2011: A Year of Change Medicare Reimbursement for Surgical and Medical Debridement

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1 2011: A Year of Change Medicare Reimbursement for Surgical and Medical Debridement Second in a Series Kathleen D. Schaum, MS Director, Medical Products Reimbursement Healthpoint, Ltd. Supported by an educational grant from Healthpoint, Ltd. First in the Series 2011: A Year of Change Medicare Reimbursement for Skin and Dermal Substitutes 2

2 Objectives of Today s Program To review coding and coverage changes affecting Medicare reimbursement for surgical and medical debridement in 2011 To understand the impact of Medicare payment changes on physicians and facilities To facilitate implementation of changes in documentation and billing procedures 3 Disclaimer Information on reimbursement in the U.S. is provided as a courtesy. Due to the rapidly changing nature of the law and Medicare payment policy, and reliance on information provided by outside sources, the information provided herein does not constitute a guarantee or warranty that reimbursement will be received or that the codes identified herein are or will remain applicable. This information is provided AS IS and without any other warranty or guarantee, expressed or implied, as to completeness or accuracy, or otherwise. This information has been compiled based on data gathered from many primary and secondary sources, including the American Medical Association, and certain Medicare contractors. (continued on next slide) 4

3 Disclaimer (continued) Physicians and other providers must confirm or clarify coding and coverage from their respective payers, as each payer may have differing formal or informal coding and coverage policies or decisions. Physicians and providers are responsible for accurate documentation of patient conditions and for reporting of procedures and products in accordance with particular payer requirements Coding Changes for Surgical and Medical Debridement 6

4 Coding Changes Address Ongoing Problems With Debridement Reimbursement OIG investigation into improper payments for surgical debridement services CMS medical reviews revealed ongoing issues regarding Improper coding Documentation Use of modifiers Frequency of debridement New system designed to solve the debridement coding dilemma CPT Physician Codes for Surgical Excision Debridement CPT Code Description Debridement; skin, partial thickness Debridement; skin, full thickness Debridement; skin, and subcutaneous tissue Debridement; skin, subcutaneous tissue, and muscle Debridement; skin, subcutaneous tissue, muscle, and bone CPT is a registered trademark of the American Medical Association 8

5 2011 Deleted CPT Codes for Surgical Debridement CPT Code Description Global Period Debridement; skin, partial thickness Debridement; skin, full thickness Debridement; skin, and subcutaneous tissue Debridement; skin, subcutaneous tissue, and muscle Debridement; skin, subcutaneous tissue, muscle, and bone CPT Code (Revised) Description Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle, and/or fascia, if performed); first 20 sq cm or less 10

6 Surface Area Debrided vs. Wound Surface Area Surgical Debridement Code Description Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less CPT Surgical Debridement Introduction Wound debridements ( ) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths 11 What Is 20 Square Centimeters or Less? Examples: CPT Code Measurement Description 20 sq cm or less = 20 sq cm or less = 20 sq cm or less = Example of Cumulative Surface Area of Debrided Subcutaneous Tissue 1 wound (3 sq cm wound surface area) (3 sq cm debrided surface area) 2 wounds (5 sq cm + 5 sq cm wound surface area) (5 sq cm + 5 sq cm debrided surface area) 3 wounds (2 sq cm + 12 sq cm + 6 sq cm cumulative wound surface area) (2 sq cm + 12 sq cm + 6 sq cm cumulative debrided surface area) 12

7 Multiple Codes Can Be Used When Wounds Are Debrided to Different Depths Example: Wound Surface Area (and Depth) Debrided CPT Code 1 15 sq cm (muscle, right leg) sq cm (subcutaneous, right leg) 3 5 sq cm (subcutaneous, left leg) New Add-on Codes in 2011 Base Procedure CPT Code (subcutaneous) First 20 sq cm (muscle) First 20 sq cm (bone) First 20 sq cm Add-on Code Each add l 20 sq cm, or part thereof Each add l 20 sq cm, or part thereof Each add l 20 sq cm, or part thereof Add-on codes are listed separately, in addition to base procedure code 14

8 Using Add-on Codes Example 1: Wound Surface Area (and Depth) Debrided CPT Code 1 10 sq cm (subcutaneous, left leg) sq cm (subcutaneous, right leg) Example 2: Wound Surface Area (and Depth) Debrided CPT Code 1 25 sq cm (muscle, left leg) sq cm (subcutaneous, right leg) The New Importance of Wound Measurement and Size New coding system dramatically increases the importance of accurate wound measurement No universally accepted methodology or guidance from AMA or CMS Typically a length x width calculation Irregularly shaped and multiple smaller wounds present a particular challenge 16

