Editor's Note: Part 1 is available here and Part 2 is available here.

Transcript

Welcome to the third video of the 3-part series entitled Clinicians' and Physicians' Vital Roles in Receiving Appropriate Medicare Reimbursement. I selected that title because most wound ulcer management professionals mistakenly believe that 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. 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'm 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 love my work, and I 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 am honored that Wound Source 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, and my phone number and email address are both shown on this slide. As I just mentioned, this series consists of three parts and will meet three objectives. In part one, we learn that Medicare reimbursement is first determined by answering four questions: who? Where? What? And why? In part two, we discussed how clinicians and physicians determine if Medicare will cover and pay for various types of debridement. And today, in part three, we will discuss how clinicians and physicians determine if Medicare will cover an pay for surgical dressings needed by their patients for use at home.

Before we begin this part, let us review the disclaimer for today's reimbursement education. Information on coding coverage and payment systems is provided as a courtesy, but does not constitute a guarantee or warranty that payment will be provided. Each attendee is advised to obtain, from the correct payer, current coding, payment system, and coverage policies, and regulations pertaining to the specific work they perform. Now, let us learn why wound ulcer management clinicians, physicians, and qualified health care professionals, whose acronym is QHP, should answer the who, where, what, and why questions. Number one, when they want to know if the surgical dressings they ordered will be covered and paid by Medicare.

And number 2, when they document in the medical record. Even though the Medicare coverage guidelines for surgical dressings needed by our patients for use at home are several decades old, I still receive many calls and emails from physicians particularly saying, "Why don't the durable medical equipment suppliers provide the types of dressings that I order for my patients to manage their wounds and ulcers at home?"

Now, the physicians and QHPs who ask the question is always surprised when I respond by saying, "You have no idea? First, you're going to need to describe the scenario to me. Who signed the order? Where will the dressing be used? What type of wound or ulcer requires the dressing? What level up to date exists? What is the frequency of dressing change? And why are the primary and secondary dressings needed?" I always explain that Medicare coverage regulations are unique to each surgical dressing category, and that the DME supplier can only supply primary and secondary dressings that are justified in the medical record and ordered appropriately by the physician or QHP. Therefore today, we're going to consider how Medicare coverage for each category of surgical dressings varies, and how clinicians and physicians determine if Medicare will cover and pay for surgical dressings needed by their patients for use at home. Let us start by considering who ordered the surgical dressings, and who will supply them to the patient. Surgical dressings for use at home by Medicare patients who have paid from Part B are part of the durable medical equipment prosthetics, orthotics, and supplies benefit.

That is better known as DMEPOS, D-M-E-P-O-S, that is its acronym. The patient's greeting practitioner should assess the patient's wound and ulcer, and verify if that wound qualifies for surgical dressings. If so, the treating practitioner should determine what primary and secondary dressings are appropriate for the wound type, and should verify that those dressing types align with the utilization and frequency of dressing change guidelines in the surgical dressing LCD and LCA. All of this information should be carefully documented in the patient's medical record. Now, if the patient's going to receive the primary and secondary surgical dressings from a DME supplier, the treating physician should write, sign, and submit a complete order to the DME supplier. Now to assist the treating physician, the DME supplier may provide a surgical dressing order sheet. However, the order sheet should not take the place of documentation in the patient's medical record. Please note that wound care nurses cannot write, sign, and submit surgical dressing orders to the DME supplier. If a Medicare patient's wound and ulcer is managed by a home health agency, the home health agency must provide the surgical dressings for the patient.

And in that case, the LCD for surgical dressings and the LCA do not apply. Now, the surgical dressing LCD and LCA provides specific documentation requirements that physicians and QHPs should follow when performing the initial wound ulcer evaluation that supports the surgical dressing orders. As you can see on this slide, the physicians and QHPs must document the description of each wound or ulcer separately, one from the other, and we should document the type of wound or ulcer that qualifies for the surgical dressing, the location and size, the length and width, and the depth of each wound or ulcer. The amount of exudate, the type of primary dressing selected, and the reason for that selection, the type of secondary dressing selected, and the reason for the selection. The size of the dressings selected, the number or amount of dressings to be used at one time, the frequency of the dressing change, and any other relevant clinical information that the physician believes is important. Now, once the patient is receiving surgical dressings through their Medicare Part B benefits, a monthly or weekly wound ulcer evaluation of each wound and ulcer must occur.

