1. Schaum, Kathleen D. MS

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Wound care professionals who work in outpatient wound care departments in critical access hospitals (CAHs) continue to have many questions about their Medicare fee-for-service payment program. This is understandable because CAHs have several payment options to choose from, but their coding and coverage regulations are like hospital outpatient wound care provider-based departments (PBDs). Here are some frequently asked questions that this author has received on this topic.


Q: What are the criteria for CAH certification?


A: The CAH must:


* Be in a state that established a state rural health plan for the State Flex Program.


* Be in a rural area or be treated as rural under a special provision that allows qualified hospital providers in urban areas to be treated as rural.


* Demonstrate compliance with the CAH conditions of participation (CoPs) at the time of application for CAH certification, and at all times subsequent to the initial certification.


* Furnish 24-hour emergency care services 7 days a week, using either on-site or on-call staff, with specific on-site response timeframes for on-call staff.


* Maintain no more than 25 inpatient beds that may also be used for swing bed services. It may also operate a distinct part rehabilitation and/or psychiatric unit, each with up to 10 beds. The CAH distinct part units must also comply with all hospital CoPs in addition to CAH CoPs.


* Have an annual average length of stay of 96 hours or fewer per patient for acute care (excluding swing bed services and beds within distinct part units). This requirement cannot be assessed on initial certification but applies after CAH certification.


* Be located either more than a 35-mile drive from any hospital or other CAH or located more than a 15-mile drive from any hospital or other CAH in an area with mountainous terrain or only secondary roads.



Q: Does Medicare pay CAH outpatient wound care departments via the Outpatient Prospective Payment System (OPPS)?


A: No, CAHs may select from 1 of 2 Medicare outpatient payment options, known as Method I and Method II:


Method I: Standard Payment Method


* The CAH bills for outpatient facility services on a Part A UB-04 claim and is paid 101% of reasonable costs (less applicable copays and deductibles).


* Physicians or other qualified healthcare professionals (QHPs) bill their own services on a Part B 1500 claim form and are paid via the Medicare Physician Fee Schedule (MPFS) that is identical to the payment they receive when they work in wound care PBDs paid under the OPPS.



Method II: Optional Payment Method


* The CAH bills on the UB-04 claim for both facility services and professional services furnished to its outpatient patients. Under this method, the physician or QHP must reassign his/her billing rights to the CAH. Payment is based on the sum of:



- For facility services: 101% of reasonable costs, after applicable deductions


- For physician professional services: 115% of the MPFS allowable amount, after applicable deductions


- For nonphysician practitioner professional services: paid based on the lesser of the actual charge or a reduced fee schedule amount of 85%. Payment is calculated as follows: [(facility-specific MPFS amount) x the nonphysician practitioner services reduction (0.85) - (deductible and coinsurance)] x 1.15.



NOTE: Even if a CAH selects this optional payment method, each physician or QHP who furnishes professional services to CAH outpatients can choose to either:


* Reassign billing rights to the CAH, agree to be included under the optional payment method, attest in writing that he/she will not bill Medicare for services furnished in the CAH outpatient department, and look to the CAH for payment for the professional services; or


* Not reassign billing rights to the CAH, file claims to Medicare for professional services, and receive standard payment under the MPFS (like Method I). In this case, the CAH only bills for facility services.



Q: Is there a standard attestation form that physicians and other QHPs should use to reassign billing rights to the CAH?


A: Physicians must use CMS Form-855R. This form should be sent to the applicable A/B Medicare Administrative Contractor (MAC) who will then require that the physician sign an attestation not to bill any professional services provided at the CAH to the A/B MAC. The CAH should create their own attestation form for signature.


Q: When billing for the CAH outpatient wound care department under Method II, what is the appropriate type of bill?


A: Use type of bill 85x on the claim for CAH outpatient wound care departments.


Q: When billing for professional fees under Method II, what are the appropriate revenue codes?


