Editor's Note: Part 1 is available here.

Transcript

Welcome to the second video of a 3-part series entitled, Clinicians' Vital Role in Receiving Appropriate Medicare Reimbursement. I selected that title because most wound ulcer management professionals mistakenly believe the Centers for Medicare and Medicaid Services and the Medicare administrative contractor that processes their claims are solely responsible for determining their reimbursement. That belief is not entirely true. If a service procedure or product is included in a Medicare covered benefit and is assigned a code, clinicians and physicians should learn and implement the coverage and coding guidelines. Their medical decision-making documentation and coding of each patient encounter determines their reimbursement. If their documentation and coding align with the coverage and coding guidelines, they will usually be paid correctly, but if their documentation and coding do not align with the guidelines, they will usually be paid incorrectly or not at all. Therefore, when all is said and done, clinicians and physicians play a vital role in their Medicare reimbursement.

My name is Kathleen Schaum and I am the president of Kathleen D. Schaum & Associates, which is a reimbursement strategy and education consulting company. I provide these consulting services to physicians and other qualified healthcare professionals, to hospital owned outpatient wound ulcer management provider based departments, and to manufacturers and distributors of wound ulcer management products. Because I really love my work and strive to educate wound ulcer management stakeholders, how to be paid correctly and fairly for the services, products, and procedures they provide to patients, I'm honored that WoundSource invited me to share reimbursement information with you. If you wish to contact me, feel free to call me on my mobile phone or to email me. My phone number and email address are shown on this slide.

As I just mentioned, this series consists of 3 parts and will meet 3 objectives. In part 1, we learned that Medicare reimbursement is first determined by answering 4 questions, who, where, what and why. Today, in part 2, we will discuss how clinicians and physicians determine if Medicare will cover and pay for various types of debridement. And in part 3, we will discuss how clinicians and physicians determine if Medicare will cover and pay for surgical dressings needed by their patients for use at home. Before we begin, let us review the disclaimer for today's reimbursement education. Information on coding coverage and payment systems is provided as a courtesy, but it does not constitute or guarantee that payment will be provided. Each attendee is advised to obtain from the correct payer, their current coding, payment system and coverage policies and regulations that pertain to the specific work they perform.

Now, let us learn why wound ulcer management clinicians, physicians, and QHPs should answer the who, where, what and why questions, number 1, when they want to know if the debridement they performed will be covered and paid by Medicare. And number 2 when they document and code for debridement that they perform. Even though debridement procedure codes are not new, I still receive many calls and emails asking, will Medicare pay me for debridement and if so, how much will I be paid? Person asking the question is always surprised when I respond by saying, I have no idea. First, you're going to need to describe the scenario to me. Who will perform the debridement? Where will the debridement take place? What level of tissue will be debrided and why will the debridement be performed?

I always explain that Medicare team may change significantly depending on the answers to the questions. Therefore, today, we are going to consider 2 things. One, how Medicare reimbursement changes based on the answers to those questions and how clinicians and physicians determine their Medicare reimbursement for debridement. Let's begin by considering the question who performed the debridement? In part 1, we learn that state scope of practice laws, hospital bylaws, hospital privileges, coverage guidelines, and coding guidelines determine which wound ulcer management stakeholders can perform a service or procedure and how much Medicare will pay them. That also pertains to surgical debridement, selective debridement, and non-selective debridement.

For example, the state scope of practice laws typically prevent therapists and wound care nurses from performing surgical debridement. Some hospital bylaws prevent nurse practitioners and physician assistants from performing surgical procedures. Therefore, NPs and PAs cannot perform surgical debridement in those hospitals. In addition, some NPs and PAs fail to obtain hospital privileges to perform surgical procedures in the provider-based department. The NPs and PAs usually find out the hard way during an audit. A very large mistake is typically made by physicians and QHPs who think that selective debridement codes are just for use by therapists. They are usually finding this out the hard way, and that is during an audit. And a final good example of the importance of considering who will perform a procedure is when physicians and QHPs perform non-selective debridement and do not receive payment because that procedure is typically only paid to provider-based departments and not to physicians and QHPs.

