MEDICARE COVERAGE DETERMINATIONS 

To ensure proper Medicare reimbursement and smooth Medicare audits, clinicians must familiarize themselves with the coding and reimbursement guidelines for wound care and ensure compliance with the CMS.

• Definition: according to CMS, the term ‘local coverage determination' represents a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts” Section 1869(f)(2)(B) of the Social Security Act (the Act).[2]
• The Medicare Part A/B Medicare Administrative Contractors (MACs) determine which types of services are covered, along with documentation needed to justify medical necessity, utilization guidelines, frequency allowed, etc. Clinicians who bill Medicare should adhere to the guidance provided by their MAC to ensure proper reimbursement and smooth audits, should they occur. 

Always refer to your MAC’s local coverage determinations for specific information on wound care Medicare coverage in your state. For a list of local coverage determinations, see topic “Medicare Coverage Determinations for Wound Care”

DIAGNOSES AND ICD-10 CODING

• Definition: The International Classification of Diseases (ICD) is a set of codes that provide a universal language for reporting diseases and injury. Maintained today by the World Health Organization (WHO), the ICD code set was created over a hundred years ago, and is currently in its 10th revision, and thus the abbreviation “ICD-10”. In the United States, the ICD-10-CM is utilized. “CM” stands for “clinical modification”, and it means that the original ICD-10 code set was expanded and clarified for national use.
• ICD codes are numeric or alphanumeric. The first three characters of the code describe the basic manifestation of the injury or sickness. 

Wound Vs. Ulcer

Although frequently used interchangeably, from a medical coding standpoint, wounds and skin ulcers are two completely different diagnoses. 

• For coding purposes, wounds are classified as acute or chronic according to their etiology.[3] For instance, traumatic wounds, surgical wounds are considered acute wounds, and pressure ulcers and non-pressure ulcers, varicose veins with ulcers, etc, are considered chronic wounds or ulcers.
• Wound: according to ICD-10 language, a wound is something that happens traumatically. All wound ICD-10 codes start with the letter “S” and are located in Chapter-19 grouped under the ICD-10 tabs of injuries, poisonings and certain other consequences of external causes
• Ulcer: the term “ulcer” refers to a break in the skin that fails to heal as it should and is typically chronic in nature. 
• For further differences between acute and chronic wounds, see section ‘Acute and chronic wounds’ in topic “Principles of Wound Healing”

Coding a Skin Ulcer

New and revised wound codes are updated every year and can be found here on Wound Reference or in ICD-10 books or software. (See topic “Wound Care ICD-10 Codes for 2020” or use My Power Search, then click on the tab ‘Web’ and on ‘ICD10Data’)

Once an ulcer has been identified, the provider must determine the ulcer type in order to use the correct code. 

For ulcers that are not pressure ulcers/injuries 

• Identify and document first any documented underlying condition (e.g., chronic venous hypertension with ulcer, type 2 diabetes mellitus with foot ulcer)
• Specify laterality
• Right, left or unspecified
• Specify ulcer severity: Select code for non-pressure chronic ulcer  (L97-, see Table 1)
• Limited to breakdown of skin
• With fat layer exposed
• With necrosis of muscle
• With necrosis of bone
• Unspecified severity 
• See coding for common ulcers: diabetic foot ulcer, venous leg ulcer, arterial ulcer 

For pressure ulcers/injuries

• Pressure ulcers/injuries codes (L89- ) are easier to complete than the codes above, as they do not have any “use additional code” instruction and the only “code first” instruction is to “code first any associated gangrene (I96). [4] 
• See coding for pressure ulcers/injuries

Coding example

1. A patient presents with ulcer to right heel with fat layer exposed. The ulcer is due to the patient’s Type 2 Diabetes 

• E11.621-Type 2 diabetes mellitus with foot ulcer
• L97.412  Non pressure chronic ulcer right heel and midfoot with fat layer exposed

