Basics of Wound Care Medical Billing
The billing of wound care services usually involves a thorough review of the patient’s medical record for the wound, including wound dimensions, chronic diseases (diabetes, chronic ulcers, quadriplegia, etc.), procedures offered to manage the wound, follow-up, first visit, photographs of the wound, and wound progress. Some of the basics of wound care medical billing are discussed below:
Importance of Place of Service (POS)
In any given day, qualified healthcare professionals (QHPs) often perform wound care services for patients in various sites of care. For example, a physician may spend the first 4 hours of the day in the hospital-based outpatient wound care department (place of service 22), then see patients for 2 hours in the hospital (place of service 21), and finally see patients for 2 more hours in his or her private office (place of service 11). Because the Medicare Physician Fee Schedule pays more for services provided in a QHP’s office than in facilities, the QHP must establish a process for informing billers exactly where each patient encounter occurred. Otherwise, the billers may assume that all the encounters occurred in the QHP’s office and will overbill the Medicare program.
HOPD and QHP
When patients are seen by a QHP in an HOPD, the patients and Medicare receive two bills: one from the HOPD and one from the QHP. When patients are seen by a QHP in his or her office, the patients and Medicare only receive one bill. Patients should be informed about whether they should expect one or two bills.
NCDs and LCDs
NCDs and LCDs provide Medicare coverage rules that specify – coverage indications, limitations, and/or medical necessity; covered/non-covered product codes, procedure codes, and modifiers; covered diagnosis codes; utilization guidelines; and documentation guidelines. Wound care professionals must know these coverage rules. If a Medicare patient’s medical condition aligns with the coverage rules, the service/product/procedure has a good chance of Medicare payment. If not, the wound care professional should explain the coverage situation to the Medicare beneficiary and give the beneficiary the opportunity to receive and personally pay for the necessary care. That is achieved by the wound care professional providing the Medicare beneficiary with an Advance Beneficiary Notice of Noncoverage (ABN) and by the beneficiary signing the notice and agreeing to pay for the care.
Related Article: USING MODIFIER 25 IN WOUND CARE? EXERCISE CAUTION
Number of Units for Same Procedure
CMS publishes a list of Medically Unlikely Edits (MUEs) that identifies the maximum number of units that may be submitted per date of service or per claim. CMS does not publish all of the edits for a number of units allowed – some are known only to CMS and the MACs that process the claims. Nevertheless, wound care professionals can easily locate the published MUEs on the NCCI web page.
Number of Units Reported
The number of units reported for the application of the CTPs should follow the description of the application code, which will either be for 25 or 100 sq cm increments of wound surface area. The number of units reported for the actual CTP depends on the number of sq cm that was opened for that application. For example: If 21 sq cm of a particular “low-cost” CTP were opened for an 18 sq cm wound on the leg, the HOPD claim to Medicare would be – C5271 1 unit QXXXX 21 units
97597 Vs. 11042
QHP should congratulate his or her coders because they are doing their best to provide correct coding rules. The 2015 CPT®* manual clearly describes 97597 as the code to use when the only epidermis and/or dermis are debrided. It is true that CMS designated 97597 as a “sometimes therapy” code. That simply means that therapists who perform 97597 are required to attach a therapy modifier to the code on the claim form. If QHPs perform 97597, they simply bill the code on the claim form; no modifier is required. It’s important to remember that wound care professionals should not select codes to report based on the reimbursement rates they like best.
With the complexities involved in coding and billing wound care services, the support of an expert can be invaluable to ensure proper reimbursement. E2E Medical Billing Services has expert coders who understand management modalities and services that are bundled by payers or packaged for payment. To know more about our wound care medical billing services call us at 888-552-1290 or write to us at [email protected]