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Share 2020 Payment Information With Your Clinical and Revenue Cycle Teams
Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure 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.
In January’s Business Briefs column, we discussed 5 revenue cycle resolutions that wound/ulcer management professionals should make for 2020. The first resolution was to work with all members of your clinical and revenue cycle teams. In the February column, we 1) reviewed some products and procedures that have been assigned or will be assigned new codes, and 2) discussed how wound/ulcer management professionals should work with their clinical and revenue cycle teams to integrate the new codes into their processes.
Because this author has received many questions about the 2020 Medicare payment for 1) hospital owned outpatient wound/ulcer management provider-based departments (PBDs) and 2) physicians in their offices and PBDs, this month’s column will provide answers to the most frequently-asked questions (FAQs). To keep your first new year’s resolution, share these payment FAQs and answers with your clinical and revenue cycle teams.
FAQs and Answers About Medicare Payment in PBDs
Q:
Is it true that PBDs are no longer paid for each application of cellular- and/or tissue-based products (CTPs) for skin wounds?
A:
No, that is not true. The PBDs still either receive 1) a packaged payment for each application of covered CTPs assigned to the high-cost or low-cost package, or 2) separate payments for the application and for covered CTPs with pass-through status—if the cost of the CTP exceeds the device offset amount built into the ambulatory payment classification (APC) group to which the application code is assigned.
This question most likely stems from the fact that the Centers for Medicare and Medicaid Services (CMS) would like to eliminate packaged payments for the high-cost and low-cost CTPs. In the draft outpatient prospective payment system (OPPS) rules for the past 2 years, the CMS proposed some other payment methods for CTPs, such as an episodic payment. However, the final 2020 OPPS rule states that the CMS is still considering how to revise the payment for CTPs and is continuing the current packaged payment system for 2020.
Whatever payment method the CMS may choose in the future, it will most likely be based on PBDs’ claims data. Therefore, PBDs must include, on their claims, the correct HCPCS code for the CTP, the total number of sq. cm. purchased, and the correct marked-up charge for the product. Because provider based departments’ future Medicare payment for CTPs will be dependent on current claims data, both the clinical and revenue cycle teams should audit their claims to verify that the correct CTP codes, the correct number of CTP units purchased, and the correct charges are actually on their claims. Do not assume that the charging information created in the PBD actually made it to the claims.
Q:
Do any of the CTPs have pass-through status in 2020? If so, what is the OPPS ambulatory payment classification device offset amounts that align with the APC groups to which the CTP application codes are assigned?
A:
Yes, PuraPly and PuraPly AM (Organogenesis) still have pass-through status through September 30, 2020. On October 1, 2020 both products will be packaged.
In 2020, when 15271, 15275, and 15277 are the appropriate application codes, the OPPS APC device offset amount is $759.52. When 15273 is the appropriate application code, the OPPS APC device offset amount is $269.41.
Unless the CMS awards pass-through status to one or more new CTPs, effective October 1, 2020 all CTPs will be packaged into the OPPS APC payments for their application.
Q:
Is the off-campus site neutral payment for clinic visits in effect for 2020?
A:
Yes, both excepted and nonexcepted off-campus PBDs will receive a 40% reduction in Medicare payment for G0463 Hospital outpatient clinic visit for assessment and management of a patient. That reduction is actually 60% less than the 2020 OPPS rate. Based on the Medicare national average allowable rate for G0463, following is the calculation of the payment amount for all off campus PBDs: $115.93 x .60 = $69.558. Clinical and revenue cycle teams that work in off-campus PBDs should calculate (by using their wage-adjusted base rate for G0463) their unique 2020 site-neutral allowable rate for G0463.
Q:
In 2020, did PBDs receive a Medicare allowable rate increase for any wound/ulcer management services/procedures?
A:
Yes, although small, the Medicare allowable rates increased in 2020 for some wound/ulcer management related services/procedures. Following are the most commonly used codes that received increases:
• Application of high-cost CTP: 15271, 15273, 15275, and 15277
• Application of low-cost CTP: C5271, C5273, C5275, and C5277
• Application of disposable negative pressure wound therapy (dNPWT) pump: 97607–97608
• Application of negative pressure wound therapy pump durable medical equipment (NPWT DME): 97606
• Autologous PRP for ulcers: G0460
• Biopsy: 11106
• Extracorporeal shock wave: 0512T
• Extremity arterial studies: 93922–93923
• Hospital outpatient clinic visit: G0463
• Hyperbaric oxygen therapy: G0277
• Surgical debridement: 11042–11044
• Surgical site preparation: 15002 and 15004
Q:
In 2020, did PBDs receive a Medicare allowable rate decrease for any wound/ulcer management services/procedures?
