Reimbursement

by Marcia Nusgart, Executive Director, Alliance of Wound Care Stakeholders

The true burden of wound care to Medicare has been relatively obscured. Traditionally, wound care procedures were performed in the hospital setting. When the Centers for Medicare & Medicaid Services (CMS) created the hospital-based outpatient payment system in 2000 with the goal of providing care in complex cases when patients did not require hospitalization, management of nonhealing wounds shifted to the outpatient setting. Today, approximately 1,500 specialized hospital-based outpatient “wound centers” across the United States provide standard wound care treatment, as well as numerous therapeutic treatments. Wound care is also provided in patients’ homes by home health services and in skilled nursing facilities.

by Thomas E. Serena MD, FACS, FACHM, FAPWCA

"Please don't bury me down in that cold, cold ground. I'd rather have them cut me up and pass me all around."
-John Prine

Fans of folk singer John Prine will recognize the homey lyrics describing his views on organ donation. Sitting at my desk a few weeks ago with John Prine twanging in my headphones, I began to slog through the new Noridan Local Coverage Determination on hyperbaric oxygen therapy.

by Mary Ellen Posthauer RDN, CD, LD, FAND

The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT) amends Title XVIII of the Social Security Act by adding a new section – Standardized Post-Acute Care (PAC) Assessment Data for Quality, Payment, and Discharge Planning. The goal of the IMPACT Act is to reform PAC payments and reimbursement while ensuring continued beneficiary access to the most appropriate setting of care. The act requires the submission of standardized and interoperable PAC assessment and quality measurement data by Long-Term Care Hospitals (LTCH), Skilled Nursing Facilities (SNF), Home Health Agencies (HHA) and Inpatient Rehabilitation Facilities (IRF).

by the WoundSource Editors

With approximately 68,000 codes (nearly five times the number of codes as ICD-9), the ICD-10 system can seem daunting. In addition to an expansion in the number of codes, with flexibility for new code development, ICD-10 codes themselves are also longer in length using 3 to 7 digits versus 3 to 5 digits.

by Samantha Kuplicki, MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN

In the last installment of my blog, we discussed a brief overview of billing for wound care products and dressings (durable medical equipment or DME) in several common care settings. Let's talk about the Hospital Outpatient Department (HOPD) a little more in-depth. Again, we will use Medicare as the standard for payment policy, as many payors use them as a model for policy-making.

by Thomas E. Serena MD, FACS, FACHM, FAPWCA

During the 2010 presidential campaign, Sarah Palin, the former governor of Alaska, quipped during a debate that then presidential candidate Obama's health care reform contained within it "death panels": bureaucrats with limited or no medical training making life and death decisions. She suffered interminable criticism for the comment and political fact checkers dubbed it the "lie of the year."

by Catherine T. Milne, APRN, MSN, BC-ANP, CWOCN-AP

My grandmother knew wound care. "Soak it in salt water," she'd say. "Keep it open to air!" she would emphatically declare the next day. You never knew what to expect. We've all heard the sage old dermatology advice "If it's wet, keep it dry, and if it's dry, keep it wet." Perhaps my grandmother was a guest lecturer at a dermatology conference and they were too intimidated not to incorporate her wisdom.

by Bruce E. Ruben MD

Have you noticed that in the fictional future, such as in the Star Trek universe, nobody uses money to pay for medical care? When you get sick, a starship medical officer scans you with a handheld diagnostic device, and then injects you with the perfect cure. No copays or deductibles. No making copies of your driver's license and insurance card. No reimbursements from insurance companies. And no explanation is ever given for how such a free society exists in the future.

by Michel H.E. Hermans, MD

In the June 2015 issue of the Journal of Ostomy Wound Management, Bell et al. published an article in which they reacted to the recent decision by CMS (January 22, 2015) to change its HCPCS code for a Manuka honey dressing for Medicare Part B patients to a non-covered code. Apparently, this ruling was based on the fact that the dressing is impregnated with more than 50% (by weight) honey. The authors, rightly so, stated that this would be a major loss for a significant number of patients who, under the previous ruling, would have been able to use the dressing as a reimbursed material. Indeed, this specific dressing is one of the materials with a good record with regard to clinical proof.

by Samantha Kuplicki, MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN

It is becoming increasingly difficult to be involved in wound care at any level without having a working knowledge of the intricacies of varying policies regarding surgical dressings for wounds. Care setting, Medicare Administrative Contractor (MAC) for your geographic region and pertinent DME Local Coverage Determinations (LCD), type of dressings desired, and wound assessment are all factors that clinicians responsible for ordering supplies should be aware of. For practical purposes, we will mainly discuss Medicare as a reference for payors, as many commercial, contracted, and private payor policies are modeled after Medicare* policies.