Wound Care Reimbursement guidelines that are worth following

In today’s scenario most of the patients expect clinicians to go by evidence-based medicine for wound closure and for preventing relapse for a persistent wound that refuses to heal. Wound care billing guidelines indicate that physicians need to provide services that are not only effective but billable at the same time. Or else, it is going to be rather difficult to sustain in the business of wound care. Hence, it is important that a multidisciplinary team comprising physical and occupational therapists (PTs & OTs) is used as they have the requisite theoretical and practical methodologies that hasten wound healing.

Ideally, a therapist (PT & OT) would first examine the skin integrity and carry out an assessment of skin afflictions, including subcutaneous changes like pressure and other areas like vascular, neuropathic (diabetic, for instance) burns, ulcers and other traumas. With mobility being the ultimate goal of therapeutic care and subsequent wound healing, therapists know that they have to get a better understanding of how to utilize various therapeutic interventions like ultrasound and electrical stimulation.  Wound care billing companies as well as the therapists are aware that wound care service is part of the therapy plan which will be reimbursed as per the Medicare Physician Fee Schedule irrespective of whether the therapist is working in a hospital based outpatient department or private practice or at any other nursing facility.

Wound care billing & coding service providers and the therapists also know that the Current Procedural Terminology (CPT) come under the 97000 series, however, the therapist is at liberty to report any CPT code (97597 – Selective debridement, first 20 sq cm, 97598 – Selective debridement for each additional 20 sq cm) provided the healthcare provider is qualified to offer the service relating to the specific code.

Wound care services providers should also realize that therapists linked to any hospital based outpatient department have to use the relevant revenue code (either PT = 042X or OT=043X) For the benefit of wound care coding companies, the Center for Medicare and Medicaid Services (CMS) has classified several CPT codes coming under the 97000 series as “sometimes therapy”, the services for which need not necessarily be provided by a therapist. In case a therapist is performing any service coming under any of these codes he or she has to use the appropriate modifier (GP= physical therapy, OP occupational therapy). Any therapist who wishes to be part of a multidisciplinary team has to be familiar with unique payment rules along with the routine rules.

While nurses have direct-supervision requirements through CMS or any other payer, PTs and OTs do not have any such requirements. Nurses need to work under the direct supervision of a physician while performing clinical services as defined by CMS as “immediately available to furnish assistance during the performance of procedures”. Whereas PTs and OTs need to just ensure that the physician has approved the established therapy plan. Therapists and wound care billing companies need to realize that it is important that therapists get the National Provider Identification (NPI) number which needs to be used on all the reimbursement claim forms they submit, however this is not required if the therapist is part of a large hospital.

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