Are you winning the reimbursement battle?
May 1, 1999 3 minutes read
WOUND CARE FORUM
Are you winning the reimbursement battle?
Editor’s note: A major part of Wound Care’s mission is to provide comprehensive, hands-on help for readers. We want to address all the issues that are important to you in your wound care practice. To do that, we need your input and feedback. With this issue, we begin a monthly question-and-answer column. Please send your questions to Wound Care, P.O. Box 740056, Atlanta, GA 30374, or fax them to the attention of Valerie Loner at (404) 262-5447. We’ll find the expert answers you need.
Question: "I am constantly faced with denial of reimbursement for wound care. What can I do to get paid and protect myself in an audit?"
Answer: According to Tamara D. Fishman, DPM, president of the Wound Care Institute in North Miami Beach, FL, "There are really two questions here: Do you consistently get your due reimbursement? And do you know how to respond to an audit? Review your billing and documentation procedures. You must use the correct evaluation and management (E&M) documentation and coding. Codes must be to the most appropriate E&M documentation. You need to be sure you are not under- or overcoding.
"Are you documenting adequately for your billing to stand up under a claim audit? You may never be audited, but every time you document in a patient’s chart, you should be ready for one. You can’t avoid random computer selection for claim audits, so it’s best to be prepared with the correct information and documentation in your clinic charts. You must document your procedures and your evaluation of the patient at each visit.
"The key to success is understanding the codes and the procedures you are doing in wound care in order to be reimbursed. This means you must be knowledgeable about Medicare documentation and coding requirements, CPT diagnosis codes, and E&M codes. Managed care clearly has become a strong factor in both reimbursement issues and quality of care issues. Both the private health care industry and government insurance are making demands on providers to be as cost-effective as possible, which often translates into an decreased reimbursement. With managed care, you must know the amount of reimbursement your contract calls for. Just because you feel you deserve something doesn’t mean that’s your contract rate. You have to be familiar with your contract, what the reimbursement rate is, and how many times you can see, evaluate, and follow up on a patient based on those codes. That’s going to vary from managed care plan to managed care plan. The bottom line is: Document, document, document."
Glenda J. Motta, BSN, MPH, ET, president of GM Associates in Mitchellville, MD, concurs that documentation will make or break your reimbursement. Prior to 1999, invoices for wound care supplies used in nursing homes were sent to one of four regional Durable Medical Equipment Regional Carriers (DMERCs), which was billed for the supplies costs. Nursing homes didn’t have to be concerned about specific coverage requirements, billing information, or the quantities of supplies used. Now, all claims for supplies from skilled nursing facilities (SNFs) must be submitted to Medicare under the facility’s own number. Motta says this change in reimbursement rules means SNFs must submit a great deal of documentation about the wound dressings they use and why they use them.
As bleak as this picture appears, there is help available to guide wound care providers through the maze of paperwork created by the new regulations. Motta and Kathi Whitaker, BSN, MSN, CETN, have co-written a 50-page booklet, Defensive Wound Management, that spells out wound documentation strategies for subacute facilities and SNFs. It’s available for $79.95 plus applicable sales tax from Pathways to Empowerment, 12300 Prospect Landing, Mitchellville, MD 20721. Telephone: (301) 390-4445. Fax: (301) 390-4446. E-mail: [email protected].
Fishman also recommends the Briggs Corp. manuals, a listing and description of which are available from the Wound Care Institute, 1541 NE 167th St., North Miami Beach, FL 33162. Telephone: (305) 919-9192. Fax: (305) 944-6260. Web site: www.woundcare.org. E-mail: [email protected]. WCI also has available a chart of dressing categories and their allowable usages.
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