Dermatology Faculty Meeting January 27, 2011

Financial Performance Efficiency, Growth, Financial Performance • 2011 CPT Changes • Debridements / Wound Care Dressings / Biological Products • Global Periods E&M Documentation

Challenges when billing outpatient Wound Care services Office of Inspector General (OIG) has included wound care services in its annual work plan. The challenges hospitals and providers face are many including: Correct code selection Adequate documentation to support medical necessity. How to bill specific wound care services. When to apply modifiers When to report separately for wound care supplies.

2011 CPT Code changes The Integumentary System has been expanded to include new guidelines to define wound care and debridement services. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by the surface area of the wound. Reported for injuries, infections, wounds and chronic ulcers.

Debridement codes 3 New Codes 2011 11045 11046 11047 6 Revised Codes 11010 11011 11012 11042 11043 11044 2 Deleted Codes 2010 11040 11041 New-Cross reference codes 97597 – 97598 skin (epidermis + dermis) (active wound care management)

Revised CPT codes Debridement of skin (Epidermis and/or dermis only) 97597: for the first 20 sq cm or less 97598: Each additional 20 sq cm Debridement, subcutaneous tissue (includes epidermis and dermis) 11042: for first 20 sq cm or less 11045: Each additional 20 sq cm. Debridement, muscle and /or fascia (includes skin and subcutaneous tissues) 11043: for first 20 sq cm or less. 11046: Each additional 20 sq cm. Debridement, bone (includes muscle, fascia, skin and subcutaneous tissues) 11044: for the first 20 sq cm or less 11047: Each additional 20 sq cm.

Active Wound Care Management It is known as Non-Excisional or Nonsurgical Wound care. These procedures are performed to remove devitalized and /or necrotic tissue to promote wound healing. These services are billed when an extensive cleaning of a wound is needed prior to the application of dressings or skin substitutes placed on to a wound. Usually performed without the use of anesthesia. 97597 – total wound surface area for the first 20sq cm or less 97598 – each additional 20 sq cm Note: Use 97598 in conjunction with 97597.(used for recurrent wound debridements) Do not report 97597 and 97598 in conjunction with surgical debridement codes 11042 – 11047 for the same wound.

Debridement Debridement is removal of foreign material and /or devitalized or contaminated tissue or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. Topical or local anesthesia is billed with codes 11042-11047.

Selection of debridement codes Single wound Report depth using the deepest level of tissue removed. Example: Bone debrided from 4cm heel ulcer and 10 sq cm ischial ulcer (code 11044). Multiple wounds Sum the surface area of those wounds that are at the same depth but do not combine sums from different depths. Example: When subcutaneous tissue is debrided from a 16sq cm abdominal wound and 10 sq cm thigh wound (11042 for first 20 sq cm and 11045 for second 6 sq cm).

Documentation requirements for debridement Medical record should support medical necessity and frequency of the treatment. Medical record should indicate the Tissue removal (skin, subcutaneous tissue, muscle, bone). Method used to debride (i.e., hydrostatic versus sharp versus abrasion methods) Character of wound dimensions description of necrotic material present description of the tissue removed degree of epithelialization etc. Before and after treatment. LCD L3178-MAC–NHIC Corp 14201 –MA 1/1/2011.

Documentation Requirements Medical necessity to be met Documented plan of care and goals. Clinical circumstances Progress of wound response to treatment for each service billed. Current wound size Wound depth Presence or absence of obvious signs of infection Presence & extent of or absence of necrotic, devitalized or non-viable tissue that would inhibit healing or promote adjacent tissue breakdown.

Clinical Assessment of Wound Complete history and physical Contributing factors (co-morbidities) Surface Size Depth Severity of the wound Signs of infection/drainage Extent of infection Existing conditions that prohibit healing Previous wound care treatment Reassessments if does not heal beyond 30 days of treatment.

Key Points for Debridement Services New and Revised Debridement codes effective from 1/1/2011 11042, 11043, 11044, 11045, 11046, 11047 depends upon: Depth of tissue removed Surface area of the wound Single wound – deepest level of tissue removed Multiple Wounds – Sum of surface area that are at the same depth Documentation always required: Size, depth, appearance of ulcer, and type of tissue removed. Medical necessity and frequency of treatment.

Dressings The following HCPCS codes are considered a dressing and therefore bundled into the procedure. (all Q codes Q4104 – Q4121) For Example: Q4108 – Integra matrix skin sub. Q4115 – Alloskin, per square cm. Q4116 – Alloderm, per square cm. Q4117 – Hyalomatrix, per square cm.

