This author has been sharing coding, coverage, and payment regulations/guidelines with wound/ulcer management stakeholders for nearly three decades. When this author provides reimbursement education in live symposiums, workshops, and webinars, many professionals report that they get paid even when they do not follow the regulations/guidelines. Unfortunately, there are many ways to push claims through the payment software and receive payment that do not align with all the regulations/guidelines. However, if the medical records do not support the paid claims, wound/ulcer management professionals can incur sizeable repayments during post-payment audits. Although this author used to worry about professionals receiving payment, now she worries more about them keeping their payments after audits.
During the COVID-19 public health emergency, the CMS temporarily suspended most audits. Therefore, wound/ulcer management professionals experienced a false sense of security when claims were paid even though their documentation and coding did not align with published regulations and guidelines. Ever since the CMS restarted the audits, this author 1) has received numerous calls from professionals who are undergoing audits pertaining to the published regulations and guidelines, and 2) has read audit reports regarding repayments for some of the issues that this author has been warning about for many years. Let us review some of the repayment issues that were recently reported.
INCORRECT REPORTING PLACE OF SERVICE WHEN APPLYING CELLULAR AND/OR TISSUE-BASED PRODUCTS
When physicians apply cellular and/or tissue-based products (CTPs) in their offices, they should purchase the CTP and report the application code and product code on the same claim. Because CTPs are typically labeled as single-use products, portions of the CTPs should not be saved and used on another person's wound/ulcer. Physicians should document the number of sq. cm. purchased for each patient, the number of sq. cm. applied, and the number of sq. cm. discarded. The amount applied and the amount discarded should be reported on separate lines of the claim.
When physicians apply CTPs in facilities such as hospital-owned outpatient wound/ulcer management provider-based departments (PBDs) or ambulatory surgery centers (ASCs), they should only report the application code and the correct place of service code on the claim. Because the PBD or ASC purchased the CTP, the facility should report both the application code and the product code on their claims.
In a recent audit described to this author, a physician applied the CTP in an ASC, but reported both the application code and the CTP code on the claim and indicated that the place of service was the office. Therefore, the physician was overpaid because he performed the work in a facility and did not actually purchase the CTP. The audit also uncovered that the physician double-billed for product not purchased because he did not discard the unused portion, used it on another patient, and billed Medicare for the product again. This resulted in a repayment of nearly $24 million.
APPLYING CTPS BEFORE STANDARD WOUND CARE
Most payers in the country expect wound/ulcer management physicians to document each patient's unique condition and detailed treatment at every encounter. In addition, most payers require documented standard wound care to be tried and failed for a minimum of 4 weeks before applying CTPs.
In a recent audit, a podiatrist did not document the patients' unique condition (copy and pasted medical notes) and did not perform standard wound care for 4 weeks prior to applying CTPs. The VA Choice Patient-Centered Community Care program determined that these CTP applications were medically unnecessary, and the repayment was $7 million.
INCORRECT REPORTING OF EVALUATION AND MANAGEMENT (E/M) WITH WOUND CARE PROCEDURES
Nearly all of the wound/ulcer management procedures performed in physician offices and PBDs are considered "minor procedures," which include E/M. Therefore, Medicare generally does not permit separate billing for E/M performed during the same encounter with a minor procedure unless the E/M service was significant, separately identifiable, and above and beyond the usual perioperative care associated with the minor procedure.
In a recent audit, E/M services were routinely reported for the same encounter when a minor procedure was performed and no other significant, separately identifiable E/M problem existed. This resulted in a repayment of more than $250,000.
FOLLOWING THE NATIONAL COVERAGE DETERMINATION (NCD), BUT NOT THE LOCAL COVERAGE DETERMINATION (LCD) AND LOCAL CODING ARTICLE (LCA)
When the CMS release an NCD, the Medicare Administrative Contractors (MACs) must implement the coverage guidelines in the NCD, but the MACs may also release LCDs/LCAs with further guidelines. In those cases, wound/ulcer management stakeholders must incorporate both the CMS and MAC coverage guidelines into their medical decision-making process, their documentation, and their coding.
In a recent audit, a physician followed the NCD guidelines, but failed to follow the LCD/LCA guidelines for the procedure. This resulted in a repayment of more than $250,000.
INCORRECT REPORTING OF MID-LEVEL PROFESSIONALS' WORK "INCIDENT TO" PHYSICIANS' WORK
If a mid-level professional, such as an NP, provides care to a patient in a physician's office and the physician and NP follow all the "incident-to" regulations, the physician can bill for the service and should be eligible to receive 100% of the Medicare allowable rate for that service or procedure (80% from Medicare and 20% from the patient or their secondary insurance). Some of the "incident-to" regulations are:
* The service must be part of the patient's normal course of treatment, for which the physician personally performed the initial service and remains actively involved during treatment.
* The physician must provide direct supervision (must be present in the immediate office suite to render assistance if needed), but the physician does not have to be present in the patient's treatment room while the mid-level provider renders the service. NOTE: If the physician is a solo practitioner, he/she must directly supervise the care provided by the mid-level professional. If the physician is in a group practice, any physician member of the group may be present in the office to supervise the mid-level professional.
* The "incident-to" service must be the type commonly performed in a physician's office, not in an inpatient facility.
* The medical record must document the essential requirements for "incident-to" services.
* The physician must incur the expense for the mid-level provider and the supplies used.
If the NP provided the service or procedure outside of the "incident-to" regulations, the NP should bill under her/his own provider number and should be eligible to receive 85% of the Medicare allowable rate (80% from Medicare and 20% from the patient or their secondary insurance). However, when an NP leaves the office and performs services and procedures without the presence of the physician, the NP should not bill "incident-to" the physician.
In a recent Office of Inspector General audit, mid-level professionals performed work in an acute care hospital and billed all the services "incident-to" physicians who were not present. This resulted in a repayment of more than a half-million dollars.
This author recommends that mid-level professionals and physicians should carefully read Medicare's "incident-to" regulations1 and implement a process for 1) clearly documenting when they perform "incident-to" work, and 2) informing their coders and billers when their work should be billed under the provider number of the mid-level professional versus the physician. Keep in mind that "incident-to" only applies when the mid-level professional provides services or procedures under direct supervision in place of service 11 Office, for established patients with established problems, and with established treatment plans that were created by the physician.
SUMMARY
When you read about, or are taught about, pertinent CMS regulations and guidelines and/or coverage and coding guidelines from the MAC that processes your claims, take the time to study the guidelines. Then make the appropriate modifications to your medical decision-making process, documentation, and coding. Once the guidelines have been implemented, print the pertinent medical records, and conduct an internal audit to verify that your medical records align with all the payers' coverage, coding, and payment guidelines. If they do, keep up the excellent work. If they do not, make the necessary refinements and conduct another internal audit to assure yourself that you will keep your payments when you are audited.
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