Over the past few months, this author read many blogs and articles written by wound and ulcer management professionals from across the country. One consistent theme centered around putting the patient first by using the best assessment methods available, developing an individualized plan of care, performing procedures and providing products that align with each unique plan and current clinical practice guidelines, adjusting the plan of care as the wound/ulcer improves or declines, fully documenting the wound/ulcer management provided, and educating patients and/or caregivers how to participate in their wound care to achieve the best possible outcome (ie, the highest possible patient satisfaction at the lowest cost to the patient and the payer). This is exactly what this author expects to read from professionals who strive to provide excellent patient-centered care.
As a reimbursement strategy/education consultant to wound/ulcer management professionals, facilities, and manufacturers, this author believes that professionals and facilities deserve to be paid adequately for their work and spends many hours educating these stakeholders how to document their work; select diagnosis codes that correctly describe the patient's condition at each visit; verify the patient's insurance coverage; determine the financial feasibility (of the covered service, procedure, and product options) to the professional, the facility, and to the patient; report the correct codes for the work performed and the products provided; and conduct internal audits to ensure compliance with pertinent regulations.
Therefore, when presenting reimbursement education seminars and performing teleconsultations during the past few months, this consultant was quite surprised to routinely be asked questions such as:
* Which surgical dressing has the highest Medicare allowable rate?
* Which cellular and/or tissue-based product (CTP) for skin wounds has the highest average sales price (ASP)?
* Does the evaluation and management (E/M) code 99213 have a higher Medicare allowable rate than the selective debridement code 97597?
Before answering reimbursement questions, this consultant always takes time to identify the exact scenario, understand the question-behind-the-question, and learn how the professional/facility intends to use the answer. Often, the professionals and facilities seemed focused on their reimbursement, rather than on the patients' needs, copayments, and outcomes. To better understand what this consultant learned, let us take a look at each of the above scenarios.
WHICH SURGICAL DRESSING HAS THE HIGHEST MEDICARE ALLOWABLE RATE?
The question-behind-the-question was: "I am also a durable medical equipment (DME) supplier and want to use the surgical dressings with the highest Medicare allowable rate." Upon reviewing the 2023 Medicare national average rates for surgical dressings, we learned that collagen dressings were among the highest paid surgical dressings. We then researched to see if any other surgical dressings were covered for the same type of wounds. This is what we found:
* Collagen-based dressings are covered for full-thickness wounds, wounds with light to moderate exudate, or wounds that have stalled. They can stay in place up to 7 days, but many are changed daily. A collagen dressing less than or equal to 16 in2 (A6021) has a 2023 national average Medicare allowable rate of $27.96 each.
* Hydrocolloid dressings without adhesive borders are also covered for wounds with light to moderate exudate and may be changed up to three times per week. A hydrocolloid dressing with no adhesive border that is less than or equal to 16 in2 (A6234) has a 2023 national average Medicare allowable rate of $22.37 each.
The physician or other qualified healthcare professional (QHP) should select the type of surgical dressing that is medically necessary for each patient's wound/ulcer and that meets the Medicare coverage and frequency of change guidelines. Table 1 displays the 2023 financial impact to the DME supplier and to the patient when collagen and hydrocolloid dressings are ordered by the physician/QHP. Selecting a surgical dressing simply because it pays more to the DME supplier usually causes the patient to incur a higher copayment. If the higher-paying dressing is medically necessary for the patient's condition, then the benefit may outweigh the patient's cost. However, the physician/QHP should discuss the copayments of various options with the patient. If patients cannot afford their surgical dressing copayments, they often do not accept the order from the DME supplier and do not return for further care.
WHICH CTP HAS THE HIGHEST PUBLISHED ASP?
The question-behind-the-question was: "I apply CTPs in my office and Medicare typically pays ASP + 6% for the product. Therefore, if I purchase the product with the highest ASP, I receive higher reimbursement." By reviewing the January 2023 Medicare Part B Drug and Biological ASP Quarterly Payment File, we identified the CTPs with the highest and the lowest ASP per cm2. We also discussed that the physicians/QHPs should (1) verify if the patient's payer covers the selected CTP for each patient's wound/ulcer type and (2) review the published evidence pertaining to each CTP to verify that they positively impact wounds/ulcers that were similar to each patient's wounds/ulcers. This is important because, if the CTP is not covered, the physician/QHP will not receive any reimbursement from the payer.
If the lower-cost CTPs provide the same outcome for that type of wound/ulcer, the patient may prefer these over the highest-cost CTP. Therefore, the physician/QHP should discuss the patient's copayment responsibility for the various CTP options available for his/her wound type. This discussion should increase the likelihood of the patient's return for future CTP applications.
Table 2 displays the 2023 financial impact to the physician/QHP office and patient when a CTP with the highest versus lowest ASP is applied. Selecting a CTP simply because it pays more to the physician/QHP office usually causes the patient to incur a higher copayment, which may not be affordable. However, if the CTP with the highest ASP is documented as medically necessary for the patient's condition, then the patient may decide that the benefit outweighs the higher cost.
DOES 99213 HAVE A HIGHER MEDICARE ALLOWABLE RATE THAN 97597?
The question-behind-the-question was: "If the E/M code pays more than the selective debridement code, I will report the E/M and not the selective debridement, even though I perform selective debridement." Of course, this consultant reminded the physicians/QHPs that when a code exists for a procedure that was performed, that code should be reported. Nevertheless, we proceeded to compare the 2022 Medicare national average allowable Medicare Physician Fee Schedule for 99213 and 97597. NOTE: We did not compare the 2023 Medicare Physician Fee Schedule rates because they were not finalized at that time.
If the physician/QHP office correctly reports 97597 when it is performed, the Medicare allowable rate is higher than the rate for 99213 (Table 3). In addition, the cost to the patient is also higher for the 8 weeks of selective debridement.
SUMMARY
This author hopes that all wound/ulcer management professionals and facilities will (1) select services, procedures, and products based on each patient's unique needs; (2) consider each patient's out-of-pocket costs; and (3) document the medical necessity of services and treatments provided at each visit, as well as the procedures performed. This will ultimately lead to appropriate reimbursement for the appropriate service, procedure, and product provided at each patient encounter.