2. A patient with a diabetic foot ulcer which may have occurred due to pressure ulcer/injury or arterial disease.

• The following statement from the National Pressure Ulcer Advisory Panel  (NPUAP) should be observed: for ICD-10 purposes, if there is an ulcer on the foot of a diabetic patient, consider it a DFU (and code using “L97-”). This is true even if arterial disease and/or pressure has played a role in its development.[4] 

Table 1. L97- ICD-10 coding

HCPCS/CPT GUIDANCE

The Healthcare Common procedure Coding System (HCPCS, commonly pronounced “hicks-picks”), is divided into two principal subsystems, referred to as level I and level II of the HCPCS.[5]

Level I HCPCS and CPT codes

• Definition: per CMS, Level I of the HCPCS consists of Current Procedural Terminology (CPT), a numeric coding system maintained and copyrighted by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals. Providers use the CPT to identify services and procedures for which they bill public or private health insurance programs. Level I of the HCPCS, the CPT codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.[5]
• Clarification: HCPCS Level I is identical to CPT, though when used to bill Medicare or Medicaid, those codes are called HCPCS Level I codes. When billing other payers, the same code is called CPT. 
• CPT codes are utilized with ICD codes to describe the medical process for the payer. For instance, a patient arrived with a specific condition (coded with ICD-10), and was treated with specific procedures (coded with HCPCS Level I/CPT codes)  
• CPT codes are divided in 3 categories. Category I is the most utilized within CPT, and it focuses on the procedures performed by providers across all care settings. Category II are supplemental tracking codes used primarily for performance management. Category III codes are temporary codes that describe emerging and experimental technologies, services, and procedures.[6]
• Category I CPT codes are arranged as follows: 
• Evaluation and Management: 99201 – 99499
• Anesthesia: 00100 – 01999; 99100 – 99140
• Surgery: 10021 – 69990
• Radiology: 70010 – 79999
• Pathology and Laboratory: 80047 – 89398
• Medicine: 90281 – 99199; 99500 – 99607

 Level II HCPCS

• Definition: per CMS, level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes were established for submitting claims for these items.

Modifiers for Wound Care and Hyperbaric Oxygen Therapy

Procedure codes (HCPCS Level I or CPT codes)  may be modified under certain circumstances to more accurately represent the service or item rendered. For this purpose, modifiers are used to add information or change the description of service to improve accuracy or specificity. The documentation of the service provided must support the use of the modifier. Please refer to your CPT and HCPCS Coding Manuals for the complete list of modifiers.[7] Table 2 includes information on the most commonly used modifiers in wound care and HBOT.

Table 2. Common Modifiers In Wound Care and HBOT

MEDICARE PHYSICIAN FEE SCHEDULE

Medicare Part B covers medically necessary physician services. Services and payment rates are published in the Medicare Physician Fee Schedule (MPFS).[8] 

Per CMS, physicians can be one of these:

• Doctor of Medicine (MD)
• Doctor of Osteopathic Medicine (DO)
• In some cases, a dentist, podiatrist (foot doctor), optometrist (eye doctor), or chiropractor

Medicare also covers services provided by other health care providers such as:

• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Clinical social workers
• Physical therapists
• Occupational therapists
• Speech language pathologists
• Clinical psychologists

Physicians’ services include: 

• Office visits 
• Surgical procedures 
• Anesthesia services
• A range of other diagnostic and therapeutic services

Physicians’ services are furnished in all settings, including: 

• Physicians’ offices 
• Hospitals 
• Ambulatory Surgical Centers 
• Skilled Nursing Facilities and other post-acute care settings 
• Hospices 
• Outpatient dialysis facilities 
• Clinical laboratories 
• Beneficiaries’ homes
• Note: Institutional providers such as hospitals, Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Skilled Nursing Facilities (SNFs) are paid for some services under the MPFS depending on the institution type and service. 

