5 Wound Care Specialty Coding and Billing Tips

October 26, 2015

5 Wound Care Specialty Coding and Billing Tips

It is a well known fact that if erroneous codes have been given, reimbursement denials will affect revenues. Resubmission rates with proper documentation will need to be given, which takes the time and effort of the physician, thus leading to loss of focus on the patient care front. In certain specialty areas, certain codes and modifiers, if not reflected accurately can be costly in the long run. To capitalize on reimbursement avenues, especially in today’s healthcare reforms and regulations scenario, wound care specialists and clinicians need to be very accurate in order to comply with CMS reimbursement guidelines.

Here are 5 Basic tips essential to set you on the right footing

  • Compliance:
    It needs to be ensured by the hospital staff, especially those who are working with wound care specialty, and the administrators, that products and services are coded with the Healthcare Common Procedure Coding System (HCPCS) for Medicare reimbursement. For example, when reporting negative pressure wound therapy services (NPWTs), covered under DME billing, it should be noted that it is capped as a rental item under Medicare and can be billed on a monthly basis for up to four months. Here the CPT codes should correlate to the HCPCS codes. When billing and coding for Wound Preparation For Grafting and NPWT, listing your national provider identifier (NPI) number in box 17 is necessary in order to receive payment.
  • Correctly coded Services:
    For specialty like surgical debridement services, one should bill with a code or modifier that accurately reflects the service provided. Also, accurate documentation to determine whether the services were medically necessary or were coded accurately should be taken into account.
  • Updated Training & Certification:
    This is especially so for hyperbaric oxygen therapy (HBOT). The facility should ensure the provider supervising the treatment meets CMS requirements. Physicians who supervise HBOT should be certified in Undersea and Hyperbaric Medicine or should at least have completed a 40-hour, in-person training program by an approved entity. Further, if HBOT is performed off-site from a hospital campus or in a physician’s office, Advanced Cardiac Life Support training and certification of the supervising physician is an essential certification that is required to collect reimbursement.
  • Validation of treatment:
    Validation of findings and treatment accorded is a must not just from a billing perspective but also from the medico-legal perspective. The patient’s chart that is maintained needs to have every bit of minute information like, measures taken, risks ascertained, tests requested for; examination observations should be down to the smallest of details like its accurate placement & the size of the wound or ulcer; and so too should the treatment chart- how the wound has been healing given that debridement codes will change as the surgical debridement services change with healing and cleaning process.
  • Documentation:
    This is the most vital and essential part of any wound care specialty department. CMS also requires appropriate direct physician supervision for coverage, meaning that the physician must be present on the premises and immediately available to furnish assistance and direction throughout the performance of the procedure. Without clear documentation, denial of reimbursements could lead to lengthy resubmissions. For instance, verification of wound measurements should always be documented and stated correctly in the patient’s file, and backed with photos. Further, the patient’s chart should include current laboratory results and nutritional assessments, in case of a Medicare audit, to establish proof that the patient qualifies for Medicare reimbursement.

Wound care coding and billing for an outpatient/physician setting is a daunting task indeed. One needs to stay updated on the new and revised CPT codes, the new treatment options, and the ever-changing documentation and compliance guidelines that are needed in order for a smooth reimbursement cycle. The above tips should help guide you to pay more attention and improve observation for an enhanced patient care as well as smooth revenue workflow


Category : Best Billing and Coding Practices