As you can see from this slide, identifying and documenting who performed the debridement is very important. Depending on the depth of tissue removed, physicians and QHPs should report the surgical debridement, which would be 11042 to 11047. Or selective debridement, which is 97597 to 97598. Now, therapists should only report the selective debridement codes which are 97597 and 97598, and provider based departments could report any of those codes depending on the work that was performed in the provider-based department. So if the physician or QHP performed surgical debridement, PBD would report 11042 to 47. If a nurse or a therapist or a physician or QHP did selective debridement, they would report 97597 to 97598, and if someone in the provider based department did a non-selective debridement, then indeed provider based department would bill 97602. So you can see how very specific this can get.

Now, where was the debridement performed? That is a very important thing because it's important to state the place of service when you ask debridement questions and when you document the debridement that was performed. Identifying the place of service where debridement was performed is important because the Medicare physician fee schedule has different allowable rates for procedures performed in the office and in facilities such as in the hospital or in a provider-based department. The allowable Medicare rates are always higher for work performed in the office because the physician or QHP incurs higher expenses in the office. Therefore, if the physician or QHP performs debridement procedures in multiple places of service, she or he should always document in the medical record where the patient encounter and the debridement procedure was happening or where it occurred.

In addition, if the physician or QHP uses a paper or electronic charge sheet, that document should have a place of service field for every service and procedure code and the coders and billers then have 2 documents from which they can verify the place of service where the physician and QHP performed each service or procedure, and the 2 places would be the medical record or the charge sheet. Another important reason to document the place of service where the debridement was performed is that some MACs do not cover certain surgical debridement performed in places of service such as the patient's home. If your MAC specifies a place of service coverage restrictions in their LCD, you should always document place of service to verify that you perform the procedure in a covered place of service.

This slide displays the 2023 Medicare physician fee schedule, national average allowable rates for surgical debridement of subcutaneous tissue, and for selective debridement when performed in the office, versus when it's performed in a facility. Noticing that in the office, as I had mentioned earlier, that the physician always gets paid a higher rate because they have more expenses in their office. So when they did the surgical debridement of subcutaneous tissue 11042 in the office, then national average rate, it's a little over $130. When they do it in a facility, such as the provider based department, it's just under $60. Similarly, when they do selective deployment, 97597 in their office, the national average rate is $102, but when they do it in a facility, it's a little over $35. Now, keep in mind, these are national average rates and your rate would be uniquely different and special for your particular state.

Now, I often receive calls from physicians and QHPs who are upset because their claims were audited and they incurred large repayments because their coders reported the office as the place of service on their Medicare claims. Unfortunately, most of the procedures that they performed were done in the provider-based department. Therefore, the physicians and QHPs were overpaid for all of those procedures. When I discussed the situation with the coders, the two most common responses from the coders are, number one, I had no idea the physician did the work outside of the office. Or number two, the physician told me that I was responsible to maximize their reimbursement, so I reported the office a place of service on all of their claims. Oh, no.

So neither of the coder's responses are acceptable and neither of those behaviors acceptable and they prove to be very costly for these physicians and QHPs. I've educated the physicians and QHPs to, number one, always inform their coders and billers about all the places of service where they work. And number two, to document the place of service where every encounter and procedure was performed. And number three, to record the place of service where they perform the procedure on their paper or electronic charge sheets. I also educate the coders and billers to refer to the place of service that is documented in the medical record and on the chart sheets. I hope that this real life scenario has convinced you about the value of always answering the question, where did I perform the debridement or in fact, any other service or procedure that you perform?

The next 2 questions, what type of debridement was performed and why was it performed? Not answering these questions thoroughly and correctly can lead to incorrect reimbursement. In fact, not documenting the reason for the debridement as well as the complete debridement procedure has led to millions of repayment dollars. When I review the results of debridement audits that failed, I always feel sad because wound ulcer management professionals have access to a plethora of debridement coding and documentation resources. The American Medical Association has done a fabulous job of describing the various debridement codes. The MACs have provided detailed local coverage determinations and local coding articles that clearly described the utilization guidelines, the documentation guidelines, and the coding guidelines for all the wound ulcer management debridement codes. The MACs have also provided and continue to provide excellent free debridement webinars. And the MACs also have published and continue to publish the results of their debridement audits and how to pass debridement audits.