MPFS Payment Rates

For most codes, Medicare pays 80 percent of the amount listed and the beneficiary is responsible for 20 percent. Examples of reductions from the published MPFS amount include: 

• Assistants at surgery receive 16 percent of the MPFS rate 
• Nurse practitioners, physician assistants, and clinical nurse specialists are paid 85 percent 
• Registered dietitians or nutrition professionals, for medical nutrition therapy services, are paid 85 percent 
• Clinical social workers receive 75 percent

For each service represented by a HCPCS Level I or CPT code, CMS calculates a payment rate using the Medicare PFS payment rates formula.[8] See Figure 1

Figure 1. Medicare PFS Payment Rates Formula (arithmetic graphic of components added and multiplied together to make up the PFS payment rate) [8] 

1) Relative Value Units (RVUs): Three separate RVUs are associated with calculating a payment under the Medicare PFS:

• The Work RVU reflects the relative time and intensity associated with furnishing a Medicare PFS service 
• The Practice Expense (PE) RVU reflects the costs of maintaining a practice (such as renting office space, buying supplies and equipment, and staff costs) 
• The Malpractice (MP) RVU reflects the costs of malpractice insurance 

2) Geographic Practice Cost Indices (GPCIs) Each of the three RVUs are adjusted to account for geographic variations in the costs of practicing medicine in different areas within the country. These adjustments are called GPCIs, and each kind of RVU component has a corresponding GPCI adjustment. 

3) Conversion Factor (CF) To determine the payment rate for a particular service, the sum of the geographically adjusted RVUs is multiplied by a CF in dollars. The statute specifies the formula by which the CF is updated on an annual basis.

Searchable MPFS

The searchable MPFS allows health care professionals, suppliers, and institutional providers to find the Medicare payment amount for each HCPCS Level I code and calculate the beneficiary coinsurance amount.[8] 

Site of Service Differential

Under the MPFS, some procedures have a separate Medicare fee schedule for a physician’s professional services when provided in a facility (such as a hospital) or a non-facility. Generally Medicare provides higher payments to physicians and other health care professionals for procedures performed in their offices because they are responsible for providing clinical staff, supplies, and equipment. This differential is viewed in the NON-FACILITY PRICE and FACILITY PRICE columns in results displayed by the searchable MPFS.[8] 

BILLING IN THE OUTPATIENT SETTING 

Evaluation and management coding

Physician’s offices and clinics operating as hospital outpatient departments (HOPDs) frequently use HCPCS Level I/CPT codes for evaluation and management (E/M) for reporting a number of their services. Further information on E/M can be found in the CMS Evaluation and Management Services Guide.[9] The sections below address some common questions on E/M in the outpatient setting. For 2021 updates, see topic "2021 Office/Outpatient E/M Services Updates for Wound Care and HBOT".

New versus Established Patient

• Determining the definition of a new vs. established patient can be confusing, but getting it correct is important and sets the stage for future billing success. The distinction between new and established patients applies only to the categories of E/M services 
• A new patient in the Provider-based wound department is any patient that has not been registered for any new service in the entire health system for the past three years.  A patient is considered new to the physician or QHP of the same specialty or subspecialty who belongs to the same group practice within the last three years.  A new wound does not a justification to report a new clinic visit code or a new E/M code i.e., 99201-99205
• CMS Definition [10]:
• New Patient: a new patient is one who HAS NOT received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.
• Established Patient: an established patient is one who HAS received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.
• For a decision tree, see Noridian's "New Patient vs Established Patient Visit Decision Tree"

OPPS Hospital Outpatient Department Facility Charges for E/M - HCPCS Level II code G0463

CMS-participating wound care programs based in hospital outpatient departments are subject to the CMS Outpatient Prospective Payment System (OPPS). For each outpatient clinic visit, there will be 2 payments: 

• One payment for the professional services furnished by the provider
• One payment for the facility (facility charge), which covers use of the room and any medical or technical supplies, equipment and support clinical staff (e.g. nurses, technicians, etc)

The facility charge for a clinic visit in which the provider completes an evaluation and assessment of a patient is billed with HCPCS code G0463, “Hospital outpatient clinic visit for assessment and management of a patient.”[11]

• HCPCS code G0463 was created for hospital use only, for any clinic visit under the OPPS. As such, there is no need to identify whether the patient is new or established.  
• G0463 does not require an organization to use any specific criteria to determine a level of service. That is, HCPCS Code G0463 is used for all facility evaluation and management visits, regardless of the intensity of service provided.