9 2010 CPT Codes for Selective Debridement CPT Code Total wound(s) surface area 20 sq cm Total wound(s) surface area >20 sq cm Description Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical applications(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; CPT Codes for Medical (Formerly Selective) Debridement CPT Code Total wound(s) surface area; first 20 sq cm or less Total wound(s) surface area; each additional 20 sq cm, or part thereof Description Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session Add-on codes are listed separately, in addition to base procedure code NOTE: The code descriptors appear to focus on wound area 18

10 Deleted CPT Codes and Use Revised Codes and for Debridement of Skin Deleted Codes (partial thickness) (full thickness) CPT Code Total wound(s) surface area; first 20 sq cm or less Total wound(s) surface area; each additional 20 sq cm, or part thereof and 2011 CPT Code for Non-Selective Debridement CPT Code Description Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical applications(s), wound assessment, and instruction(s) for ongoing care, per session Per session (not size-dependent) 20

11 Example for Patient Treated in HOPD Visit 1 2 HOPD Code Brief Description Physician Code Debridement, muscle (first 20 sq cm) Debridement, muscle (add l 20 sq cm) Debridement, sharp selective, open wound (first 20 sq cm) Debridement, sharp selective, open wound (add l 20 sq cm) HOPD: Non-selective debridement (eg, enzymatic) Physician: Outpatient Visit Medicare Payment 22

12 2010 vs Medicare Global Period for Physicians CPT Code 2010 Global Period 2011 Global Period Code Deleted Code Deleted (new code) (new code) (new code) NA NA (add-on in 2011) NA NA NA NA vs National Average Medicare Payment Rates for Physicians CPT Code 2010 Physician Rate in Office 2011 Physician Rate in Office 2010 Physician Rate in Facility 2011 Physician Rate in Facility $43.51 Deleted $25.81 Deleted $50.15 Deleted $31.71 Deleted $68.58 $86.64 $43.14 $ $30.92 $ $ $ $ $ $53.68 $ $ $ $ $ $88.34 $ $63.05 $72.03 $31.34 $ (Add-on in 2011) or $77.80 $24.12 or $ NA NA NA NA $

13 2010 vs National Average Medicare Payment Rates for HOPDs CPT Code 2010 APC Payment 2010 Patient Co-Payment 2011 APC Payment 2011 Patient Co-Payment $ $20.73 Deleted Deleted $ $20.73 Deleted Deleted $ $37.63 $ $ $ $ $ $37.63 $ $ $ $ $ $ $ $ $ $ $ $20.73 $ $ (Add-on in 2011) $ $20.73 $ $ $59.10 $11.82 $62.70 $ Impact of Skilled Nursing Facility (SNF) Consolidated Billing Therapy is consolidated into Medicare payment to SNFs and are considered sometimes therapy codes by Medicare Physicians must bill the SNF (rather than Medicare Part B) for and services provided to patients stays covered by Medicare Part A NOTE: When physicians provide wound care evaluation and management services for patients with wounds that do not require debridement, physicians bill for subsequent nursing facility care 26

14 Medicare Coverage 27 Existence of a Code and a Medicare Payment Rate Does Not Guarantee Coverage Check with the following sources to ensure coverage for a specific debridement procedure: Medicare Payer Local Coverage Determination (LCD) Guidelines relative to size determination may vary Private Payer Medical Policy for Coverage 28

15 Example: LCD Debridement Coverage Differences TrailBlazer Health Enterprises: L26721 Medicare will cover up to five surgical debridements, CPT code and/or 11044, per patient, per year. Services beyond the fifth surgical debridement, CPT code and/or 11044, per patient, per year, will be payable only upon medical review of records that demonstrate the medical reasonableness and necessity (appeal). Wisconsin Physicians Service Insurance Corporation: L28572 Payment for prolonged, repetitive debridement services requires adequate documentation of complicating circumstances that reasonably necessitated additional services. It is expected only one debridement involving true removal of muscle and/or bone to be required for management of most wounds within a 12 (twelve) month period. 29 Summary of 2011 Debridement Changes Deleted codes: and Reported with and (per session, based on wound size) is now an add-on code New descriptions for 11042, 11043, and (based on depth of tissue debrided and surface area debrided) New add-on codes: 11045, 11046, and Global period removed for and Size of wound and wound measurement have a greater importance Physicians and NPPs must bill skilled nursing facilities directly for medical debridement services during Medicare Part A covered stays 30

16 Implementation Checklist Review and implement coding, Medicare payment, and LCD changes that took effect on January 1, 2011 Make appropriate changes to debridement protocol, charge sheet, Charge Description Master, and documentation Monitor Medicare contractor s website on a monthly basis for LCD changes; review new guidelines with every member of the wound care team 31 Live Question and Answer Session To ask Kathleen Schaum a one-on-one question, contact her at: Kathleen.schaum@healthpoint.com 32