OPPS allowable rates. Likewise, HOPD claims submitted during calendar year 2016 will be used by CMS to set 2018 OPPS rates. When new advanced wound care technology receives a CPT or HCPCS code, CMS does not always have enough claims data to establish accurate and/ or adequate rates. In order to educate CMS about the true costs for providing new and/or existing services, procedures, and products, HOPDs must carefully consider their cost of labor, equipment, drugs, biologics, supplies, and overhead. HOPD staff members should carefully discuss with their chief finance officers the charges they load into their charge description masters (CDMs). REMEMBER: The HOPD’s charges in 2016 will be used by CMS to set the OPPS allowable rates for 2018. Following are two recent wound care examples where HOPD claim charges caused inadequate OPPS allowable rates: 

1. Several years ago, CMS decided to package the payment for cellular and/or tissue-based products for wounds (CTPs) into the payment for the procedure to apply the CTPs. CMS used the claims data for CTPs to determine the amount of dollars they would add to the allowable rate for the procedure, which resulted in the packaged payment rates for “high cost” and “low cost” CTPs. When the packaged payment rates were released they were shockingly low and many thought CMS made a mistake in evaluating the HOPD claims. Unfortunately, CMS was correct and the claims data did not reflect the true costs of the CTPs for the following reasons: 

• Many claims reported the unit of “1” rather than the total number of square centimeters that were purchased for the procedure. 

• When product was wasted, many HOPDs only charged for the number of square centimeters applied, instead of the number of square centimeters purchased for the application. 

• For wounds ≥ 100 sq cm, many HOPDs did not include the true cost of the multiple pieces of CTPs used or of the large-size CTPs purchased to cover those large wounds. 

• Although HOPDs had to purchase the same amount of CTPs to cover wounds ≥ 100 sq cm applied to the feet and to the legs, many HOPDs charged less for the CTPs applied to the feet than for the same amount of CTPs applied to the leg. 

This problem can be rectified if HOPDs throughout the country carefully examine: 

• their actual costs to purchase CTPs for wounds up to 99.9 sq cm and for wounds ≥ 100 sq cm; correct CDM if the HOPD charges are inadequate; 

• if units of purchased CTPs are recorded appropriately in the medical record, charged appropriately in the HOPD, handled appropriately by the CDM, and dropped appropriately onto the claim. 

2. Several years ago, when disposable negative pressure wound therapy (NPWT) was introduced, HOPDs added the new codes to their CDMs but many forgot to add the cost of the disposable equipment into their charge calculation. In fact, many HOPDs charged exactly the same rates for disposable NPWT (they purchased the equipment) as they did for traditional NPWT (they did not purchase the equipment/supplies – the patient acquired the traditional negative pressure pump and supplies from the durable medical equipment supplier who billed Medicare). Because many HOPDs inaccurately established the disposable NPWT charges in 2013, their Medicare claims caused the 2015 HOPD Medicare allowable rates to drop well below the cost of the product. Due to a slight improvement in 2014 claim charges and CMS’ restructuring of the skin procedures ambulatory payment classification groups, the 2016 Medicare allowable rate for disposable NPWT increased. Wound care professionals can significantly influence the HOPD allowable rate for NPWT by immediately ensuring that charges in their CDM for 97607 and 97608 truly reflect the cost of the product, labor, and overhead. If they do not, HOPDs should take this opportunity to immediately correct their CDMs. REMEMBER: HOPD 2016 charges are determining 2018 HOPD allowable Medicare rates. 

CARRIER-PRICED PRODUCTS & PROCEDURES 
When new advanced wound care technology is released, the manufacturer usually does everything possible to apply for and to receive relevant code assignments for the new technology. The next step is to establish an adequate payment rate for wound care professionals to perform the service/procedure or to use the product. Sometimes, CMS does not have enough claims data to publish a rate on a particular fee schedule. In those cases, CMS and the MACs expect the wound care professionals will educate them about the actual cost and/or cost savings of the technology, the labor to perform it, and any other overhead costs. So, the big question becomes: How can wound care professionals educate their MAC’s medical director when a service/procedure or product is carrier priced?