Documentation to support HCPCS G0463

While having a single code simplifies some aspects of submitting a hospital outpatient claim for a facility evaluation and management service, it does not eliminate the need for detailed clinical documentation. Clinical support staff is still required to document the services and education provided to the patient during their visit. Therefore, there must be clinical documentation by the clinical support staff found in the chart to substantiate billing G0463 by the facility representing overhead expenses.[11]

Payment for HCPCS G0463

• Payment for G0463 under the 2020 Outpatient Prospective Payment System (OPPS) averages $115.92 and, according to the Centers for Medicare & Medicaid Services (CMS), is revenue neutral because it is based on “average reimbursement” to hospitals for all outpatient levels.
• However, it is important to note a hospital’s 2020 revenue generated from G0463 will depend on its clinic acuity mix. That is, if a clinic serves a population with more complex conditions, it may experience higher acuity levels, and payment received by G0463 might not be enough to offset facility costs of office visits.[12] 
• Thus, to ensure that Medicare takes into account each clinic’s acuity level and continues to pay a fair amount for patient assessment and management, it is imperative that each facility’s charge master be updated to represent G0463 as 10 separate charges just as they were represented under the prior system of codes 99201-99205 & 99211-99215, retired in 2013. Table 3 illustrates how the facility charge master might look.
• The rationale behind this suggestion lies in the fact that a hospital’s revenue generated from G0463 in a given year (e.g. 2020) depends on its clinic acuity mix and the average E/M levels it reported 2 years before (e.g. 2018). That is, the amount billed today determines what CMS will pay the clinic in 2 years. By establishing different levels/prices for the G0463 code, the clinic is communicating patient acuity to CMS and helping secure its future payments.
• Hospitals should consider tracking outpatient acuity levels for all payers, not only for CMS. Calculating a single service level for Medicare will compromise critical metrics related to outpatient acuities at the facility, diagnoses that typically correspond to each level, treatment and medications by level, etc. In addition, hospitals should also consider tracking new vs. established clinic visits.[12] 

Table 3. Facility’s charge master updated to represent G0463 as 10 separate charges according to acuity levels, and new versus established patients

*Amount Billed figures are examples only

Procedures

Billing for Debridement - Active Wound Management

Proper wound care coding requires careful reading of all Current Procedural Terminology (CPT) code descriptors and related CPT Manual instructions. Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressing. For a list of local coverage determinations on debridement, see section ‘Medicare Administrative Contractors and Local Coverage Determinations’ in topic “Debridement”.

The sections below provide an overview on the different types of debridement from a coding perspective, along with billing tips. For further information on types of debridement, see section ‘Types of debridement’ in topic “Debridement” 

Selective Debridement Codes

The CPT codes used for selective debridement are: 

• 97597- Debridement (e.g, high pressure waterjet with / without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g. fibrin, devitalized epidermis and/or dermis, exudate, debridement, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area, first 20 SQ CM or Less. 
• 97598 - each additional 20 sq cm (add on code)* 
• *Size refers to the total surface area of all wounds for selective debridement codes

Billing Tips for Selective Debridement

• For documentation requirements and more tips, see sections ‘Documentation’ and ‘Coding and Reimbursement’ in topic “How to Perform Conservative Sharp Debridement” 
• Selective debridement involves removal of devitalized epidermis/dermis. There is no removal of viable, recognizable material
• Facility reimbursement code 97598 is packaged into the payment for the primary procedure 97597. This is not the case for physician fees
• Use 97597 for debridement of the first 20 sq cm of wound surface area. Use 97598 for each additional 20 sq cm debrided or portion thereof.  
• When coding for multiple areas add the total surface area if wounds are all the same depth and same tissue. [13]
• If debridement is done to prepare for a procedure is it not reported separate and is included in the primary procedure. [13]

Non-Selective Debridement Code 

The CPT code used for non-selective debridement is:

• 97602- Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

Billing Tips for Non-selective Debridement

•  The 97602 charge is only billable by the facility and is not paid to Providers
• For Part B, CPT code 97602 has been assigned a status indicator "B"(Bundled) in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare Part B.

