Since the beginning of the year, this author has had the honor of delivering numerous wound management-related reimbursement presentations throughout the country. At the end of each session, the attendees always comment about how much they learned about coding, payment, and coverage regulations. However, after the attendees return to their wound management businesses and share the new reimbursement information with their clinical and revenue cycle teams, this author frequently receives emails and phone calls asking, "Where can I find the reference to [some piece of reimbursement information] that you presented?"

Because wound management professionals and their entire revenue cycle team should routinely review reimbursement resources, here are some references that have been frequently requested to aid in this process.

Business Process Issues

* The new Medicare Benefit Identifier cards were released in phases by geographic location and are currently in a transitional implementation period. Effective January 1, 2020, providers and professionals may not submit claims with the old Medicare numbers based on beneficiaries' social security numbers. The Centers for Medicare & Medicaid Services (CMS) has an excellent website about the new cards: http://www.cms.gov/medicare/new-medicare-card

* The new D4 Undersea and Hyperbaric Medicine physician specialty code allows these physicians to be compared with each other rather than with other, unrelated specialties. The following announcement is about this new specialty code: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/

* Direct physician supervision is required in hospital-owned outpatient wound management provider-based departments (PBDs) for all services and procedures except the application of an Unna Boot, the application of multilayer compression bandages, and smoking cessation sessions. The following document lists the various CMS decisions about whether direct or general supervision is required: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientP

* Hospital-owned outpatient wound management PBDs often submit monthly claims to Medicare, which jeopardizes accurate justification of medical necessity for each encounter. When asked why they submit monthly claims, PBDs claim the CMS considers wound management to be a "repetitive service" that must be billed monthly. The following document proves that the PBD is not a "repetitive" service: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatte

* Hospital-owned outpatient wound management PBDs often market their services to skilled nursing facilities (SNFs) and home health agencies (HHAs) and promise them that they will not incur any charges for the work of the PBD. That is not true if the service and/or procedure provided is on the SNF or HHA consolidated billing list. See http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html and http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/codin.

Coding Issues

* To streamline the physician and qualified healthcare professional (QHP) documentation during evaluation and management visits, the following changes took effect on January 1, 2019: (1) Physicians/QHPs are not required to reenter the patient's chief complaint and history that a staff member already entered into the medical record; however, they must indicate in the medical record that the information was reviewed and verified; and (2) for established visits, physicians/QHPs are now only required to document changes since the last visit. A very good review of this regulation can be found here: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatte.

* When physicians purchase and apply cellular and/or tissue-based products for skin wounds in their offices, they must document the entire procedure, including the amount of the product purchased, applied, and wasted. If a portion is wasted, the Medicare claim must report the product "Q" code on two claim lines: one for the amount applied and the other for the amount wasted. Many offices do not believe this and ask for the reference, which is http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatte.

* The National Correct Coding Initiative Edits are among the most useful coding references and tools available to wound care professionals and providers because they clearly identify when Medicare believes one procedure is integral to another procedure. This reference should be consulted to determine if Medicare will pay for two procedures performed at the same encounter (http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.ht).

* Effective July 15, 2019, when a National Correct Coding Initiative Edit exists for two procedures that a physician/QHP performs on different anatomic locations of the same patient during the same encounter, the physician/QHP may append modifier -59 or -XS to either column I or column II codes. Because this appears to be a little-known fact, here is the reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatte.

* The medically unlikely edits (MUEs) are the maximum number of units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Most providers believe they will never get paid for units of service that exceed the MUE number, which is not true: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html.

Coverage Issues

* When this author mentions Medicare Local Coverage Determinations (LCDs), multiple audience members usually raise their hand and ask, "What's an LCD?" Put simply, LCDs are your Medicare Administrative Contractor's (MAC's) policies about coverage guidelines. All wound management physicians/QHPs should read all of the LCDs that pertain to the work performed and should incorporate these guidelines into their practices. Information on LCDs can be found here: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

* All wound management stakeholders should participate in the LCD Process as well as the LCD Reconsideration Process. Recent regulations have made both processes transparent and open to everyone, including Medicare beneficiaries. This document explains both: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMatte.

* This author is always surprised to learn that very few wound management physicians/QHPs use the Advance Beneficiary Notice of Noncoverage. This document should be given to a patient when a service normally covered by Medicare may not be covered for that patient and should include a description of the service, the reason Medicare may not pay, and the estimated cost. Follow this link to a great instruction booklet about these notices: http://www.sfdph.org/dph/files/CBHSdocs/BHISdocs/UserDoc/abn_booklet_icn006266.p.

Payment Issues

* Most wound management stakeholders do not realize that the Medicare fee-for-service program does not pay for telehealth services when a patient is in his/her home and that the originating site must be located either (1) outside of a metropolitan statistical area or (2) in a Rural Health Professional Shortage Area that is located either outside of a metropolitan statistical area or in a rural census tract. This author is continually challenged about this regulation and frequently shares this reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProdu.

* Wound management stakeholders are surprised to learn that the Merit-Based Incentive Payment System was expanded in 2019 to include physical therapists, occupational therapists, registered dietitians, and nutrition professionals. See: http://www.cms.gov/Medicare/Quality-Payment-Program/Quality-Payment-Program.html.

Audit Issues

* Most wound management professionals and providers have not proactively educated their revenue cycle team about the new Medicare Targeted Probe and Educate (TPE) program. Therefore, many failed the first round of the program because they did not submit the correct documentation, or they ignored the request and did not submit any documentation. Then, they failed to take advantage of the education program that the MAC offers at the end of each TPE round. If the entire medical team and revenue cycle team participate in the education program and implement what they learned, no one should fail the second TPE audit round! To learn about TPE audits, visit http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medi.

* All wound management professionals and providers should conduct monthly audits on topics (1) for which they receive claim denials, (2) when their MAC is conducting TPE audits, (3) that the Office of Inspector General has included on its Work Plan, and/or (4) that the Comprehensive Error Rate Testing program includes in its reports. You can find the OIG Work Plan at https://oig.hhs.gov/reports-and-publications/workplan/index.asp and the CERT program information at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medi.

Summary

As you enter the second half of 2019, this author recommends familiarizing yourself with these very important reimbursement resources. We expect our favorite sports team to know the rules of the game, to have a game plan, and to follow their playbook at each game. Similarly, we must know the reimbursement rules, develop protocols that are aligned with the rules, follow protocols, and thoroughly document our work.