2004 Medicare Legislation and Regulations Impact Wound Management

Advances in Skin & Wound Care, Apr 2004 by Schaum, Kathleen D

Q: Has the Medicare Part B program ceased coverage of surgical dressings containing silver?

A: Yes and no. The Durable Medical Equipment Regional Carriers (DMERCs) recently clarified that coding of surgical dressings impregnated with silver is based on the other materials and features of the dressing, without regard for the silver. If the other material meets the definition of a dressing, such as gauze or foam, the product must be billed with one of those appropriate Health Care Procedure Coding System (HCPCS) codes. Examples of this include SilvaSorb Gel (Medline Industries, Mundalein, IL), which is A6248, and Silverlon Antimicrobial Silver Island Dressings (Argentum Medical, Clarendon Hills, IL), which is A6254 to A6256. HCPCS code A6248 is defined as hydromel dressing, wound filler, gel, per fluid ounce. Because SilvaSorb is mainly a hydrogel, it was verified into the hydrogel category. HCPCS codes A6254 to A6256 are defined as specialty absorptive dressing, wound cover, with any size adhesive border, each dressing. Because Silverlon Antimicrobial Silver Island Dressings met all of the criteria for the specialty absorptive dressing category, they were verified into this category by the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC).

If the other material serves only to deliver silver to the wound and does not meet the definition of a dressing, the product must be billed with HCPCS code A9270, which is noncovered item or services. An example of this classification is Acticoat Antimicrobial Barrier Dressing (Smith & Nephew, Largo, FL).

The SADMERC also states that HCPCS code A4649, surgical supply, miscellaneous, should not be used for dressings containing silver.

Q: What is the status of the physical therapy caps that went into effect on September 1, 2003?

A: Since therapy caps were introduced in the Balanced Budget Act of 1997, caps have been enforced and removed several times.The new Medicare Prescription Drug, Improvement, and Modernization Act of 2003, signed on December 8, 2003, placed an immediate 2-year moratorium on the enforcement of the therapy caps. This applies to claims received on or after December 8, 2003, through December 31, 2005, regardless of the date services were rendered.

In the meantime, Medicare plans to track therapy utilisation, requiring therapists to use correct therapy modifiers (!able 1) with the appropriate therapy codes on claims containing revenue codes 042X, 043X, or 044X.The Centers for Medicare and Medicaid Services (CMS) memo that reviews the modifier details is available online at: http://www.cms.hhs.gov/manu als/pm_trans/R30CP.pdf.

Some therapy codes must always include the therapy modifiers (Table 2). Other therapy codes (Table 3) need the therapy modifiers only if the patient is under a therapy plan of care and the therapist is not in private practice and service is"intcgral to an outpatient rehabilitation therapy service."

Q: Are there any new ostomy or surgical dressing HCPCS codes for 2004?

A: As of December 15,2003, there were no new ostomy or surgical dressing categories for 2004. The SADMERC did, however, convert several ostomy (Table 4) and surgical dressing (Table 5) HCPCS codes from temporary K codes to permanent A codes. These include the dressing set and canister set for the negative pressure wound therapy electrical pump. The, HCPCS code for the negative pressure wound therapy electrical pump was also changed from K0538 to E2402.

In addition, many compression bandage category descriptions were changed from "per roll" to "per yard."This category description change caused the "per roll" A codes to be deleted and new "per yard" A codes to be added.

All sites of service that use HCPCS codes to track products used and/or to bill Medicare Part B or other payers should change these HCPCS codes on their paper and/or electronic systems. Hospital-owned outpatient wound departments should update their charge masters with these new codes and with the"per yarcTbilling units.

Q: What is the status of Medicare coverage for autologous blood-derived products?

A: In 1992, CMS issued a national noncoverage determination for platelet-derived wound healing formulas. In April 2003, CMS made a determination that autologous platelet-rich plasmas were sufficiently different from platelet-derived growth factor to not fall under the 1992 national noncoverage determination. The inclusion of cells in the gel, the use by the provider versus at-home use, and marketing as a process versus a product were the differences noted in the CMS review.

On May 8, 2003, CMS began a national coverage determination process for autologous blood-derived products for chronic, cutaneous, nonhealing wounds. On December 15, 2003, CMS issued a decision memorandum. The memorandum states the intent of CMS to issue a national noncoverage determination for autologous platelet-rich plasma. This determination was based on the absence of specific evidence in the literature that autologous platelet-rich plasma is reasonable and necessary for the treatment of chronic, cutaneous, nonhealing wounds.