The purpose of the evaluation is to document the continued medical necessity for the surgical dressings that are ordered for the patient to use at home. In most cases, monthly evaluations are required, but weekly evaluations are required in three situations. The first is for beneficiaries in a nursing facility. The second is for beneficiaries with heavily draining wounds and ulcers. And the third is for beneficiaries with infected wounds and ulcers. These monthly or weekly evaluations and documentation must include type of each wound, such as a surgical wound, a debrided wound, a pressure ulcer.

The location of the wound, the wound size, that's the length times width, and the depth of each wound. The amount of drainage from each wound, and any other relevant wound ulcer status information. And please note that these evaluations must be available to payers and auditors upon requests, so they're very important they be in the medical record. In addition, the DME suppliers must receive a written order from the physician or QHP prior to the delivery of the surgical dressings.

Now, when the prescribing practitioner is also the supplier such as, for example, a lot of times podiatrists also have a DME supplier number. In that case... And they're permitted to furnish surgical dressings, a separate order is not required. However, the medical record must contain all of the required order elements and all of the documentation. In addition, a new order is required if a new dressing is added or if the quantity of an existing dressing needs to be increased. And if there's no change for three months, that a new order is still required every three months for each dressing that is used. Now, this slide outlines the information that's required in the detailed written order. It has to have the beneficiary's name or their Medicare beneficiary identifier, the order date, the primary dressing descriptions, the size of that dressing, the number and amount to be used at one time, the frequency of the dressing change, and the expected duration of need.

And if a secondary dressing is needed, we also have to have the secondary dressing's description, the size of it, the number and amount to be used at one time, the frequency of the dressing change, and the expected duration of need. We also have to have the prescribing practitioner's name or their national provider identifier, and the prescribing practitioner's signature and signature date. And please note that this written order and what's in the medical record documentation must align. Now, let's discuss the importance of knowing where the patient's surgical dressing will be changed.

When the treating practitioner educates the patient or caregiver to change her or his surgical dressings at home, the patient may acquire the dressings from a DME supplier if the patient paid for their Medicare Part B supplement. Those primary and secondary surgical dressings are strictly for the patient's use at home. Because physician, and QHP offices, and PBDs are required to purchase their own dressings used at every encounter, patient may not provide the office or PBD with surgical dressings that they receive from the DME supplier for their use at home.

And when the treating practitioner determines that the patient requires skilled care from a home health agency, the agency must provide the surgical dressings for the patient. If the patient has previously received surgical dressings from a DME supplier, the home health agency is not allowed to use any of those dressings. By now, you should have figured out that the Medicare Part B program only separates and pays for surgical dressings separately when they are used by the patient's at home. So far, you have seen that treating practitioners orders and documentation helped to determine if Medicare will cover and pay for surgical dressings. We also learned that the Medicare Part B program only separately pays for surgical dressings ordered for the patient's use at home. Now, we must consider what primary and secondary dressings are ordered and why. The surgical dressing LCD and LCA clearly describe several things. One, the types of wounds or ulcers that qualify for surgical dressings, and two, the coverage guidelines for most of the surgical dressing categories.

If the treating practitioner does not follow these guidelines, the DME supplier will not be able to supply the dressings that were ordered, and will not be able to build a Medicare program for the patient. Therefore, every practitioner who orders surgical dressing for patients for them to use home must read the surgical dressing LCD and LCA, and incorporate the guidelines into their medical decision making, into their documentation, and into their orders. And because the surgical dressing LCD and LCA contain hundreds of details, we cannot cover all the details in this short video. However, we can review a few examples of the specific guidelines for some very commonly ordered surgical dressings. Now, not all wounds and ulcer types qualify for Medicare Part B covered surgical dressings. A qualifying wound or ulcer as defined as either of the following. It must be a wound that is caused by or treated by a surgical procedure, or a wound that has been debrided by any method such as surgical debridement, mechanical debridement, chemical debridement, or autolytic debridement.And please note that the surgical procedure or the debridement must be clearly documented in the patient's medical record.

Now, both primary and secondary dressings are eligible to be classified as surgical dressings, and the LCD describes primary dressings as therapeutic or protective coverings applied to wounds either on the skin or caused by an opening to the skin. And secondary dressings are described as materials that serve a therapeutic or protective function, and that are needed to secure the primary dressing. The LCD describes the various categories of surgical dressings and provides specific guidelines for most of the surgical dressing categories. And these guidelines include the description of each dressing and the billing unit, such as is it billed as each, or per square centimeter, or per six inches, or per gram, or per fluid ounce.

It also describes the wound types that are covered for each dressing category, and the frequency of change that the dressing is allowed to be changed. Now, let us review the coverage guidelines for several of the common surgical dressing categories. The first category is the hydrogel dressing wound filler gel. That category is covered when used on full thickness wounds, such as stage 3 or 4 ulcers with minimal or no exudate.

