Business Briefs: Correct Orders and Documentation Determine Medicare Coverage and Payment

The following table is the complete interview from the June 2010 Business Briefs section of Today’s Wound Clinic. Interviews were conducted by Kathleen D. Schaum, MS, is President and Founder 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. TABLE IV Contact information Manufacturer - ConvaTec, Inc U. S. Corporate Office - Skillman, NJ Web Site - www.convatec.com NPWT Brand - Engenex® NPWT System Interviewee name and title - Joseph Rolley, VP Global Government Affairs & Health Policy Manufacturer - Prospera Technologies, LLC U. S. Corporate Office - Fort Worth, TX Web Site - www.prospera_npwt.com NPWT Brand - Pro Series: PRO-I, PRO-II. PRO-III Interviewee name and title – Cindy Ahearn, Director of Clinical Services Manufacturer - Smith & Nephew, Wound Management U. S. Corporate Office - St. Petersburg, FL Web Site - www.smith-nephew.com NPWT Brand - EZCARE, RENASYS EZ, RENASYS GO, VISTA Interviewee name and title - Randall R. Carson, Director, Government Affairs & Reimbursement, North America 1) Do the providers use the Negative Pressure LCD as a guidance document for order, utilization, and documentation? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “I don’t believe most providers are familiar with the LCD, but suppliers certainly are and can be a source of expertise on NPWT documentation requirements. NPWT is one of the more challenging DME payment categories. Successful reimbursement requires cooperation and collaboration between providers and suppliers to ensure the requirements of the policy are met with each claim.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC “An experienced NPWT provider is probably informed and knowledgeable about the LCD. When the guidelines are followed, the entire transaction of NPWT can go smoothly. However, I don’t believe the majority of providers know about the LCD document or that it can be used as a guidance tool. That being said, providers for years have relied heavily upon the distributor or manufacturer for guidance and to assist in completing the necessary assessment documentation. The lack of understanding of the LCD on behalf of the provider increases the risk of the patient having to pay higher out-of-pocket if the claim is denied.” 2) What recommendations would you like to give the providers regarding the Negative Pressure LCD? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “It is important for prescribing physicians to be at least familiar with the NPWT LCD and Article. This can happen through dialog with NPWT suppliers, but it would be best to read the LCD directly and to refer back to it every so often for refreshers. NPWT provides therapeutic benefits for chronic, complex, and other wound types, but it is reimbursed only if certain conditions are met and documented in the medical record. Supporting the supplier in filing reimbursement claims ultimately supports patients by ensuring they have access to the medical technologies they need.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC “Learning how services are reimbursed BEFORE you start writing orders should be the #1 goal. If the provider becomes knowledgeable about the LCD document for their region and studies it (or even calls the Medicare contractor), it will make writing the order, using appropriate utilization and necessary documentation much easier. You must know the rules. It is beneficial for the provider and the DME supplier to work in concert in order to ensure appropriate reimbursement for all.” 3) What problems do you face pertaining to physicians’ orders for NPWT? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “Our suppliers have not had major problems with physician orders per se. Rather the challenges have been in identifying the prescribing physician and ensuring the medical record meets the requirements of the LCD.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC “Our provider order forms are designed to follow the LCD guidelines. By making it a check off or short answer form, the providers are less likely to leave out essential details. They normally appreciate the guidance and thus it expedites the process.” 4) What “ordering” recommendations do you have for providers? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “Ensure orders are for patients whose wounds meet the requirements of the LCD. If they don’t, then other types of wound therapies should be considered.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC “Have a set prescription form that follows the LCD guidelines and the updated Medicare bulletins. It is easier for the provider and increases the probability of appropriate reimbursement.” 5) What are the major documentation deficiencies that you encounter? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “Issues arise more frequently when therapy is initiated in the community rather than in the hospital. Documentation of the 30-day conservative treatment period is important in these instances. Otherwise, the issues center mostly on wound measurement and documentation of progression in the medical record.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC “Without following a preset order form, the lack of signatures, starting/ending service dates, lack of wound measurement, and lack of last debridement are among the most common omissions.” Randall R. Carson, Director, Government Affairs & Reimbursement, North America, Smith & Nephew, Wound Management “In general, the rationale for utilizing NPWT is often not clear and has to be gleaned from a variety of records. Clinicians should document the reason NPWT is appropriate at the point in time it is being ordered for each patient. Documentation of positioning and turning is very often deficient. Documentation of group 2 or 3 support surfaces is often deficient. Providing the ICD-9 code (no narrative) is often problematic. Documentation of compression is often problematic and time-consuming for providers to locate. For chronic wounds, the records are often in disparate locations and are difficult to obtain.” 