At a recent wound care symposium postconference, I challenged the attendees to test their 2016 wound care reimbursement knowledge pertaining to issues that are often unknown or misunderstood. I provided the attendees with some wound care reimbursement statements-some statements were correct, whereas others were incorrect. After the attendees evaluated each statement, we discussed their answers, which, of course, usually led to more questions. Because of the interactive nature of the postconference, the 3 hours flew by quickly. Although this column does not have the space to print all the postconference learnings, I am sharing the wound care reimbursement statements and the short answers/explanations with you.

Before you begin the self-test, see Figure 1 for the acronyms that are used in the wound care reimbursement statements.

Figure 1. COMMON REIMBURSEMENT ACRONYMS

Now read the wound care reimbursement statements in Figure 2 and determine if each statement is correct or incorrect. After you have evaluated each statement, continue reading the remainder of this article for the short answers/explanations.

Figure 2. 2016 WOUND CARE REIMBURSEMENT

Coding Statements

#1 Incorrect

The HCPCS code descriptions, for CTPs that are covered by Medicare, are "per square centimeter," not "per piece."

#2 Incorrect

The HOPDs must not bill Medicare beneficiaries more than they bill other payers. Because other payers do not use the G0463 code, HOPDs should still use their mapping system to determine the correct clinic visit code. The HOPDs should charge all payers the rate attached to the mapped clinic visit code. In other words, G0463 should have 10 different Medicare charges affiliated with it.

#3 Correct

The description of 97602 clearly requires an order for nonselective debridement: removal of devitalized tissue from wound(s), nonselective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.

#4 Incorrect

The CMS labels 97597/97598 as "sometimes therapy" codes. If therapists perform the debridement, they are required to attach the therapy modifier to the code. If QHPs perform the debridement, they simply bill the appropriate code.

#5 Correct

The CMS hosted a podcast to clarify this topic on May 21, 2015.

#6 Incorrect

The QHPs should always report the Place of Service code to designate where the work was performed. Remember that work performed in the office is paid at a higher rate than work performed in facilities.

#7 Incorrect

The CMS has a robust ICD-10-CM website that includes the actual codes and many instructional tools.

Payment Statements

#8 Incorrect

The HOPDs may only Medicare for a clinic visit at the same encounter when a procedure was performed, if a separate, identifiable service was provided.

#9 Incorrect

The current year's NCCI Manual and the current quarter's PTP NCCI edits are the resources that HOPDs/QHPs should use to answer these types of questions. Sales representatives are not reimbursement experts and have no control over the NCCI Manual and NCCI edits.

#10 Correct

The following entities may adjust the level of codes (up or down) on claims and still pay the claims rather than denying the claims:

* MACs

* RAs

* ZPIC

* SMRCs

* CERT contractors

#11 Incorrect

The CMS publishes the HOPD and QHP allowable rates on their website. Note: The ASP rates for CTPs applied in a QHP office are in a separate drug/biological file.

#12 Incorrect

Orders must be written and signed by a QHP, who is physically present, before the WOCN changes a wound care service, product, or procedure.

#13 Incorrect

HOPDs require "direct physician supervision" for all HOPD services except the application of an Unna boot and the application of multilayer high-compression bandage systems.

#14 Incorrect

The HOPDs should report the correct HCPCS codes and the appropriate charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged.

#15 Incorrect

The HOPD will receive additional payment for the CTP with "pass-through status" only if the cost of the product is greater than the portion of the APC payment that is considered the device offset.

#16 Incorrect

The HOPDs do not incur costs for negative-pressure wound therapy durable medical equipment. The HOPDs do incur costs for disposable negative-pressure wound therapy pumps with exudate management systems. Therefore, HOPDs should set their charges for 97607/97608 at a higher rate to account for their costs to purchase the disposable negative-pressure system.

Coverage Statements

#17 Incorrect

The MCD contains all NCDs and LCDs, local articles, and proposed NCD decisions. The MCD is intended for use by Medicare contractors, physicians and other QHPs, and other healthcare industry professionals.

#18 Incorrect

Each MAC's LCDs can be found in 1 of 2 places:

* MAC's website

* CMS MCD

#19 Incorrect

A local policy may consist of 2 separate, though closely related, documents: the LCD and an associated article. The LCD contains only reasonable and necessary language. Any unreasonable and necessary language a Medicare contractor wishes to communicate to providers may be accomplished through the article. At the end of an LCD that has an associated article, there is a link to the related article and vice versa.

#20 Incorrect

All categories of LCDs should be reviewed by the physicians and other QHPS, as well as the entire revenue cycle team, on a monthly basis:

* active LCDs

* draft LCDs

* future effective LCDs

* retired LCDs

The physicians and other QHPs should provide appropriate comments to the MAC medical directors when LCDs are in draft form.