Use the Correct Payment File to Find Medicare Allowable Rates

By Kathleen D. Schaum, MS   Billers for wound care physicians often call me to ask: “Does Medicare really pay separately for cellular and/or tissue-based products for wounds (CTPs) [outdated term “skin substitutes”] assigned “Q” Healthcare Common Procedure Coding System (HCPCS) codes when the CTPs are purchased by physicians and used in their offices?”   I always remind the billers that Medicare may pay for those products if they are deemed “medically necessary” for each specific patient and if all of the criteria of their Medicare Administrative Contractor’s Local Coverage Determination (LCD) are met.   Then, the billers often tell me they cannot find the Medicare allowable rates for these products on their Medicare Physician Fee schedule (MPFS). Because this is such a frequent question, I thought I should share this information with our readers here. The MPFS contains the Medicare allowable rates for the services and procedures they perform. That MPFS can be found online at: www.cms.gov/apps/physician-fee-schedule.   The average sales price (ASP) file contains the Medicare allowable rates for separately payable drugs and biologics, such as many of the CTPs that have been assigned “Q” HCPCS codes. The ASP file can be found online at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. This file is updated on a quarterly basis (January, April, July, and October). Therefore, I always remind billers to review the ASP file during the first week of each quarter.   Billers for wound care physicians who provide surgical dressings to their patients for their use at home often ask similar questions. The MPFS does not include Medicare allowable rates for surgical dressings because Medicare expects those supplies to be included as a part of the services/procedures performed in physician offices. If the physician has met the requirements to supply surgical dressings for his/her patient’s at-home use, the biller can find the Medicare allowable rates on the Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) FeeSchedule. The DMEPOS Fee Schedule can be found online at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.   At the Wound Clinic Business seminars, Andrea Clark and I often receive questions about the Medicare allowable rates for CTPs that have been assigned “Q” HCPCS codes and that are applied in hospital-based outpatient wound care departments (HOPDs). Those Medicare allowable rates can be found in Addendum B of the Outpatient Prospective Payment System. Addendum B can be found online at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html. Like the ASP file, the Medicare allowable rates for CTPs applied in HOPDs are updated on a quarterly basis. Therefore, Andrea and I always remind Wound Clinic Business attendees to review Addendum B during the first week of each quarter.   For an in-depth discussion of the MPFS, the ASP files, and Addendum B, mark your calendar to attend the all-day 2013 Wound Clinic Business seminar in the city of your choice: www.woundclinicbusiness.com. Better yet, bring your entire revenue cycle team and your medical staff to the seminar: It is a great opportunity to learn together! Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & AssociatesInc., Lake Worth, FL. She can be reached for questions and consultations bycalling 561-964-2470 or at kathleendschaum@bellsouth.net. Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and theauthors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.