6) What documentation suggestions would you like to give providers? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “I think it would be helpful to use a checklist that lists the key documentation requirements specific to NPWT. I would not think this necessary for other types of DME, but it may be useful for NPWT.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC Make preset clinical forms and monthly progress report forms similar to the prescription forms. This guides the data collector in recognizing the necessary documentation. It would be helpful to make an easy to use “guidance sheet” for providers and nurses so they understand upfront what data is necessary.” 7) Do you have any suggestions to assist providers justify the medical necessity for NPWT? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “The LCD is pretty clear on the requirements for medical necessity. Familiarity with those requirements would be the best guide.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC “Read the LCD and the updated bulletins. Know the indications, contraindications, and precautions. Occasionally, providers may order NPWT for wounds that do not qualify. This may include wounds that are too shallow, have too much necrosis, or minimal amounts of exudate. This is because some providers are probably not aware that: Medicare covers NPWT if the wound has a minimum depth of 0.5 cm Medicare requires providers to order a stationary pump with the largest capacity canister for heavily exudating wounds. Medicare only allows 10 canisters per month unless the wound produces more than 90 ml (cc) of exudate per day” Randall R. Carson, Director, Government Affairs & Reimbursement, North America, Smith & Nephew, Wound Management “If NPWT is being used as a first-line therapy, it is important that the medical record indicate the rationale. Previous therapies have to either have been tried or ‘ruled out;’ often, it is not clear why they were ruled out. Said another way, the clinician should clearly outline the barriers to healing that warrant use of NPWT without trying more conservative therapy first.” 8) What reimbursement advice would you like to offer to providers who order your product for their patients? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “Frankly, I don’t think providers need to be NPWT reimbursement “experts”. Having familiarity with the LCD and working with a knowledgeable, professional NPWT supplier would handle 90%+ of the issues we see. The only other advice I would give is to stay abreast of NPWT policy changes by subscribing to the many CMS newsgroups and commercial news services. The NPWT category is subject to ever changing health policies. These are likely to increase over the next few years.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC “Providers should understand the guidelines before they start to ensure positive outcomes for the patient and the facilities. Select the wounds that qualify for NPWT and have a Goal of Therapy in mind: Why are you choosing NPWT? What do you want it to do and how long do you think it will have to be used to achieve the Goal? NPWT is an adjunctive therapy for wound healing. If you don’t have improvements within 2 weeks, NPWT may not be the right choice at that time. Stay current with the latest science on NPWT.” Randall R. Carson, Director, Government Affairs & Reimbursement, North America, Smith & Nephew, Wound Management “Understand the LCD guidelines about orders and medical records. Understand who can provider direct supervision for the application of the product in the wound clinic. Understand the payer’s rules about physicians providing the patient’s diagnosis that justifies medical necessity for the procedure/product.” 9) What reimbursement advice would you like to offer to medical equipment distributors that supply and bill Medicare for your product? Joseph Rolley, VP Global Government Affairs & Health Policy, ConvaTec, Inc “Diversify your payer mix to include both public and private payers. While Medicare may be a fairly predictable source of reimbursement, competitive bidding and other challenges are coming down the road, which may disrupt this. Having multiple sources of payer revenue provides a hedge against these disruptions and also helps in securing hospital referral sources.” Cindy Ahearn, Director of Clinical Services, Prospera Technologies, LLC “Know the LCD and bulletin updates regarding NPWT. You can be successful if you follow the guidelines. Stay current with the industry and intermediary actions. Develop a close relationship with the manufacturer, in order to better understand, represent, and service the product.” Randall R. Carson, Director, Government Affairs & Reimbursement, North America, Smith & Nephew, Wound Management “We have had providers attempt to bill for our NPWT but have stopped due to the high audit rate and the long time required to be paid due to the prepayment audit protocol. I would advise distributors that for the initial six months (?) or until audits diminish, to gather the medical records to support each placement. That will expedite responding to prepayment audit requests and speed the payment process. Otherwise, smaller suppliers are unable to commit the financial resources up front to ‘keep the lights on’ while Medicare does its diligence.”