Surgical Debridement Codes Involving Subcutaneous and Deeper Tissue

• 11042 Debridement, subcutaneous tissue incl epidermis and dermis, first 20 sq cm or less
• 11045 each additional 20 sq cm (add on code)*
• 11043 Debridement, muscle and/or fascia incl epidermis and dermis and subQ, first 20 sq cm or less
• 11046 each additional 20 sq cm (add on code)*
• 11044 Debridement, bone , incl subcutaneous tissue, muscle, and/or fascia, epidermis and dermis, first 20 sq cm or less 
• 11047 each additional 20 sq cm (add on code)*
• Use Add-On codes when debrided tissue at the same depth Is greater than 20 sq. cm. 

Billing Examples

1. When tissue removed is at the same depth: 18 sq cm of subcutaneous tissue debrided from the right leg and 12 sq cm of subcutaneous tissue debrided from the left leg

2. When tissue removed is at the different depths:15 sq cm of muscle debrided from a leg wound and 15 sq cm of devitalized epidermis or dermis removed from different wounds.

Billing Tips for Surgical Debridement

• Surgical debridement involves sharp removal of tissue at the wound margin/and or base until viable tissue is removed
• Coding is based on the deepest level of viable tissue removed, not the tissue cut into
• Report only the deepest debridement of the wound if physician documents debridements to different levels of the same wound
• For all wounds debrided at the same level, add the total area of all wounds for a single charge
• The post debridement wound size should be larger after excisional debridement due the physician removing viable tissue
• Provider must perform pre- and post debridement photos, documentation of bleeding should be mentioned
• Provider’s fees are not packaged. 
• Reasons for denial include: 
• 1. Performing deep debridement in POS other than inpatient hospital, outpatient hospital or ASC 
• 2. Billing of debridement by unqualified personnel.

Billing for Cellular and/or Tissue Based Products 

• Also known as "Skin Substitutes". Please refer to section ‘Coding, Coverage and Reimbursement’ in topic “Cellular and/or Tissue Based Products” and its checklist

Billing for Cauterization of Hypergranulation Tissue 

Topical application of silver nitrate is often used in wound care to help remove and debride hypergranulation tissue “proud flesh” or calloused rolled edges in wounds or ulcerations. Silver nitrate may also be utilized to cauterize bleeding wounds. Silver nitrate is a highly caustic material, so it must be used with caution to prevent damage to healthy tissues.

Many wound clinics include a cauterization charge utilizing silver nitrate on their charge master. The AMA defines this code as follows:

• 17250 - Chemical cauterization of granulation tissue (i.e., proud flesh)

AMA guidelines

• Do not report 17250 with removal or excision codes for the same lesion
• Do not report 17250 when chemical cauterization is used to achieve wound hemostasis
• Do not report 17250 in conjunction with 97597, 97598, 97602 for the same lesion 

Billing tips for cauterization

• Wound providers may bill 17250 to treat hypergranulation “proud flesh” of chronic wounds. 17250 may NOT be billed to achieve hemostasis post debridement or to cauterize active bleeding wounds. The billing charge master should include a descriptor defining the code definition and its limitations.
• APC Status Indicator Q1 (packaged code) Paid under OPPS; Addendum B displays APC assignments when services are separately payable.
• Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “S,” “T,” or “V.”
• In other circumstances, payment is made through a separate APC payment.
• National Correct Coding Initiative (NCCI) edits are applicable. The purpose of the NCCI Procedure-to-Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. See section 'National Correct Coding Initiative (NCCI)' below.

Billing for evaluation and management and procedures on the same day

It is important to preface by noting that payment for diagnostic (with the exception of pathology and laboratory) and/or therapeutic procedure(s) (code ranges 10040-69990, 70010-79999 and 90281-99140) already includes taking the patient’s blood pressure, temperature, asking the patient how he/she feels and getting the consent form signed. Since payment for these types of services is already included in the payment for the procedure, it is not appropriate to bill for an Evaluation and Management (E/M) service separately. 