A:
Yes. Although small, the Medicare allowable rates decreased in 2020 for some wound/ulcer management related services/procedures. Following are the most commonly used codes that received decreases:
• Application of casts and strapping: 29445, 29580, 29581, and 29584
• Application of NPWT DME: 97605
• Biopsy: 11102 and 11104
• Chemical cauterization: 17250
• Ear wax removal: 69210
• Low frequency non-thermal ultrasound: 97610
• Non-selective debridement: 97602
• Selective debridement: 97597
Q:
Did any wound/ulcer management services/procedures have an OPPS status indicator change for 2020?
A:
No, the 2020 OPPS status indicators for the most common wound/ulcer management services/procedures are identical to the 2019 OPPS status indicators.
Q:
I heard that physicians and other qualified healthcare professionals (QHPs) are no longer paid when they perform services in PBDs. Is this really true?
A:
No, that is not true. Physicians and other QHPs are paid the Medicare facility allowable rate for the work they perform in PBDs.
FAQs and Answers About Medicare Payment Rates for Physicians Who Perform Work in PBDs:
Q:
Is it true that the Medicare Physician Fee Schedule now includes an allowable rate for physicians to apply new dNPWT pumps in PBDs?
A:
Yes, physicians can now receive payment for applying medically necessary new dNPWT pumps in PBDs. The 2020 Medicare national average allowable rates, for work performed in PBDs, are $23.46 for 97607 and $26.35 for 97608.
Q:
Did any physician services/procedures performed in PBDs receive Medicare allowable rate increases for 2020?
A:
Yes. Although most were small, the Medicare allowable rates increased in 2020 for some wound/ulcer management related services/procedures that are performed by physicians in PBDs. Following are the most commonly used codes that received increases. Please note the few procedures that have significant increases.
• Application of casts and strapping: 29445, 29580–29581, and 29584
• Application of CTPs: 15271–15272, 15275–15278
• Application of NPWT DME pump: 97605–97606
• Application of dNPWT pump: 97607–97608 (significant increase because codes were not paid prior to 2020)
• Ear wax removal: 69210
• Extremity arterial studies: 93922–93923
• Evaluation and management: 99202, 99204–99205, and 99211–99215
• Hyperbaric oxygen therapy: 99183
• Low frequency non-thermal ultrasound: 97610
• Selective debridement: 97597–97598 (significant increase)
• Surgical debridement base codes: 11043–11047
• Surgical site preparation: 15003 and 15005
Q:
Did any physician services/procedures performed in PBDs receive Medicare allowable rate decreases for 2020?
A:
Yes. Although small, the Medicare allowable rates decreased in 2020 for some wound/ulcer management related services/procedures that are performed by physicians in PBDs. Following are the most commonly used codes that received decreases:
• Application of CTPs: 15273–15274
• Autologous PRP for ulcers: G0460
• Biopsy: 11102–11107
• Chemical cauterization: 17250
• Evaluation and management: 99201 and 99203
• Surgical debridement: 11042
• Surgical site preparation: 15002 and 15004
FAQs and Answers About Medicare Payment Rates for Physicians Who Perform Work in Their Offices:
Q:
Is it true that the Medicare Physician Fee Schedule now includes an allowable rate for physicians to purchase and apply new dNPWT pumps in their offices?
A:
Yes, physicians can now receive payment for purchasing and applying medically necessary new dNPWT pumps in their offices. The 2020 Medicare national average allowable rates for work performed in the office are $342.85 for 97607 and $343.93 for 97608.
Please note that these codes can only be reported when a new dNPWT pump is purchased and applied. If the physician only changes a cartridge or a dressing for a dNPWT pump that was applied during a previous office visit, the physician cannot report 97607 or 97608 for that visit. Instead the physician should report an appropriate evaluation and management code or a procedure code (if performed) for that visit.
Q:
Did any physician office services/procedures receive a Medicare allowable rate increase for 2020?
A:
Yes. Although most were small, the Medicare allowable rates increased in 2020 for some wound/ulcer management related services/procedures that are performed by physicians in their offices. Following are the most commonly used codes that received increases. Please note the few procedures that have significant increases.
