Coding, Measuring, Claims Processing, and More ... - Wounds

7/12/2011Debridement 2011: An Update onReimbursement for Debridement: Coding,Measuring, Claims Processing, and MoreThird in a SeriesKathleen D. Schaum, MSDirector, Medical Products ReimbursementHealthpoint BiotherapeuticsSupported by an educational grant from Healthpoint Biotherapeutics.© 2011 Healthpoint Biotherapeutics HS1092-0511http://woundsresearch.com/2011reimbursementFirst in the Series 2011: A Year of Change—Medicare Reimbursementfor Skin and DermalSubstitutesSecond in the Series 2011: A Year of Change—Medicare Reimbursementfor Surgical and MedicalDebridement2© 2011 Healthpoint Biotherapeutics HS1092-05111

7/12/2011Objectives of Today’s Program To briefly review the 2011 coding, payment, and coveragechanges affecting Medicare reimbursement for surgical andmedical debridement To understand why some surgical and medical debridementclaims were denied during the first quarter even though the newand revised codes were properly used To discuss how ―size‖ should be calculated for coding purposes3© 2011 Healthpoint Biotherapeutics HS1092-0511DisclaimerInformation on reimbursement in the U.S. is provided as a courtesy. Due to therapidly changing nature of the law and Medicare payment policy,and reliance on information provided by outside sources, the informationprovided herein does not constitute a guarantee or warranty thatreimbursement will be received or that the codes identified herein are or willremain applicable.This information is provided “AS IS” and without any other warranty orguarantee, expressed or implied, as to completeness or accuracy, or otherwise.This information has been compiled based on data gathered from manyprimary and secondary sources, including the American Medical Association,and certain Medicare contractors.4© 2011 Healthpoint Biotherapeutics HS1092-05112

7/12/2011Disclaimer (continued)Physicians and other providers must confirm or clarify coding and coveragefrom their respective payers, as each payer may have differing formal orinformal coding and coverage policies or decisions. Physicians and providersare responsible for accurate documentation of patient conditions and forreporting of procedures and products in accordance with particularpayer requirements.5© 2011 Healthpoint Biotherapeutics HS1092-0511Debridement 2011:An Update on Reimbursement forDebridement: Coding, Measuring,Claims Processing, and More6© 2011 Healthpoint Biotherapeutics HS1092-05113

7/12/20112010 CPT ® Physician Codes forSurgical Excision – DebridementCPT ® CodeDescription11040 Debridement; skin, partial thickness11041 Debridement; skin, full thickness11042 Debridement; skin, and subcutaneous tissue1104311044Debridement; skin, subcutaneous tissue,and muscleDebridement; skin, subcutaneous tissue,muscle, and boneCPT is a registered trademark of the American Medical Association7© 2011 Healthpoint Biotherapeutics HS1092-05112011 Deleted and Revised CPT ® Codesfor Surgical DebridementCPT ® CodeDescription11040 Debridement; skin, partial thickness11041 Debridement; skin, full thickness11042Debridement, subcutaneous tissue (includes epidermis anddermis, if performed); first 20 sq cm or less1104311044Debridement, muscle and/or fascia (includes epidermis, dermis,and subcutaneous tissue, if performed); first 20 sq cm or lessDebridement, bone (includes epidermis, dermis, subcutaneoustissue, muscle, and/or fascia, if performed); first 20 sq cm or less8© 2011 Healthpoint Biotherapeutics HS1092-05114

7/12/20112011 New Surgical Debridement Add-On CodesBase Procedure CPT ® Code11042 (subcutaneous)First 20 sq cm11043 (muscle)First 20 sq cm11044 (bone)First 20 sq cmAdd-on Code+11045Each add’l 20 sq cm, or part thereof+11046Each add’l 20 sq cm, or part thereof+11047Each add’l 20 sq cm, or part thereof Add-on codes are listed separately, in addition to baseprocedure code9© 2011 Healthpoint Biotherapeutics HS1092-0511Add-On Code ExampleWound Debrided Surface Area CPT ® Code1 10 sq cm (subcutaneous, left leg) 110422 15 sq cm (subcutaneous, right leg) +1104510© 2011 Healthpoint Biotherapeutics HS1092-05115

7/12/2011Deleted CPT ® Codes 11040 and 11041 –Use Revised Codes 97597 and 97598 for Medical DebridementDeleted Codes1104011041Revised CPT ® Codes97597+9759811© 2011 Healthpoint Biotherapeutics HS1092-05112010 CPT ® Codes for Selective DebridementCPT ® Code97597Total wound(s)surface area ≤20 sq cm97598Total wound(s)surface area >20 sq cmDescriptionRemoval of devitalized tissue from wound(s),selective debridement, without anesthesia(e.g., high pressure waterjet with/withoutsuction, sharp selective debridement withscissors, scalpel and forceps),with or without topical applications(s), woundassessment, and instruction(s) for ongoing care,may include use of a whirlpool, per session;12© 2011 Healthpoint Biotherapeutics HS1092-05116

7/12/20112011 CPT ® Codes for Medical(Formerly Selective) DebridementCPT ® Code97597Total wound(s)surface area; first20 sq cm or less+97598Total wound(s)surface area;each additional20 sq cm, or part thereofDescriptionDebridement (eg, high pressure waterjetwith/without suction, sharp selectivedebridement with scissors, scalpel, and forceps),open wound, (eg, fibrin, devitalized epidermisand/or dermis, exudate, debris, biofilm),including topical application(s), woundassessment, use of a whirlpool, when performedand instruction(s) for ongoing care, per session Add-on codes are listed separately, in addition tobase procedure code13© 2011 Healthpoint Biotherapeutics HS1092-05112010 and 2011 CPT ® Code forNon-Selective DebridementCPT ® Code97602DescriptionRemoval of devitalized tissue from wound(s), nonselectivedebridement, without anesthesia (eg, wetto-moistdressings, enzymatic, abrasion), includingtopical applications(s), wound assessment, andinstruction(s) for ongoing care, per session Per session (not size-dependent) HOPDs use as long as they do not bill for another medical orsurgical debridement of the same wound during that visit14© 2011 Healthpoint Biotherapeutics HS1092-05117

7/12/2011Unanswered Questions About Size? For coding purposes,should we report thewound size before orafter debridement? When a wound ispartially debrided, howshould we report thewound size for codingpurposes?15© 2011 Healthpoint Biotherapeutics HS1092-0511CPT ® AssistantOfficial source for CPT ® coding guidancePublished by:American Medical AssociationMay 2011/Volume 21 Issue 5168

7/12/2011Size and Code Selection Clarification Select debridement codes based on thedeepest level of tissue debrided Debridement codes should only be based on the measurementof the wound surface that was actually debrided When the entire wound is debrided, the woundmeasurement after debridement should be reported When multiple wounds are debrided at the same depth,combine the debrided surface measurements of those wounds– Do not report each wound separately17© 2011 Healthpoint Biotherapeutics HS1092-0511Coding ExamplesSurgical and Medical Debridement18© 2011 Healthpoint Biotherapeutics HS1092-05119

7/12/2011Use Add-On Codes When Debrided Tissue at theSame Depth Is Greater Than 20 sq cm Example: 15 sq cm of subcutaneous tissue debrided from rightleg and 10 sq cm of subcutaneous tissue debrided from left legCPT ® CodeUnits11042 1 unit11045 1 unit19© 2011 Healthpoint Biotherapeutics HS1092-0511Use Multiple Codes When Different Tissue DepthsAre Debrided on Different Wounds Example: 10 sq cm of muscle debrided from one wound; 15 sqcm of devitalized epidermis and dermis debrided from aseparate woundCPT ® CodeUnit11043 1 unit9759759 1 unit20© 2011 Healthpoint Biotherapeutics HS1092-051110

7/12/2011Use Appropriate Codes When Working in HOPDs Visit 1: 35 sq cm of muscle debrided Visit 2: 25 sq cm of devitalized dermis and debris Visit 3: Physician assessed and nurse applied enzymatic debriding agentVisit HOPD Code Physician Code1211043 1 unit 11043 1 unit+11046 1 unit +11046 1 unit97597 1 unit 97597 1 unit+97598 1 unit +97598 1 unit3 97602 1 unit 99212-99215 1 unit21© 2011 Healthpoint Biotherapeutics HS1092-05112011 Medicare Payment22© 2011 Healthpoint Biotherapeutics HS1092-051111

7/12/20112010 vs. 2011 Medicare Global Period for Physicianshttp://www.cms.gov/apps/physician-fee-schedule/overview.aspx lastreviewed 5/31/2011CPT ® Code 2010 Global Period 2011 Global Period11040 0 Code Deleted11041 0 Code Deleted11042 0+11045 (new code)11043 10+11046 (new code)11044 10+11047 (new code)97597 NA+97598 (add-on in 2011) NA97602 NA000000NANANA23© 2011 Healthpoint Biotherapeutics HS1092-05112010 vs. 2011 National Average Medicare Payment Rates for Physicianshttp://www.cms.gov/apps/physician-fee-schedule/overview.aspx last reviewed5/31/2011CPT ® Code2010 Physician Rate inOffice2011 Physician Rate inOffice2010 Physician Rate inFacility2011 PhysicianRate in Facility11040 $43.51 Deleted $25.81 Deleted11041 $50.15 Deleted $31.71 Deleted11042 $68.58 $86.64 $43.14 $47.23 +11045 $30.92 $18.0111043 $264.01 $190.61 $230.82 $122.32 +11046 $53.68 $38.0511044 $363.20 $290.84 $319.32 $212.35 +11047 $88.34 $66.2597597 $63.05 $72.03 $31.34 $24.12+97598(Add-on in 2011)or$77.80$96.15+$24.12or$42.40$35.67$11.5597602 NA NA NA NA+24© 2011 Healthpoint Biotherapeutics HS1092-051112

7/12/20112010 vs. 2011 National Average Medicare Payment Rates for HOPDshttp://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage last reviewed5/31/2011CPT ® Code2010 APC Payment2010 PatientCo-Payment2011 APC Payment2011 PatientCo-Payment11040 $103.63 $20.73 Deleted Deleted11041 $103.63 $20.73 Deleted Deleted11042 $188.15 $37.63 $188.16 $37.64+11045 $188.16 ÷2 $37.64÷211043 $188.15 $37.63 $188.16 $37.64+11046 $188.16÷2 $37.64÷211044 $551.56 $110.32 $584.96 $117.00 +11047 $584.96÷2 $117.00÷297597 $103.63 $20.73 $103.14 $20.63+97598(Add-on in 2011)$103.63 $20.73 $103.14÷2 $20.63÷297602 $59.10 $11.82 $62.70 $12.54 25© 2011 Healthpoint Biotherapeutics HS1092-0511First Quarter 2011 Claims Denials:97597 and 97598 on Same Claim2010 Correct Coding Edit 2011 Revised Codes 97597 – base code– Total wound(s) surface area lessthan or equal to 20 sq cm 97598 – base code– Total wound(s)surface area greaterthan 20 sq cm If debrided surface was greaterthan 20 sq cm, 97598 wasappropriate code CCI edits denied 97597 if billedwith 97598 97597 – base code– First 20 sq cm or less 97598 – add-on code– Each additional 20 sq cm, or partthereof If debrided surface was greater than20 sq cm, 97597 + 97598 are theappropriate codes CCI edits corrected on 4/1/201126© 2011 Healthpoint Biotherapeutics HS1092-051113

7/12/2011First Quarter 2011 Medically Unlikely Edits(MUEs): Add-On Codes50 sq cm subcutaneoustissue debrided 11042 11045OR 11042 11045 11045591 unit2 units1 unit1 unit1 unit50 sq cm of epidermisand dermis debrided 97597 97598OR 97597 97598 97598591 unit2 units1 unit1 unit1 unit27© 2011 Healthpoint Biotherapeutics HS1092-0511Impact of Skilled Nursing Facility (SNF)Consolidated Billing “Therapy” is consolidated into Medicare payment to SNFs 97597 and +97598 are considered ―sometimes therapy‖ codesby Medicare Physicians and HOPDs must enter into contracts with SNFS tobill the SNFs (rather than Medicare Part B) for 97597 and97598 services provided to patients covered byMedicare Part A28© 2011 Healthpoint Biotherapeutics HS1092-051114

7/12/2011Medicare Coverage29© 2011 Healthpoint Biotherapeutics HS1092-0511CPT ® Assistant Provider Guidance Surgical and medical debridement can be reported by anyqualified health care professional. ―They are not restricted to asingle type of health care professional.‖ REMEMBER: State Practice Acts and payers determine ifyour specialty is ―qualified‖ to perform surgical and medicaldebridements.30© 2011 Healthpoint Biotherapeutics HS1092-051115

7/12/2011CPT ® Assistant Place of Service Guidance Surgical and Medical Debridement can be performed in:– Hospitals– Physician Offices– Ambulatory Surgery Centers– Nursing Facilities CAUTION: Some LCDs and medical policies may list othercovered places of service.31© 2011 Healthpoint Biotherapeutics HS1092-0511Summary: Debridement 2011:An Update on Reimbursement for Debridement:Coding, Measuring, Claims Processing, and More Deleted codes: 11040 and 11041 Revised descriptions of 11042, 11043, and 11044 (based ondepth of tissue debrided and debrided surface in sq cm)– New add-on codes: 11045, 11046, and 11047 New descriptions for 97597 and 97598 (based on debridedsurface in sq cm)– 97598 is now an add-on code32© 2011 Healthpoint Biotherapeutics HS1092-051116

7/12/2011Summary: Debridement 2011:An Update on Reimbursement for Debridement:Coding, Measuring, Claims Processing, and More Coding is dependent on depth of tissue debrided and debridedsurface in sq cm (length in sq cm X width in sq cm) For coding purposes, measure the debrided surface after thedebridement For coding purposes, code and bill only for the sq cm debridedwhen partially debriding a wound Global period has been removed for 11043 and 11044, whichresulted in reduced Medicare payments to physicians33© 2011 Healthpoint Biotherapeutics HS1092-0511Summary: Debridement 2011:An Update on Reimbursement for Debridement:Coding, Measuring, Claims Processing, and More The CCI edits caused claims with 97597 and 97598 on thesame claim to be paid incorrectly Medically Unlikely Edits may cause multiple units of add-oncodes to be denied Physicians and HOPDs must establish contracts to bill skillednursing facilities for medical debridement services provided topatients during Medicare Part A covered stays Providers must obtain, read, and implement Medicarecontractor’s LCD that pertains to debridement34© 2011 Healthpoint Biotherapeutics HS1092-051117

7/12/2011Live Question and Answer SessionTo ask Kathleen Schaum a one-on-one question, contact her at:561-964-2470Kathleen.schaum@healthpoint.com35© 2011 Healthpoint Biotherapeutics HS1092-051118