Transcript Wound Care Reimbursement 101

Wound Care
Reimbursement 101:
Keys to Success
Melissa Johnson PT, DPT, CWS
Southside Regional Director
Wound Care and Hyperbaric Services
Piedmont Healthcare, Atlanta GA
WHO SHOULD KNOW THE
RULES?
 Any
provider providing services to
patients
 Any
provider documenting and billing
services
 All
of YOU should know the basics
Our Challenge in Today's
Healthcare
 Using
diagnosis codes to support
medical necessity
 Keeping up with constant change
with coding
 Meeting documentation requirements
 Adapting to changing payment
systems
 Surviving an audit
 Continuing to maintain or make
revenue
3 Focus Areas for Success
 Coverage
– Are the procedures I am performing
covered?
 Coding
– Are the ICD 9 codes and CPT codes
medically necessary?
 Payment
– Am I getting reimbursed for the
treatment I am performing?
Tools For Success

Every year you should?
– Purchase or have available an updated CPT
book and ICD 9 book
– Know your Practice Act in your state
– Know your MAC (Medicare Administrative
Contractor)
– Read and monitor all local coverage decisions
(LCD) and national coverage decisions (NCD)
for your MAC jurisdiction throughout the year
– Verify insurance and payer to ensure prior
authorizations for procedures are not required
(ie; negative pressure, debridement, etc.)
Definitions


CPT – (Current Procedural Terminology)
Procedure/treatment being performed
ICD – 9 – Diagnosis code for what is being
treated; ex: diabetic foot ulcer – 250.80 and
707.15

MAC – Medicare Administrative Contractors

LCD – Local Coverage Decision

NCD – National Coverage Decision
Definitions continued

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
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Medical Necessity - Per guidelines the
procedure being performed meets medical
necessity for the diagnosis being treated
Modifiers –two digit code that modifies a
service/procedure so they can be billed
together
Revenue Codes – identifies who is doing
the procedure or treatment; i.e. physical
therapist is revenue code GP 420
Physician Fee Schedule – the fees that are
billed to Medicare patients for procedures
provided
What is your MAC?



MAC – Medicare administrative contracts
were formed to replace the contractors for
Medicare that process claims
19 MACS were formed (15 for part A and
B, then 4 others for durable medical)
Jurisdictions were created in 2009 to
replace fiscal intermediaries in each state
MAC MAP
Review All Medical Policies Related
to Your Business

Private Payers, Medicare Managed Care,
Medicaid, Workers Compensation, etc.
– Medical Policies for top 10 private payers
– Obtain prior authorization if required
 Ex:

Negative Pressure
Medicare
– Local Coverage Decisions
– National Coverage Decisions
 http://www.cms.gov/medicare-coverage-
database/overview-and -quick-search.aspx
Local and National Coverage
Decisions




These are your playbook
Documentation guidelines, CPT and ICD 9 codes
for medical necessity, descriptions, etc
Opportunities to respond and impact LCD in your
MAC regions
Need any LCD or NCD pertaining to all
procedures performed in the clinic
– Examples of NCD

Hyperbaric Oxygen
– Examples of the LCD



Physical Therapy
Debridement
Skin Biologicals
How do I know what I can bill
together?

National Correct Coding Initiative Edits
(NCCI)
– Allows bundling of services together by using a
modifier
– Shows what services can not be billed
together.
– Resource Website http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/How-To-UseNCCI-Tools.pdf
Example of NCCI Edit
CPT only copyright 2011 American Medical Association. All rights reserved.
National Correct Coding Edits
Column I Code: Comprehensive procedure
includes all the codes listed in column II
component codes
Column II Code: Component of
comprehensive procedure
Indicator 0- Not allowed even with
modifier
Indicator 1- Allowed with appropriate
modifier ( usually but not always 59
modifier
Indicator 9 – Edits are no longer active;
code combinations are billable, and no
modifier is needed
Types of Modifiers

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Modifier 25 – separate identifiable
evaluation and management service by
same physician or other healthcare
professional on same day of procedure
Modifier 59 – separate and distinct
procedure
Modifier 50 – bilateral procedure
NCCI Edit Example
 Mr
Jones has been treated in your
clinic for a abdominal wound where
debridement and negative pressure
wound therapy has been performed.
He has Medicare.
 Will
both procedures be reimbursed?
 Can
we add a modifier?
Questions
Review 2012 Coding Updates

Medical debridement (active wound
management)
– 97597 first 20 sq cm
– 97598 each additional 20 sq cm

