Most Reimbursement Questions Cannot Be Answered With a Simple “Yes” or “No”

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Every month wound/ulcer management professionals contact this author/consultant and say, “I have a simple question for you. Will I get paid if I perform [name of service, product, and/or procedure]?" When I answer them honestly by saying, “It depends. You will have to describe your scenario,” they frequently get impatient and say, “Just tell me, is the answer yes or no.” Because this author/consultant also trains sales representatives how the services, procedures, and/or products they sell fit into the various payment systems of their customers, I often receive the same response from them.

Professionals and sales representatives, who are willing to describe the scenario that aligns with their question, quickly learn that one answer does not apply to all scenarios surrounding the same service, product, and/or procedure. In fact, the professionals and sales representatives often request that I provide education to them and their revenue cycle team about coding, coverage, and payment for their target physicians and places of service. I often hear professionals and sales representatives who have attended my training sessions, say, “If Kathleen asks you what the question behind the question is, you have not provided enough detail in your scenario.”

To better explain this to you, let us look at a question I received via email just last week. I am not going to answer the question in this article because I was not given enough information. Instead, I am going to describe all the scenario components that should have been provided before this or any other reimbursement question is asked. The question was, “Will I get paid if I report 15002 and the application of a cellular and/or tissue-based product (CTP) for skin wounds (15271–15278) at the same encounter?” Because I did not receive enough information, I made a courtesy call to the person who sent the question and tried to obtain details about the scenario. Very quickly, I concluded that this person and her revenue cycle team did not know the scenario details and did not understand some of the essential wound/ulcer management reimbursement fundamentals. When I offered to create a virtual reimbursement education class for the team, the person said, “We do not need a class. Just answer ‘yes’ or ‘no’ to my question.” Because I could not honestly answer the question, I thanked the person for contacting me and encouraged her to contact me once she has more details about the scenario surrounding her question.

Because I often encounter situations like this, I decided to share the scenario components that you need before you or I can answer reimbursement questions. If you do not understand the components and facts, I recommend that you research the answers and/or attend an educational program about the topic.

Scenario Details That Should Be Collected Before Asking Reimbursement Questions

• What is the specialty of the professional who will perform the work?
• Where is the work performed?
• What payer(s) is/are involved?
• What does the payer’s coverage policy say about the topic?
• Do you have a contract with the patient’s payer?
• Does the payer follow the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits?
• Is the patient in a Medicare Part A covered skilled nursing facility stay or receiving Medicare Part A covered care by a home health agency?
• What is the patient’s diagnosis?
• Are you managing a burn, a traumatic wound, a necrotizing infection, or a chronic ulcer such as a diabetic foot ulcer or a venous ulcer?
• Is this a new wound/ulcer?
• What brand CTP does the physician or qualified healthcare professional (QHP) intend to apply?
• Why is that brand CTP reasonable and necessary for that patient?
• How many times does the physician/QHP expect to apply the CTP in a 12-week period?

Facts That Should Be Considered When Answering Reimbursement Questions

• Documentation in the specific patient’s medical record
• Code description and guidelines
• Medical specialty(ies) covered to perform these surgical procedures.
• Contracts with private and commercial payers
           o   The professional’s and facility’s contract with each payer may dictate who can perform the work, where it can be performed, for what diagnosis it can be performed, if the two procedures will be paid at the same encounter, how much they will be paid, and if the specific brand of CTP is covered.
• Coverage policies of each patient’s insurance plan
           o   Covered places of service where procedure(s) may be performed.
           o   One, or both, of the procedures may only be covered for a certain diagnosis or diagnoses, or for certain types of wounds/ulcers; the coverage guidelines for both procedures may not align.
           o   One, or both, of the procedures may only be covered for new wounds/ulcers.
           o   Specific CTP brands that are covered
• Outpatient Prospective Payment System (OPPS) status indicators
• Medicare Physician Fee Schedule (MPFS) global days and multiple procedure reductions
• NCCI PTP edits for code pairs

Summary

Because wound/ulcer management is performed by a variety of medical professionals, for a wide range of wounds and ulcers, for patients in various places of service and who have a wide variety of insurance plans with disparate coverage and payment guidelines, wound/ulcer management stakeholders should not assume that all services, procedures, and products are paid the same for each patient.

Now that you have read the scenario details and the facts that must be considered before answering a reimbursement question, you should clearly understand why this author/consultant could not answer the question, about surgical site preparation and the application of a CTP at the same encounter, with a simple “yes” or “no.” Therefore, you should not make the mistake of answering reimbursement questions if you do not have the scenario details and if you do not understand all the reimbursement facts that must be considered.

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@gmail.com.