However, under both the Center for Medicare & Medicaid Services (CMS) and CPT® guidelines, an E/M service may be separately billed with a minor procedure as long as a new or separately identifiable problem was addressed when a minor procedure was performed by the same physician on the same day of the procedure or other service. In that case, the E/M service needs to be clearly documented and substantiated and modifier 25 needs to be properly appended to the appropriate E/M service code. [14][15]

Modifier 25

The AMA CPT manual gives the definition of modifier -25 as follows [16]:

•  “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.” 

Further explanation of the modifier is given as follows: 

• “The physician may need to indicate that on the day of a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the modifier ‘ -25’ to the appropriate level of E/M service...”

CMS Guidelines for Use of Modifier –25 in Association with Hospital Outpatient Services

CMS guidelines for use of Modifier 25 include [17] :

1. Should a separately identifiable E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, information substantiating the E/M service must be clearly documented in the patient’s medical record, to justify use of the modifier –25.
2.  Modifier –25 may be appended only to E/M service codes and then only for those within the range of 99201-99499. For outpatient services paid under OPPS, the relevant code ranges are: 99201-99215 (Office or Outpatient Services) 99281-99285 (Emergency Department Services) 99291 (Critical Care Services) 99241-99245 (Office or Other Outpatient Consultations)
3. Since payment for taking the patient’s blood pressure, temperature, asking the patient how he/she feels, and obtaining written consent is included in the payment for the diagnostic and/or therapeutic procedure, it is not appropriate to report a separate E/M code for these types of service.
4. When the reporting of an E/M service with modifier –25 is appropriate (that is, the documentation of the service meets the requirements of the specific E/M service code), it is not necessary that the diagnosis code for which the E/M service was rendered be different than the diagnosis code for which the diagnostic medical/ surgical and/or therapeutic medical/surgical procedures(s) was performed 
5. It is not necessary that the procedure and the E/M service be provided by the same physician/practitioner for the modifier –25 to apply in the facility setting. It is appropriate to append modifier –25 to the qualifying E/M service code whether or not the E/M and procedure were provided by the same professional.        

Billing examples

• Question 1. Can a provider charge for an initial visit and the debridement? The patient presents for the first time and has a complete history and physical. Due to the nonviable and necrotic tissue in the wound, the physician also decides to do a sharp debridement with a curette. Can the provider charge for both the wound care visit itself and the debridement?
• Answer: A provider cannot bill both the visit and the debridement unless the medical record documentation supports a significant, separately identifiable E/M service was performed. If the documentation supports that, a provider could bill both and append the modifier 25 to the E/M service. If the documentation does not support a significant, separately, identifiable service, the services are not separately payable.      
• Question 2. If a provider or qualified healthcare professional (QHP) performs a procedure, can they bill for an E/M service if it has a higher reimbursement than the procedure code?
• Answer: When a procedure code such as selective debridement 97597 is performed, the procedure code should be reported even if it pays less than the E/M. In addition, the provider and the facility will bill the procedure code which is the work performed. It is important to remember that providers cannot select codes based on the reimbursement rate. Doing so could be costly as the recoupment from Medicare may be triple damage.[18]

Billing tips

• In the outpatient department, physicians should only charge for procedures they physically perform such as debridements, biopsies, etc.
• When nursing staff performs procedures such as non-selective debridement (e.g. collagenase), application of compression or negative pressure wound therapy, the facility will bill.
• The provider charge and the facility charge do not have to match.

OPPS payment status indicator for HCPCS codes

• Definition: an OPPS payment status indicator is assigned to every HCPCS Level I code. The status indicator identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged. The status indicator may also provide additional information about how the code is paid under the OPPS or under another payment system or fee schedule.
• Examples include:
• Services with status indicator A are paid under a fee schedule or payment system other than the OPPS. 
• Services with status indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service. 
• Services with status indicator T are paid separately under OPPS but a multiple procedure payment reduction applies when two or more 
• Services with a status indicator of T are billed on the same date of service
• Common wound procedures and their accompanying Status Indicator include: 
• G0277: Status Indicator  S-Significant Procedure, Not Discounted when Multiple
• 97597: Status Indicator T- Significant Procedure, Multiple Reduction Applies
• 11042: Status Indicator T- Significant Procedure, Multiple Reduction Applies
• 29581: Status Indicator T- Significant Procedure, Multiple Reduction Applies
• 97605: Status Indicator Q1- Packaged codes
• For a list of OPPS payment indicators, see CMS Addendum D1

