Top 5 Tips while Billing for Wound Care Supplies - PowerPoint PPT Presentation

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Top 5 Tips while Billing for Wound Care Supplies


Billing tips shared in this article would help you to receive accurate insurance reimbursement while you are billing for wound care supplies. – PowerPoint PPT presentation

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Title: Top 5 Tips while Billing for Wound Care Supplies

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Top 5 Tips while Billing for Wound Care Supplies
  • Billing for wound care supplies to Medicare or
    private insurance carriers has always been a
    challenge. Every payer has its unique billing
    guidelines and reimbursement policies making it
    difficult to receive accurate reimbursement for
    wound care supplies. In this article, we shared
    the top 5 tips while billing for wound care
    supplies which will help you to reduce claim
    denials and accurately bill insurance carriers.
    Most of the guidelines we followed in this
    article are referred from The Centers for
    Medicare Medicaid Services (CMS) billing
    guidelines as most private payers consider it as
    a reference. 
  • 1. Defining Key Terminologies for Wound Care
  • The definitions applicable to wound care supplies
    are found in the 42 Code of Federal Regulations
    (CFR) 413.65. For accurately billing for wound
    care supplies let's understand definitions of
    outpatient encounters wound care supplies and
    other applicable terminologies. 
  • The Centers for Medicare Medicaid Services
    (CMS) defines hospital outpatients and outpatient
    encounters as a hospital outpatient is a patient
    who has not been admitted to the hospital as an
    inpatient, but is registered as a hospital
    outpatient and receives services, rather than
    supplies alone, directly from the hospital.

Top 5 Tips while Billing for Wound Care Supplies
  • This definition specifically speaks to the
    situation of a hospital merely dispensing
    supplies and no provision of services. In this
    case, the hospital would be acting as the
    supplier, similar to a durable medical equipment
    (DME) supplier, and is unable to bill supplies
    alone as a hospital provider.  
  • An encounter is defined as direct personal
    contact between a patient and a clinician
    authorized by state licensure and hospital staff
    bylaws (e.g., privileges) to order or furnish
    services for diagnosis or treatment of the
  • We should review the definition (i.e.,
    requirements) for supplies that can be separately
    reported as covered charges but are not
    considered routine supplies. The cost of
    routine supplies that are not patient-specific,
    often referred to as floor stock, are generally
    included or packaged into the visit or procedure
    charge and are not separately itemized on a
    patient account or bill. Some examples of
    routine supplies are exam table paper, cotton
    swabs, and wipes. Even though Medicare payment to
    the wound care PBD for its services and
    procedures includes payment for the non-routine
    patient-specific supplies (e.g., specific sterile
    surgical dressings, enzymatic debriding agents),
    each of the non-routine supplies should be
    reported as a separate charge under appropriate
    revenue codes in the covered column of the
    claim. This will ensure the non-routine charges
    are reported to Medicare or the other insurer
    while not being billed directly to patients. 

Top 5 Tips while Billing for Wound Care Supplies
  • If the item or supply is identifiable to an
    individual patient, typically via either order
    for the item or supply or documentation regarding
    the direct application of the specific item or
    supply to the patient, and that item or supply is
    not reusable (e.g., single-use, disposable, or
    represents a cost for each preparation, as with
    the sterilization of surgical instruments), it is
    separately chargeable on patient accounts.
    Therefore, most patient-specific wound care
    supplies, if properly ordered and documented in
    the medical record, meet the requirements for
    separate charges on patient accounts. 
  • 2. Understanding Top Denial Reasons
  • Once you understand top denial reasons, your
    billing team can take precautionary measures to
    avoid them. You can make required changes in your
    billing process flow to avoid these
    top denial reasons while billing for wound care
    supplies. Note that we referred to the Medical
    Review Department research report to identify top
    denial reasons. 
  • Wound debridement was not seen in the document.
    For those who dispense wound dressings, this
    simple rule is not complicated and in fact, is
    rather obvious. Debridement, either mechanical or
    chemical, must be documented as a part of the
    wound treatment regimen.

Top 5 Tips while Billing for Wound Care Supplies
  • If you are treating wounds routinely without
    debridement, this falls below the standard of
    care for wound treatment.
  • Documentation does not support moderate-high
    exudative full-thickness wounds (stage III-IV)
    Alginate dressings are dressings indicated for
    wounds that produce heavy drainage. Why would CMS
    pay for foam or an alginate dressing if there is
    no documentation of drainage or exudate in the
    wound? The same can be said of the use of
    hydrogel. Should CMS pay for a hydrogel if there
    is no documentation of excessive dryness in the
    wound? In the era of EHR, there is simply no
    excuse for not templating and documenting the
    characteristics of the wounds. 
  • Wound evaluation missing type, location, size,
    depth, and/or drainage amount These simple and
    painfully obvious findings should be recorded
    whether you are dispensing dressings or not.
    Again, using the simple wound template described
    above can assure that these basic clinical
    findings are recorded. As it is the case that
    wound/surgical dressings are reimbursable only
    if the wound is a full-thickness wound, it goes
    without saying that the depth and staging must be
  • Order did not specify the quantity to be used at
    one time. This is information that should be
    recorded both in the patients medical record and
    in the detailed written order (DWO) and is no
    different than what is required in writing a
    prescription for an antibiotic or any other
    prescription product.

