Payers Regulate Code Selection for Wound Care Procedures

Advances in Skin & Wound Care, Nov/Dec 2004 by Schaum, Kathleen D

Q: Our hospital is opening a multidisciplinary outpatient wound care department. Physicians will assess and manage the patients' wound care needs. In preparing our Chargemaster, we have questions about selecting the appropriate CPT* codes. I've received conflicting information about coding from other hospital-owned outpatient wound care departments in various states. Do physicians have access to all the CPT codes?

A: Even though a procedure has a code, it may not be covered by the various payers for every wound care professional in every site of service. To determine which codes apply to the hospital-owned outpatient wound care department, first identify who will work in the department, which procedures will be performed, and who will perform them. Next, research the major payers'coverage and payment policies for the professionals who are performing those procedures in your site of service. For example, Medicare is a major payer for many patients with wounds who are referred to outpatient wound care departments. Therefore, you must review Medicare's National Coverage Decisions (NCDs) and Local Coverage Decisions (LCDs), as well as its articles and guidance documents.

In hospital-owned outpatient wound care departments that are physician-driven, such as yours, the wound care team must review both the Medicare carrier's and the Medicare fiscal intermediary's directives.

Medicare Carrier Process

To administer the Medicare Part B program, the Centers for Medicare & Medicaid Services (CMS) contracts with insurance companies. These carriers safeguard the Medicare Trust Fund by paying only for services that are reasonable and necessary. If a Medicare NCD exists, the local Medicare carriers are obliged to follow the NCD. When NCDs do not exist, each Medicare carrier is permitted to make its own LCDs that address the reasonableness and necessity for various services and procedures. The Medicare carriers are required to communicate their policies and regulations to providers through official notices, bulletins, newsletters, telephone answers to Part B-covered providers, and training programs.

Because physician services performed at hospital-owned outpatient wound care departments are funded by Medicare Part B, all personnel who work at the facility should review the Medicare carrier's directives regarding procedures the physicians plan to perform.

Medicare Fiscal Intermediary Functions

CMS also contracts with insurance companies to administer the Medicare Part A program and to process some Medicare Part B claims. Like a Medicare carrier, the Medicare fiscal intermediary (FI) follows NCDs, is permitted to make its own LCDs, and is required to communicate its policies to providers.

Although hospital-owned outpatient wound care department procedures are funded by Medicare Part B, the Medicare FI makes their coverage and coding decisions and processes their claims. Therefore, reviewing the FI's LCDs, articles, and newsletters pertaining to wound care procedures is also important.

Coordinating Medicare Carrier and Fl Policies

From time to time, the policies of the Medicare carrier and the FI may differ. Consider the following hypothetical example involving a wound care program.

Fast Heal Wound Care Department is owned by Best Care Hospital and is physician-driven. More than 60% of outpatients present with venous ulcers. Fast Heal Wound Care Department uses multilayer, sustained, graduated, highcompression bandage systems to manage these wounds. In February 1999, the CPT Editorial Panel of the American Medical Association (AMA) recommended that the existing CPT code 29580 (strapping, Unna boot) be used with modifier-22, if appropriate, to report this procedure when performed by a physician or nonphysician practitioner. In the July 1999 CPT Assistant, the American Medical Association verified this recommendation and suggested: "When appending the modifier22, it may be helpful to include a copy of the procedure report that describes the unusual procedure performed."

The Medicare carrier for the physicians who practice at Fast Heal Wound Care Department published an article verifying that they concur with the AMA's recommendation and will accept CPT code 29580-22 for reasonable and necessary applications of multilayer, sustained, graduated, high-compression bandage systems.

The Medicare FI published an LCD stating that the CPT code 29580 can be used only to represent the application of Unna boots that contain zinc paste. If the hospital-owned outpatient wound care departments under their jurisdiction apply multilayer, sustained, graduated, high-compression bandage systems, they must include that work in their acuity scoring system for clinic visits.

In this fictitious example, the physicians who apply multilayer, sustained, graduated, high-compression bandage systems should follow their Medicare carrier's direction and code their work with CPT code 29580-22. They should also include a procedure report with the claim. Fast Heal Wound Care Department should incorporate the application of multilayer, sustained, graduated, high-compression bandage systems into its acuity scoring for the 5 levels of new and established patient clinic visits.