National Correct Coding Initiative Edits (NCCI)

Procedure to Procedure (PTP) Edits 

• Definition: the Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.[19]
• Relevance: payment for certain CPT codes are bundled into other CPT codes. That is, CMS pays for only one of the CPT codes, even though more than one service/procedure was performed for a specific patient on the same day. For instance, a patient with a venous leg ulcer presents to the wound clinic. The provider performs a selective debridement (CPT 97597) and the staff applies a multi-layer compression wrap on the same leg after the debridement (CPT 29581). The nurses enter the technical charges for that patient as 97597, 29581. When the billing department enters the 2 charges into their PTP edit tool to determine payment, the tool shows that payment for 97597 would be processed as expected, however code 29581 shows as a column 2 code for 97597. That is, if both 97597 and 29581 are submitted, only 97597 will be paid. [20][21] 
• PTP edits do not apply if the procedures are performed at different anatomical sites or different patient encounters.
• A service that is denied based on PTP code pair edits or MUEs may not be billed to Medicare beneficiaries; a provider cannot utilize an Advance Beneficiary Notice of Noncoverage (ABN) to seek payment from a Medicare beneficiary.[19]
• Modifiers: each NCCI PTP code pair edit has an assigned modifier indicator. Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass a PTP code pair edit if the clinical circumstances do not justify its use. If the Medicare Program imposes restrictions on the use of a modifier, the modifier may only be used to bypass a PTP code pair edit if the Medicare restrictions are fulfilled.[19]
• A modifier indicator of "0" indicates that NCCI-associated modifiers cannot be used to bypass the edit.
• A modifier indicator of "1" indicates that NCCI-associated modifiers may be used to bypass an edit under appropriate circumstances.
• Modifier 59 - Distinct Procedural Service: the 59 modifier may be used when 2 procedures not normally reported together are appropriate under the circumstances. See section ‘Modifiers' above.
• For a tool that indicates if procedure codes commonly used in wound care and HBOT are eligible for payment when reported together, see topic "NCCI Edits for Hospital and Physician Services".

NCCI Tools - Looking up Procedure-to-Procedure (PTP) Code Pair Edits  

• The NCCI tools found on the CMS website (including the “National Correct Coding Initiative Policy Manual for Medicare Services”) help providers avoid coding and billing errors and subsequent payment denials.
• The tables are updated quarterly and loaded into the Medicare claims payment processing systems and onto the CMS NCCI webpages. Click the Quarterly PTP and MUE Version Update Changes link in the menu on the top left side of the National Correct Coding Initiative Edits webpage.
  
• Refer to the CMS Medicare Learning Network (MLN) "How to use the Medicare National Correct Coding Initiative (NCCI) Tools" [19]

Medically unlikely edits (MUE)

• Definition: Medically Unlikely Edits (MUEs) are used by the MACs, including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE.
• Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS contractors use only. Confidential MUE values are not releasable.
• The National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edit files and Medically Unlikely Edit (MUEs) files are updated at least quarterly. 
• For further details see blog post "CMS Medically Unlikely Edits (MUE)"

NCCI TOOLS - LOOKING UP Medically Unlikely edits (MUE) 

• To view the tables of MUEs, select Medically Unlikely Edits from the menu on the left side of the National Correct Coding Initiative Edits webpage on the CMS website.[19]
• Scroll to the bottom of the page and click on the link to the table you want to review. The table links appear under the Related Links section.
• Units of service (UOS) are defined by the code descriptor (also referred to as the narrative description of the code).
• Table 4 below shows MUEs for common wound services performed in the outpatient setting. 

Table 4. MUEs for common wound services performed in the outpatient setting