Top 5 Tips while Billing for Wound Care Supplies
  • Simply recording the information in a detailed
    written order and not having identical
    information documented in the medical record will
    undoubtedly result in a claim rejection. The
    number of wound dressings allowed for each wound
    is dictated by the type of dressing being used. 
  • Order did not specify dressing change frequency.
    Again, this is information should be recorded in
    the patients medical record and in the detailed
    written wound dressing prescription order
    described above. In most cases, the order should
    indicate that the patient is to change the
    dressing 1 time per day (collagen
    powder/alginate) or 1 time every 3 days (foam).
    Again, this should be templated on the detailed
    written order form that is embedded into your
  • 3. Dont Neglect Deductibles
  • As more private carriers are increasing
    deductible amounts and co-pays for DME services,
    it is imperative that patient benefits and
    deductible amounts be recorded prior to
    dispensing DME. If the patients deductible has
    not been met, the amount for the wound dressings
    or their co-pay amount needs to be collected at
    the time of dispensing. Make sure that your
    patients are aware of these amounts as many
    products cannot be returned (e.g., any opened
    wound dressing or used compression garment).

Top 5 Tips while Billing for Wound Care Supplies
The allowable number of dressings per wound is
most often determined by Medicare and is based on
a 30-day period. Each product has its own unique
purpose and design and it is imperative that the
physician make the determination of how many
units are covered in a 30-day period. Its not
always necessary to dispense items based on
thirty days and each wound should be assessed
individually to determine the frequency and
duration of dressing changes. Making sure that
the number of dressings dispensed and the type of
dressing being utilized matches the description
of the wound in your note is vital. It is
appropriate to dispense a full month's supply if
you determine that the patient will need that
amount based upon your description of the wound,
among other contributing factors that could
impact wound healing.   4. Understanding Billing
Guidelines of Private Payers Private insurance
varies by state, plan, and provider. When
dispensing wound care products from your office,
its always best to obtain benefits for all
services you offer in your practice prior to the
patient visit, including wound care supplies, in
order to smoothly and quickly expedite coverage
Top 5 Tips while Billing for Wound Care Supplies
While its not a common scenario, some carriers
will not cover wound care supplies being
dispensed by the physician. Learning which plans
have this restriction is important. Adding wound
care supplies to your list of items asked about
when obtaining benefits will save a lot of time
and frustration. In the event a particular payer
will not cover the items from your office, a
local supplier should be able to accommodate your
request. Make sure the patient has a prescription
and its clear the items cannot be substituted,
as many of these companies try to reduce their
cost by providing the cheapest product possible
to maximize their profits. Even though products
may be in the same category, not all products are
created equal. If the supply house values your
business, it should be able to supply the
products you request and maintain a healthy
bottom line.  5. Outsource Medical Billing As
you know there are a lot of factors that
determine reimbursement for wound care supplies.
Whether its payer reimbursement policy or
individual patient plan coverage, its always
challenging to receive accurate reimbursement
while billing for wound care supplies. Wound care
billing has always been a tough job requiring
experienced wound care coders who have knowledge
of coding guidelines for local and federal
insurance carriers.
Top 5 Tips while Billing for Wound Care Supplies
When you outsource your wound care billing to a
medical billing company, you keep the headache of
billing and coding to the billing company. You
can focus only on your practice while the billing
company ensures every single submitted claim gets
reimbursed. Just complete a careful evaluation of
the medical billing company and leave the
headache of wound care billing to them.  Medical
Billers and Coders (MBC) is a leading medical
billing company providing complete medical
billing and coding services. We understand the
unique billing challenges of wound care billing
and shared these top 5 tips while billing for
wound care supplies for provider education. You
can refer following reference links for a
detailed understanding. For more assistance
needed in wound care billing and coding and to
receive accurate reimbursement for your wound
care supplies, email us at info_at_medicalbillersand or call us 888-357-3226.   Reference
A Step-by-Step Approach to Billing Wound Care
Products Through Your Office Medicare Coverage
Payment of Outpatient Wound Care
Supplies Cardinal Health Wound Care supplies 2022
Coding Guide
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