However, hydrogel dressings are not reasonable and necessary for stage 2 ulcers, and the allowed dressing change frequency for hydrogel wound fillers is up to once per day. And the quantity of a gel filler used for each wound must not exceed the amount needed just to line the surface of the wound.

Additional amounts used if you want to fill a cavity are not reasonable and necessary, and therefore the maximum utilization for hydrogel wound fillers is three units, which is three fluid ounces per wound every 30 days. And also, use of more than one type of hydrogel dressing, such as a filler and a cover or an impregnating gauze, like two of those together, is not reasonable and necessary for the same wound at the same time.

Therefore, all of this information should be documented in the patient's medical record and should be included in the written order. Now, let us review the coverage guidelines for collagen dressings or wound fillers. These categories of dressings are covered when used on full thickness wounds, such as stage 3 or 4 ulcers, with light to moderate exudate.

Collagen dressings are not reasonable and necessary for wounds with heavy exudate, third degree burns, or active vasculitis. And collagen is covered for wounds or ulcers that have stalled or are not progressing or healing. In addition, the LCD states that collagen dressings or wound fillers can stay in place for up to seven days. And finally, let us review the coverage guidelines for foam dressings. They're covered when used on full thickness wounds such as stage 3 or 4 ulcers with moderate to high exudate. When used as a primary dressing, the change is up to three per week. If it's used as a secondary dressing for wounds or ulcers with a high amount of exudate, the dressing changes also up to three per week. But if you have a womb filler that is foam, it may be changed up to one time per day. The LCD provides some other very logical guidelines such as, do not use combinations of hydrating dressings and absorptive dressings on the same wound.

An example of this logical guideline is that the durable medical equipment MAC will not cover a hydrogel, which is hydrating, and an alginate, which is absorptive on the same wound. The LCD also addresses the size of the dressing that the durable medical equipment MAC will cover. The LCD says that the size of the dressing ordered must be based on the size of the wound or ulcer. It then says that the pad size of the dressing should usually be two inches larger than the wound or ulcer, so you can imagine it's one inch all around the wound or ulcer.

And the LCD also describes an exception to the guidelines, and the exception is that alginates and other fiber gelling dressings could be closer to the size of the wound or ulcer size, so not extend so much over the wound margins. As I mentioned earlier, the LCD provides cautions that the frequency of dressing change depends on the type and use of the surgical dressing, and the LCD states a few very important things.

It says when combinations of primary dressings, secondary dressings, and wound fillers are used, so when you're using more than one dressing in a wound, the change frequencies of the individual products should be similar. Meaning that if one is changing three times a week, the other should be able to be changed three times a week. And the product that's in contact with the wound determines the change frequency. So whatever's contacting the wound, whatever the LCD says, you're allowed to change that particular dressing, that is going to set the change frequency for both the primary and the secondary dressing. And it is not reasonable and necessary to use a combination of products with differing change intervals. An example of this is it's not reasonable and necessary to use a secondary dressing that has a weekly change frequency over a primary dressing with a daily change frequency, such claims will be denied as not reasonable and necessary.

As we come to the end of part 3 with Clinicians' and Physicians' Vital Roles in Receiving Appropriate Medicare Reimbursement, I hope you clearly understand how the treating practitioner practitioner determines if Medicare will cover and pay for surgical dressings needed for their patient's use at home. Reading and following the surgical dressing's LCD and LCA are pivotal to your patients receiving the dressings they need for home use. The DME suppliers are in the business of supplying surgical dressings, but they can only fulfill primary and dressing orders that align with a surgical dressing LCD and LCA. For your convenience, this slide provides the links to the surgical dressing LCA and LCD. In addition, the last link on the slide is one of my favorite LCAs. It provides the medical record documentation requirements for all products that you might order from a DME supplier. Wound ulcer management treating practitioners should follow all three of these coverage documents, because you want Medicare to cover and pay for the surgical dressings that are needed by your patients at home.

And remember that the DME suppliers want to supply them, but these LCDs and LCAs apply to everything you order and everything they supply. And so if your orders and your documentation don't align with this LCD and these LCAs, then the DMEs are handicapped and they can't provide exactly what you ordered. Thank you for allowing me to share reimbursement information with you. 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, and/or their sales representatives, feel free to contact me at the number or the email that was listed on the slide at the beginning of the presentation. Good luck in doing your part to gain positive Medicare coverage and payment, and don't underestimate your vital role in this process. Thank you.

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.