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
  Billing
• 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.

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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
  patient.
• 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. 

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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.

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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
  recorded. 
• 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.

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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
  EHR.
• 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).

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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
determination.
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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.
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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
coders.com 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