New Codes for Biologic products Human Skin Equivalents are bioengineered skin products used in wound treatment. Two new HCPCS codes to be used for Application of Apligraf or Dermagraft to a lower extremity only (effective for services on or after 1/1/2011). Application of tissue cultured skin substitute or dermal substitute for use of lower limb, includes the site preparation and debridement if performed: G0440 for first 25 sq cm or less G0441 each additional 25 sq cm

CPT Codes for Biologic products If the site is other than lower extremity continue using the following CPT codes. Skin substitute: 15340 for first 25 sq cm or less 15341 for each additional 25 sq cm

Global Period Global surgical package refers to a policy of bundling payment for the various services associated with an operation into a single payment. CMS identifies specific services included in the global surgical package when provided by the same physician who performs the surgery. Postoperative follow-up visit (99024), normally included in the surgical package, to indicate that an E/M service was performed during post-op period for a reason related to the original procedure. 99024 is a non-paying code. It should be only used internally to track non-billable follow up services within the postoperative/global period. “Rounding” on patients within the global period will be part of the global package and should not be billed separately. More details in a later slide. Billing Compliance Training - Surgery 17

Post operative /Global Periods Medicare assigns post operative global periods of: zero or 10 days to minor surgeries 0 days for Biopsies, intra-lesional injections, Moh’s 10 days for Minor surgeries (Excisions, destructions, Intermediate /complex repairs, I&D etc…). Includes E&M services on the day of a minor procedure and during the 10 day postoperative period generally not payable. 90 days to major surgeries 90 days for Major surgeries (flaps and grafts). Includes E&M services on the day before and/or day of a minor procedure and during the 90 day postoperative period generally not payable.

Medicare’s Global Surgical Package Services considered part of the global surgical fee include: Preoperative visits after the decision is made to operate beginning with the day before major surgical service and the day of minor surgeries. Visits during post op period that are related to the recovery from the surgery . These services include: post op pain management dressing changes removal of sutures, staples or drains local incision care removal of operative packs All medical or surgical services due to complications that do not require additional trip to the operating room. E/M visit unrelated to the procedure can be billed with 24 modifier.

Post-operative follow-up care An established patient E/M visit can be billed with no modifier appended for routine follow up care related to procedures with zero global days, such as: dressing changes wound checks suture removal 99211 is only used if a nurse saw the patient.

Evaluation and Management: A Focus on History ROS (Review of Systems) often under-documented An inventory of body systems obtained through a series of questions asked of the patient by the provider to identify signs/symptoms experienced by the patient. It is the number of systems counted, not the number of responses per system Problem Pertinent (1 System): the system directly related to the problem Extended (2-9 Systems): the system directly related to the problem AND a limited number of additional systems Comprehensive (At least 10 systems): the system directly related to the problem plus all additional body systems Abbreviated Documentation for a Comprehensive Review of Systems: IF at least 10 systems were reviewed, abbreviated documentation is allowed: Instead of listing each body system, it is permitted to individually list those body systems with positives or pertinent negatives plus the statement: “all other systems were reviewed and are negative”. The wording of this phrase is critical to getting credit.

Established Patient Visits (2 of 3) Code & Extent of Work 99213 99214 99215 Expanded Problem Focused Detailed Comprehensive History HPI = 1-3 ROS = 1 HPI = 4+ ROS = 2-9 PFSH = 1 ROS = 10+ PFSH = 2 of 3 Single Exam General Multi Bullets =6 At least 6 Bullets Bullets = 12 At least 12 bullets Bullets = 23 2 in 9 systems MDM Dx/mgmt = 2 Data = 2 Risk = Low Low Dx/mgmt = 3 Data = 3 Risk = Mod Moderate Dx/mgmt = >4 Data = >4 Risk = High High

New Patient Visits & Consults (3 of 3) Code & Extent of Work 99203 / 99243 99204 / 99244 99205 / 99245 Detailed Comprehensive History HPI = 4+ ROS = 2 - 9 PFSH = 1 ROS = 10 + PFSH = 3 Single Exam General Multi Bullets =12 At least 12 Bullets Bullets = 23 in Skin Single System Exam MDM Dx/mgmt = 2 Data = 2 Risk = Low Low Dx/mgmt = 3 Data = 3 Risk = Mod Moderate Dx/mgmt = >4 Data = >4 Risk = High High

1997 Skin Exam Criteria (slide 1 of 3) System/Body Area Elements of Examination Constitutional ∙ Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) ∙ General appearance of patient (e.g.,, development, nutrition, body habitus, deformities, attention to grooming) Eyes ∙ Inspection of conjunctivae and lids ENMT ∙ Inspection of lips, teeth and gums ∙ Examination of oropharynx (e.g., oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx) Neck ∙ Examination of thyroid (e.g., enlargement, tenderness, mass) Cardiovascular ∙ Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness) GI (Abdomen) ∙ Examination of liver and spleen ∙ Examination of anus for condyloma and other lesions Lymphatic ∙ Palpation of lymph nodes in neck, axillae, groin and/or other location Extremities ∙ Inspection and palpation of digits and nails (e.g., clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

1997 Skin Exam Criteria (slide 2 of 3) System/Body Area Elements of Examination Skin • Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas: • Head, including the face • Back • Neck • Right upper extremity • Chest, including breasts and axillae • Left upper extremity • Abdomen • Right lower extremity • Genitalia, groin, buttocks • Left lower extremity NOTE: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements. • Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis Neurological/ Brief assessment of mental status including: Psychiatric • Orientation to time, place and person • Mood and affect (e.g., depression, anxiety, agitation)

1997 Skin Exam Criteria (slide 3of 3) Content and Documentation Requirements Level of Exam Perform and Document: Problem Focused One to five elements identified by a bullet. Expanded At least six elements identified by a bullet. Problem Focused Detailed At least twelve elements identified by a bullet. Comprehensive Perform all elements identified by a bullet; • document every element within each System identified inside a border. • and at least one element in each System/Body Area without a border.

Questions ? Thanks for attending!