 In some cases, they can present the technology and its costs and/or cost savings at an open LCD meeting. 

• In some other cases, the wound care professional can request a peer-to-peer teleconference with the MAC’s medical director. 

o Some wound care professionals prefer to educate their MAC medical director about the technology and its costs/cost savings before they begin submitting bills for the technology. These educational teleconferences are usually very beneficial for both parties and may even lead to an agreed upon Medicare allowable rate or a plan for establishing a reasonable allowable rate. 

o Other wound care professionals prefer to submit a claim for the carrier-priced technology and to monitor how the claim is paid by the MAC. If the paid rate is adequate for the new technology, the wound care professional continues using and billing for the technology. If the paid rate is inadequate, the wound care professional appeals the claim and often requests a peer-to-peer teleconference with the MAC medical director. 

• In all cases, wound care professionals should thoroughly document their work. REMEMBER: Wound care professionals’ documentation must justify the medical necessity for the new technology and claims must “paint the picture” of the care provided: 

o Use specific primary, secondary, and tertiary ICD-10 codes. 

o Use the relevant procedure/product code(s). 

o Report the appropriate number of units. 

o Report reasonable charges, and very importantly: 

o Include four items in the narrative field of the electronic claim (field No. 19 of a paper claim): 

1. name of the product, 

2. size of the product, 

3. product number, and 

4. invoice price per each (not the price of a case). 

NOTE: Some MACs will accept copies of invoices at the time of claim submission. Some MACs will request a copy of the invoice before they pay the claim for new technology 

Now, let’s think about two recent examples of carrier-priced, new advanced wound care technologies that are used by QHPs in their offices. NOTE: The following information only pertains to QHP offices. These products do have published Medicare allowable rates on the OPPS that pays the HOPDs: 

1. With the plethora of new CTPs on the market, CMS has not routinely been listing the average sales prices for many of the new CTPs on the Medicare Part B drugs and biologics average sales price file: www.cms.gov/medicare/ medicare-fee-for-service-part-b-drugs/mcrpartbdrugavgsalesprice/ index.html. Therefore, those CTPs are carrier priced when the QHP applies them in his/her office. When drugs and biologics are carrier priced, most MACs require the four items previously listed to be in the narrative field of the electronic claim: product name, product size, “Q” code or “C” code, product number, and invoice price per piece. 

2. The new disposable NPWT codes 97607 and 97608 are also carrier priced in QHP offices. Therefore, QHPs should include the same four items in the narrative field of the electronic claim: product name, product size, product code [either 97607 or 97608], product number, and invoice price per piece. 

SUMMARY 
As wound care professionals review advanced wound care technologies utilized in practice, they should be asking themselves if they’re doing their respective part to influence the appropriate payment and coverage for that particular service, procedure, or product. Use this checklist as a reminder: 

❑Review current LCDs. 

❑ Use the LCD Reconsideration Process to request changes to LCDs. 

❑ Comment on drafted and new LCDs. 

❑ Participate in open LCD meetings facilitated by one’s MAC. 

For those working in an HOPD: 

❑ Review the CDM carefully to verify it includes all codes that are relevant to the work performed in the HOPD and that it correctly represents the description of the codes, the units, and the complete cost. 

❑ Verify the HOPD documentation specifies the brand of CTP purchased, the amount applied, and the amount wasted. Verify the correct procedure code, the correct product code (along with the correct number of units), and the correct charge are on the claim. 

❑ Verify the CDM charge for disposable NPWT includes the cost of the equipment. 

For those working in a QHP’s office: 

❑ Set charges to include payment for all work. 

❑ Charge for the correct number of CTP square centimeters purchased for each application. 

❑ Set disposable NPWT charges to include the cost of the equipment and the cost of labor and practice expense. 

❑ Educate MAC medical directors about new technology, its clinical efficacy, its cost, its cost savings, and its patient satisfaction. 

❑ Initiate peer-to-peer teleconferences with MAC medical directors. 

❑ Include the previously outlined four items in the narrative field of claims that include carrier-priced services, procedures, and products. 

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