In addition, I, and numerous other reimbursement consultants, have written about and provided many education classes about debridement documentation and code selection. Therefore, physicians, QHPs and PBDs should not be failing debridement audits. Because there are different levels of debridement, clinicians and physicians are responsible for documenting, number one, why the debridement is necessary, and number two, a complete description of the debridement procedure, including the tissue removed. Because debridement is performed so often, physicians, QHPs and PBDs should want their documentation and coding to paint the full picture of the reason for the procedure and all the steps of the procedure.

Despite the large number of debridement documentation on coding resources available, this consultant sees a large number of medical records that just say, debrided ulcer return for another debridement in one week. That documentation does not align with the debridement code descriptions. When I review the MACs LCD, LCA, their debridement documentation checklists, their archived webinars and their detailed slides and their audit reports, I am surprised that the physicians QHPs and PBDs have not attempted to use their MACs resources to design their debridement documentation templates. When asked, most physicians and QHPs and PBDs say, I do not know that the Office of Inspector General investigated debridement, wrote a report about its poor documentation and inaccurate code selection and continues to include debridement on its work plan. And because they don't know and not paying attention to it, that's where the huge repayments are coming from. So physicians, QHPs and PBDs can and must do a better job at documenting why they are debriding and the complete debridement procedure.

As shown on this slide, plenty of debridement resources are available. Do yourself a big favor and read these resources and proactively implement guidelines. As we come to the end of part 2 of Clinicians' and Physicians' Vital Roles in Receiving Appropriate Medicare Reimbursement, I hope you clearly understand how clinicians and physicians determine if Medicare will cover and pay for debridement. If debridement is medically necessary, you should be proud to document that you performed the debridement. And state in what place you performed the debridement, why you debrided the wound ulcer, and a complete description of the procedure. And don't forget to use the plethora of available resources to guide your medical decision-making documentation and coding of the debridement performed.

Thank you for allowing me to share the debridement reimbursement information with you. I look forward to sharing more information in part 3, when we will discuss how clinicians and physicians determine if Medicare will cover NP for surgical dressings needed by patients for use at home. In the meantime, if I can be of assistance to provide reimbursement consultation, and or education to individuals, groups, health systems, local, regional, or national symposiums, manufacturers, executives, or sales representatives, feel free to call me at the number or email listed on the slide at the beginning of the presentation. Good luck in doing your part to gain Medicare coverage and payment. Don't underestimate your vital role in this process.

About the Speaker

As the founder and president of her consulting company Kathleen D. Schaum & Associates, Inc., Kathleen Schaum shares her 50+ years of knowledge and experience with wound/ulcer management stakeholders. For the past 24 years, Kathleen has educated and consulted with wound/ulcer management providers and manufacturers. In addition, Ms. Schaum has guided manufacturers’ reimbursement strategies for nearly 500 wound/ulcer management products and procedures and has provided reimbursement education to 6,000+ executives and sales representatives. Ms. Schaum consults with numerous new and established hospital owned outpatient wound/ulcer management departments and wound/ulcer management professionals regarding the “business side of wound/ulcer management.” Her reimbursement teleconsultation services, Charge Description Master reviews, and coding/billing guidance provides a “lifeline” for many wound/ulcer management professionals and revenue cycle teams.

Ms. Schaum continuously monitors reimbursement legislation and regulations and attends many reimbursement meetings and seminars to maintain her own knowledge regarding this ever-changing topic. Then she willingly shares that knowledge with wound/ulcer management stakeholders at national and regional symposiums and via her monthly reimbursement columns: Payment Strategies in Advances in Skin & Wound Care and Business Briefs in Today’s Wound Clinic, as well as her new column, entitled Consultation Corner, which appears quarterly in Today’s Wound Clinic. Based on her published articles, Kathleen was recently recognized as a world expert of reimbursement health insurance – she is in the top 0.089% and ranks number 26 out of 30,441 published worldwide authors.