Surgical debridement codes, depth of
tissue not per wound
– First 20 sq cm (11042, 11043, 11044)
– Each additional 20 sq cm (11045, 11046 and
11047)
– “Only bill for the area of the wound that was
debrided “– CPT Assistant May 2012
Example
 MR.
Jones is a patient that has a 5 x
5 x 3 pressure ulcer on his sacrum.
 You sharply debride devitalized
tissue from the entire wound surface.
 How would you bill?
 5x5 = 25 sq cm;
 Bill one unit of 97597 and one unit of
97598
 Questions?
Multi-Layer Compression
 29581
redefined- include leg (below
knee), including ankle and foot
 Addition of Multilayer Compression
Codes
– 29582 – Application of multi layer
compression system; thigh and leg,
including ankle and foot
– 29583- ……; upper arm and forearm
– 29584 …….; upper arm, forearm, hand
and fingers
Skin Substitute Graft Codes
 All
Graft codes now are the same
15271, 15272- apply to trunk,
arms,
legs,
15275, 15276- scalp, eyelids,
mouth , neck , hands, and feet
For Grafts over 100 sq cm based on
% of body
15273, 15274, 15277, 15278
Medicare Physician Fee Schedule

Fee schedule is a list of CPT codes that are
given a value based on a formula for
payment

Fee schedule is set by your MAC

Medicare pays 80% of physician fee

Patient pays 20% or if they have a
secondary insurance
Documentation
 If
its not documented it didn’t
happen
 Documentation should reflect
objective data and goals
 Documentation should reflect
services that are medically necessary
and meet utilization guidelines
Audits
 Do
internal audits of documentation
often identify areas of improvement
 Prepare
 The
for auditors
question is not if I will be
audited or when?
Meaningful Use
 American
Recovery and
Reinvestment Act of 2009 specifies 3
components:
– Use of certified HER in a meaningful use
as E- Prescribing
– Use of EHR technology for electronic
exchange of health information to
improve quality of care
– Use of HER to submit clinical quality and
other measures
Therapy Cap and G Codes
 Taxpayer
Relief Act 2012
– Outpatient hospitals will fall under
therapy cap through 2013
– Exceptions extended through
12/31/2013
– Therapy provided in critical access
hospitals (CAH) now subject to cap
Therapy Cap
 Therapy
Cap
– $1900 dollars for Physical Therapy and
Speech Therapy combined
– KX modifier required if cap is exceeded
and greater than $1900
– If dollars extend greater than 3700 the
record is subject to medical manual
review
Functional Limitation Reporting
All outpatient rehab, part A and part B will
be required to report functional limitations
in Jan 1 to July 1, 2013 as a testing period
 Claims submitted after July 1, 2013
without G codes will be unpaid
 Data collection is to assist in future
payment system
 Therapist driven, not billing

– Functional reporting must be documented by
therapist based on individual function
Documentation
 Documentation
needs to include:
– Functional Limitation documented in
chart
– Assign Category and G codes
– Assess and Report Severity
Example of G Codes
Severity Codes
APTA STATEMENT
Program Basics

Therapists will use valid and reliable
assessment tool(s) and/or objective
measure (s) in determination of the
severity of the functional limitation
– Multiple tools may be used
– Therapist judgment may be used in the
severity modifier determination in combination
with the data gathered
– Documentation of G-codes and the rationale
for selection must be included in the medical
record
2013 Wound Care Updates

Surgical Package Definition
– Identifies any supplies that are being billed
outside of what is required for procedure


3 collagen dressing codes have been
redefined with removal of word “pad”
Manual Therapy Code
– Considered by CPT a separate and distinct
service and can be reported together when
performed with multi layer compression
More Updates
6 New Q codes for biologicals
- Q4131 – Q4136 – may not be covered by some
MACS
Definition of Modifier 25 has been revised

Definitions changed throughout CPT
“Providers” to “professionals”
“Practitioners” to “individuals”
“Physician” to “qualified healthcare professional
or individual”
New Negative Pressure

NOT a replacement for 97605 and 97606
G0455 – Negative Pressure Wound
Therapy using a mechanical powered
device, not durable medical equipment,
including provision of cartridge and
dressing , topical application and
instructions for ongoing care; total wound
surface area less than 50 sq cm
 G0456 - …………; Greater than 50 sq cm

Websites

Physical Therapy State Practice Act
– www.fsbpt.gov



www.apta.org
http://www.apta.org/Payment/Medicare/
CodingBilling/FunctionalLimitation/
www.cms.gov
– Local coverage and national coverage decisions
Questions?
[email protected]