A: Professional fees should be billed with codes and charges that correspond to 1 of the following revenue codes:


* 096x, eg, 0960 general


* 097x, eg, 0977 physical therapy


* 098x, eg, 0982 outpatient services



NOTE: Claims submitted with unlisted codes (eg, XXX99) and with revenue code 096x, 097x, or 098x will be returned to the provider. If the CAH cannot find a more specific code, the physicians or other QHPs should contact the American Medical Association to request a code be assigned.


Q: When billing under Method II, does the multiple procedure payment reduction apply?


A: Yes, the multiple procedure payment reduction applies when multiple physician services are furnished by the same physician to the same patient in the same session on the same day. The CAH will receive 100% of the fee schedule amount for the highest valued procedure, 50% of the fee schedule amount for the second highest valued procedure, and 25% of the fee schedule amount for the third through the fifth highest valued procedures.


Q: When billing under Method II, is the physician's or other QHP's name required on the claim?


A: Yes. The attending/rendering provider's first and last name and valid national provider identifier is required.


Q: When a CAH bills under Method II, how does the A/B MAC know the credentials of other QHPs?


A: The CAH informs the MAC about the other QHP's credentials by adding a modifier to the submitted code. CAUTION: Failure to add a modifier when applicable will result in overpayment and potential audit.


Q: Do the "direct physician supervision" regulations apply to CAH outpatient departments?


A: In the calendar year (CY) 2009 and CY 2010 OPPS/ASC proposed rule and final rule with comment period, CMS clarified that direct physician supervision is generally required for hospital outpatient therapeutic services that are furnished in hospitals, CAHs, and in provider-based departments of hospitals. For several years, there was a moratorium on the enforcement of the direct supervision requirement for CAHs and small rural hospitals, with the latest moratorium on enforcement expiring on December 31, 2016. Therefore, in CY 2017, direct physician supervision was required in CAH outpatient wound care departments. In the 2018 outpatient prospective payment system Final Rule, CMS reinstated the nonenforcement of direct supervision enforcement instructions for outpatient therapeutic services for CAHs and small rural hospitals having 100 or fewer beds for CYs 2018 and 2019. Unfortunately, that left 2017 unaddressed. The new Bipartisan Budget Act of 2018 that was passed by Congress and signed into law on February 9, 2018 suspended the enforcement of the direct supervision requirement for CAHs and small rural hospital in 2017.


Q: Does packaging of cellular and/or tissue-based products for skin wounds apply to CAH outpatient departments?


A: No. They are paid separately for the application procedure and products.


Q: I heard that CAHs may be reimbursed by Medicare for telehealth services. Is this true?


A: Yes, it is true.


Q: What type of wound care-related services via telehealth may be eligible for reimbursement to outpatient wound care departments in CAHs?


A: The wound care related services are limited to consultations, office or other outpatient visits, and smoking cessation services.


Q: Some of our physicians told us that the -GT modifier is no longer needed on CAH telehealth claims. Is that true?


A: No, it is not true for CAHs. The -GT telehealth service rendered via interactive audio and video telecommunications system modifier is still required on CAH claim forms. NOTE: Because Alaska and Hawaii are permitted to provide asynchronous telecommunication for telehealth, CAHs in those 2 states should use modifier-GQ when they use asynchronous telehealth systems.


Q: Does the 3-day preadmission payment window, which applies to hospital-based outpatient wound care PBDs that are paid under the OPPS, apply to outpatient wound care departments in CAHs?


A: No, outpatient services provided to a beneficiary, who then becomes an inpatient, are not bundled into the CAH inpatient payment. The CAH outpatient services are billed separately from inpatient services. EXCEPTION: The 3-day preadmission payment window does apply if the CAH is wholly owned or operated by a hospital that is paid by the Medicare inpatient prospective payment system.


Q: Are the National Correct Coding Initiative and Medically Unlikely edits applicable to outpatient wound care departments in CAHs?


A: Yes


Q: Where can I find printed information about CAH reimbursement?


A: Two great resources are:


* Medicare Benefit Policy Manual, CMS IOM Publication 100-02, Chapters 1, 6, 8, 10, and 15


* Medicare Claims Processing Manual, CMS Publication 100-04, Chapters 1, 3, 4, and 6



Q: Does the CMS have a CAH website?


A: Yes: