BALTC Q&A
Editor’s note: This month’s "Q&A" was modified from the HCPro book The Medicare Billing Manual for Long-Term Care, written by Frosini Rubertino, RN, CDONA/LTC, C-NE, CPRA.
For more information or to order this new long-term care billing resource, call customer service at 800-650-6787 or visit www.hcmarketplace.com/prod-11115. To submit a question for upcoming issues, email Product Manager Adrienne Trivers at [email protected].
Q: SNFs that are not accredited suppliers of durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) lost the opportunity to bill their DME Medicare Administrative Contractor (MAC) for Part B supplies after September 30, 2009. What does this mean for SNFs that bill their fiscal intermediary (FI) or MAC for Part B?covered wound care supplies?
A: The DMEPOS accreditation requirement has to do with the supplier number, for which SNFs do not need to bill their FI/MAC. Therefore, SNFs billing their FI/MAC for certain Part B supplies, such as wound care, ostomy, and urological items, do not have to be accredited. Accreditation does not apply to the Medicare provider number.
Maintaining the ability to bill for wound care supplies is excellent news for SNFs, because many facilities use more wound care supplies than other Part B items, such as ostomy or urological supplies; this type of Part B billing may provide more revenue.
What can you bill?
Before billing for wound care supplies, SNFs must know what types of supplies they can actually bill to Medicare Part B.
Not all wound care supplies are covered by Part B. When it comes to wound care supplies, SNFs can only bill Part B for dressings used in debridement and surgical dressings, which are needed to treat wounds resulting from surgical procedures.
Debridement refers to the process of removing dead tissue or foreign material from and around a wound. Routine dressings, such as supplies used for cleaning purposes, are not billable under Part B.
Dressings are broken down into two categories: primary and secondary. Primary dressings are applied directly to the wound, and secondary dressings, such as tape and gauze, protect the primary dressings. Medicare will cover both the primary and secondary dressings if the wound being treated is caused by a surgical procedure, has been or is being debrided, and is under a physician’s order.
Gather the information
Although a good working relationship between the clinical and billing staff is always important, collaboration is essential to the wound care billing process. The clinical team must provide the biller with specific information before wound care supplies can be properly billed. For example, clinical documentation must include information about swelling, pain, size, or dimensions of the wound, as well as when the dressings were changed.
The documentation must also include detailed information about any changes or improvement in the wound. If there is no indication of healing, there should be some documentation of dialogue with the physician about changing treatment to facilitate improvement.
SNF billers rely on the clinical staff to provide information about the type and quantity of supplies used by each resident. Unless wound care supplies are ordered specifically for a resident, tracking and determining the cost per patient for certain supplies, such as a bag of gauze or roll of tape, can become quite cumbersome.
However, the clinical staff can make this task easier by documenting the supplies and quantities used and recording this information on the resident’s treatment sheet.
Coverage criteria
SNFs must understand the policies and local coverage determinations (LCD) of their FI/MAC before billing for wound care supplies. Every FI/MAC has its own set of LCDs, which can be interpretations or further explanations of the national coverage determinations (NCD) established by CMS. FIs and MACs also develop their own unique LCDs that are separate from the NCDs.
SNFs must carefully adhere to the LCDs of their FI/MAC, which can be found on the contractor’s website, because the LCDs outline specific criteria that must be met for services to be covered. For example, LCDs can indicate frequency requirements for dressing changes or the type of documentation needed to support the medical necessity of wound care supplies. LCDs will also indicate appropriate modifiers to include on the UB-04.
If the FI/MAC does not have an LCD, the NCDs on the CMS website apply.
A great place to start
When it comes to billing Part B supplies, wound care is a great place to start. Wound care supplies are excellent revenue sources, and billing your FI or MAC for these Part B items tends to be easier than billing for other supplies. For most facilities, everything for wound care is done in-house; a treatment nurse performs the wound care, you know how the wound originated, and you know what is being provided.
To be successful with wound care billing, it is critical to establish procedures for tracking the supplies used by each resident. Although establishing these tracking measures, as well as the billing procedures, may be time-consuming, these systems can often be applied to other Part B?billable supplies, making Part B billing a more manageable process.
Common wound care supplies
Facilities submitting Part B claims for wound care supplies will bill for a variety of items. The following is a list of some of the more common types of items used for wound care:
- Wound pouches
- Alginate dressings
- Composite dressings
- Contact-layer dressings
- Foam dressings
- Gauze
- Hydrocolloid dressings
- Hydrogel dressings
- Special absorptive dressings
- Transparent film
Surgical Dressings
Surgical dressings are limited to primary dressings, which are either therapeutic or protective coverings applied directly to wounds or lesions that are on the skin or are caused by an opening to the skin, and to secondary dressings, which are therapeutic or protective (i.e., are needed to secure the primary dressing).
The wound can be either from a surgical procedure or from a debridement of a wound by the following procedures:
- Surgical, with the use of a sharp instrument or laser
- Mechanical, such as irrigation of the wound or the use of wet-to-dry dressings
- Chemical, such as topical application of enzymes
- Autolytic, such as application of occlusive dressings to an open wound
The dressings used for mechanical debridement to cover chemical debriding agents or wounds to allow for autolytic debridement are covered, but the agents themselves are not. Autolysis is a breakdown of all or part of a cell or tissue by self-produced enzymes.
When billing the DME MAC for surgical dressing supplies, review the allowable product list maintained by the Pricing, Data Analysis, and Coding (PDAC) Contractor by visiting www.dmepdac.com and selecting DMECS Coding listed under Top PDAC Links.
Before beginning to bill Medicare for surgical dressings, obtain the LCDs from your FI/MAC. If it does not have an LCD for surgical dressings, obtain the LCD in effect for your DME MAC. The DME MAC LCD is located in the supplier manual’s medical policy section, which you should review thoroughly. It will outline the limitations of coverage and medical necessity requirements that are essential for accurate billing for surgical dressings. It also will note any HCPCS modifiers that may be required for specific HCPCS codes. Pay special attention to billing limits that are discussed by HCPCS classification.
Just because a HCPCS code is listed in the LCD does not mean it is always an allowable Medicare item. Review the entire policy and read the fine print to be sure you understand it thoroughly. Often, specific conditions must be met for a particular supply to be covered under the surgical dressing benefit category, or a set of modifiers may be required. Be sure to read all materials provided with the policy to ensure that all billing requirements are met.
Surgical dressings are subject to the annual Part B deductible and the 20% coinsurance payment. The payments are made based on the DMEPOS Fee Schedule. To bill for the surgical dressings, you must track the following:
- Name of the resident
- Date of services
- HCPCS codes to identify the supplies used
- Number of units
- ICD codes for supplies provided
Review each HCPCS code to determine how to report units. Most surgical dressing HCPCS codes use square-inch measurements (e.g., A6196 alginate or other fiber-gelling dressing, wound cover, pad size of 16 inches or less, each dressing).