• Application of CTPs: 15271, 15273–15278
• Application of casts and strapping: 29580, 29581, and 29584
• Application of dNPWT pump: 97607–97608 (significant increase because these codes were not paid prior to 2020)
• Application of NPWT DME pump: 97605–97606
• Biopsy: 11102–11104, and 11106–11107
• Cauterization: 17250
• Ear wax removal: 69210
• Evaluation and Management: 99201, 99204–99205, and 99211–99215
• Hyperbaric oxygen therapy: 99183 and G0277 (G0277 increase is significant)
• Low frequency non-thermal ultrasound: 97610 (significant increase)
• Selective debridement: 97597–97598 (significant increase)
• Surgical debridement: 11042–11047
• Surgical site preparation: 15002 and 15004
Q:
Did any physician office services/procedures receive a Medicare allowable rate decrease for 2020?
A:
Yes. Although small, the Medicare allowable rates decreased in 2020 for some wound/ulcer management related services/procedures that are performed by physicians in their offices. Following are the most commonly used codes that received decreases:
• Application of CTPs: 15272
• Application of casts and strapping: 29445
• Autologous PRP for ulcers: G0460
• Biopsy: 11105
• Evaluation and Management: 99202–99203
• Extremity arterial studies: 93922–93923
• Surgical site preparation: 15003 and 15005
Q:
I heard that some Medicare Administrative Contractors (MACs) are requiring extra information on physician office claims for CTPs. Is that true?
A:
Yes, that is typically true for CTPs which do not have a published price on that quarter’s Average Sales Price (ASP) file.1 For some unknown reason, even when manufacturers report the ASP of their CTPs, the CMS does not publish all the reported ASPs. In those cases, the MACs need to know the actual invoice price of the CTP purchased for each patient application in order to correctly pay the physician office. Following are 2 examples of MAC directives about this issue:
1. On August 13, 2019 Noridian Healthcare Solutions provided this direction for physician offices to report CTPs that are not listed on the ASP file:2
• “Enter procedure code and total invoice price in Item 19 of CMS-1500 claim form or Loop 2400/SV101-7 for EMC. If the claim does not include the required information, the item will deny as unprocessable.
• “The invoice price must be in currency format and must include the decimal. For example: If the invoice price is $1,300.00 per each, report $1,300.00.
• “Noridian will reimburse for the invoice price plus shipping, but no additional fees (tax, handling fees, delivery fees, administrative fees).
• “Providers must maintain an invoice copy within the patient’s file and it must be made available to Noridian upon request.”
2. On December 4, 2019 First Coast Service Options modified their required new process for providing the invoice amount on incoming claims for specific CTPs that are not listed on the ASP file:3
• “Obtain the total invoice cost for the patient and service. You must report the amount from the invoice that is applicable for the patient and service on the claim; you are not submitting the retail amount or amount you charge for the service.
• “Enter the invoice amount on block 19 of the CMS-1500 paper claim form or its electronic equivalent of Loop 2300 Segment NTE in the following format (including cents): INV. $00.00
• “If you do not list the information appropriately on the claim, or if the information is missing, we will send an additional documentation request (ADR) to you requesting the invoice. We will monitor these claims on a post payment basis to ensure accurate claims processing.
• “Make sure to sign up for eNews and check this article regularly for new codes that may be added to this process.”
If First Coast Service Options or Noridian Healthcare Solutions is the MAC for your physician’s office, verify that you are submitting the invoice price correctly on your claims. If your office submits claims to a different MAC, review that MAC’s website and/or contact that MAC to verify their instructions for submitting invoice prices on claims for CTPs that are not listed on that quarter’s ASP file.
Summary
Now that you have read the answers to the FAQs about the 2020 Medicare payment for PBDs and physicians (in the office and in PBDs), your clinical and revenue cycle teams should take the time to review the actual 2020 Medicare allowable rates for your site of care. Then the teams should review your charging system to ensure that your 2020 charges reflect your current cost of doing business. Finally, your teams should conduct internal audits to verify that your claims reflect what was documented, coded, and charged.
Physician office clinical and revenue cycle teams should perform 2 additional tasks:
1. If your physician(s) plan to order dNPWT for their patients, you should add the codes and charges for application of dNPWT pumps to your charging system.
2. If your physician(s) purchase and apply CTPs in the office, you should verify that you are reporting, in the proper field of the paper or electronic claims, the invoice price for CTPs that are not listed on the ASP file.
Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.
1. ASP Drug Pricing Files. Available at https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/2020-asp-drug-pricing-files. Last accessed February 14,2020.
2. Noridian Healthcare Solutions Process For Providing Invoice Price on Claims. Available at https://med.noridianmedicare.com/web/jfb/topics/claim-submission/submission-errors-solutions/skin-substitute-codes. Last accessed February 14, 2020.
3. First Coast Service Options Process for Providing Invoice Amount on Certain HCPCS Codes. Available at https://medicare.fcso.com/coverage_news/0422001.asp. Last accessed February 14, 2020.
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