1. Schaum, Kathleen D. MS

Article Content

This author sincerely thanks all of the wound/ulcer management stakeholders who have supported and read this journal for the past 35 years and this reimbursement column for the past 21 years. In addition to the knowledge and advanced technology that we could not have envisioned 35 years ago, we also have benefitted from reimbursement for many procedures, products, and sites of care in recent decades. Following are a few examples:


* Products such as advanced surgical dressings, negative-pressure wound therapy (NPWT) durable medical equipment and disposable equipment, cellular and/or tissue-based products (CTPs) for skin wounds, total contact casts, and multilayer compression bandage systems


* Procedures such as application of durable medical equipment and disposable NPWT equipment, hyperbaric oxygen therapy, application of CTPs and multilayer compression bandage systems, low-frequency nonthermal ultrasound, and application of autologous platelet-rich protein for ulcers


* Services such as prolonged office/outpatient evaluation and management (E/M) visits, telehealth, real-time audio or video virtual visits, remote assessments of recorded video and/or images submitted by patients, patient-initiated online non-face-to-face digital e-visits via a Health Insurance Portability and Accountability Act-compliant patient portal or email, smoking cessation education, interprofessional telephone/internet/electronic health record (EHR) consultations (eConsult), remote patient monitoring, and medical nutrition therapy


* Diagnostics such as extracorporeal shock waves for wound healing; noncontact real-time fluorescence wound imaging; transcutaneous visible light hyperspectral imaging measurement of oxyhemoglobin, deoxyhemoglobin, and tissue oxygenation; and noncontact near-infrared spectroscopy studies of flaps or wounds


* Sites of care such as hospital-owned outpatient wound/ulcer management provider-based departments (in addition, skilled nursing facilities and home health agencies now receive higher reimbursement when they manage patients with wounds/ulcers)


* Professionals such as therapists, nurse practitioners, and physician assistants receive separate Medicare payment for their work



Keeping up with this explosion of services, procedures, products, and technology, as well as the coding, coverage, and payment legislation/regulations that had to be implemented, has kept all wound/ulcer management stakeholders on our toes. Therefore, for 21 of the 35 years of this fabulous journal's publication, this author has been dedicated to providing the reimbursement education necessary for professionals and providers to receive appropriate payment and prevent repayments and fines when audited.


One might think that this author would run out of reimbursement information to share each month. In reality, because reimbursement keeps changing, this author has to make a tough decision each month-what is the most important reimbursement news to report?


At this point, you may be wondering if this author has any reimbursement pointers for the financial success of wound/ulcer management professionals and providers for the future. The answer is a resounding "yes." As you carefully read each of the following pointers, if you cannot definitively say "yes, I am doing that perfectly," move quickly to correct it. As always, this author recommends establishing a formal process for reading pertinent reimbursement updates, attending pertinent reimbursement programs, and disseminating pertinent new reimbursement information to your entire clinical and revenue cycle team in a timely manner.


Coding Pointers


* Purchase new International Classification of Diseases, Current Procedural Terminology (CPT),* and Healthcare Procedure Coding System code books in the last quarter of every year.


* Review new, changed, and deleted codes, as well as the coding guidelines that pertain to those codes.


* Educate all members of your clinical team and your revenue cycle team about the changes.


* Update your EHRs, charge sheets, and charging systems to align with the coding changes.


* Know exactly when and when not to use modifiers on your claims.


Coverage Pointers


* Sign up to receive the CMS email updates regarding reimbursement topics relevant to your business:


* Sign up to receive your Medicare Administrative Contractor's emails:


* Sign up to receive the MedLearn Network Connects Newsletter:


* Research, read, and print all of the CMS National Coverage Determinations (NCDs) and your Medicare Administrative Contractor's Local Coverage Determinations (LCDs) and Local Coding Articles (LCAs) that pertain to your business.


* Review the NCD, LCD, and LCA database monthly to learn about any new, revised, or retired coverage documents; share with all physicians, podiatrists, qualified healthcare professionals, and revenue cycle staff.


* Incorporate all pertinent NCD, LCD, and LCA coverage guidelines into your medical decision-making, documentation (including EHR templates), ordering, and auditing processes.


* Print and read a representative sample of your complete documentation for various patient encounters monthly; compare that documentation with Medicare's coverage guidelines. REMEMBER: Auditors do not read your EHR screens. They read the printed medical record produced from your EHR. This author and many wound/ulcer management professionals and providers have learned that the printed medical records do not always "paint the picture."


Payment Pointers


* Learn the current year's Medicare payment regulations for services, procedures, and products that you perform and that you order for your patients; expect payment regulations to change many times over the next 35 years.


* Keep up to date with the National Correct Coding Initiative (NCCI) procedure-to-procedure edits that pertain to the procedures you perform. Read the relevant portions of the NCCI Policy Manual at the beginning of each year and review the pertinent NCCI Edit files that are updated each quarter.


* Review private payer, Medicare Advantage, and Medicaid contracts carefully before you sign them to ensure you will be paid adequately for the work you perform.


* Read the skilled nursing facility and home health agency Medicare consolidated billing updates every year and incorporate the regulations into your practices.


Audit Pointers


* Conduct internal audits that should identify coding, coverage, and payment errors before you are audited. If you are not sure what topics to audit, consider starting with these 10 commonly audited wound/ulcer management services, procedures, and products:


1. CTPs for skin wounds


2. Debridement


3. E/M of new and established patients


4. E/M or clinic visits reported with Modifier 25 when minor surgical procedures are performed


5. Hyperbaric oxygen therapy


6. Modifier use to unbundle procedures that are part of NCCI procedure-to-procedure edits


7. NPWT durable medical equipment


8. Work that is part of skilled nursing facility or home health agency consolidated billing and that is inappropriately billed to Medicare


9. Surgical dressings, especially alginate, collagen, and foam dressings


10. Telehealth


* If you receive an Additional Documentation Request, better known as an ADR, verify which auditing contractor sent the request and exactly what the auditor needs. If you are not sure, contact the auditor before you begin printing and assembling the requested documentation. Most important, submit the requested documentation at least 2 weeks before it is due.


* If you are selected for a Targeted Probe and Educate (TPE) audit and you fail the first round, take advantage of the educational session that is offered before the second round begins. Everyone on the team should attend the education session, including the medical director, physicians, qualified healthcare professionals, podiatrists, program director, nurses, therapists, chargemaster director, coders, and billers.



Just as clinical knowledge and technology have changed and advanced, reimbursement for wound/ulcer management in various sites of care and for all professionals and providers has changed every year for the past 35 years. We can expect many more reimbursement changes in the next 35 years. Wound/ulcer management professionals and providers should recognize that appropriate reimbursement is totally in their control if they:


* Establish processes to maintain their knowledge


* Document thoroughly


* Code accurately


* Maintain compliance at all times



Your financial success for the next 35 years depends on treating your business with the same care and attention used to treat your patients!


Writing the longest running column in this journal's 35-year history has truly been an honor. However, it could not have been accomplished without the cooperation and guidance of the dedicated editors who have worked tirelessly to produce this high-quality journal. As long as she is able and invited to write this column, this author is committed to working with the Editors-in-Chief and editorial staff to bring timely reimbursement education to the loyal readers.


Now let us thank Advances in Skin & Wound Care for supporting the wound/ulcer management professionals and providers for the past 35 years and for publishing the Payment Strategies column for the past 21 years.


* CPT is a registered trademark of the American Medical Association. [Context Link]