Wound Care Articles and Insights
January 22, 2019

CMS Regs in 2019: Three Things You Need to Know

Vanessa Ploessel

Each year, the Centers for Medicare & Medicaid Services (CMS) releases new regulations and major policy changes. If you haven’t reviewed the list for 2019, now’s the time! Our finance team offers three things every outpatient hospital wound care team should know about:ONE: There’s a new revenue code for skin substitutes - and that’s a good thing!Formerly coded 636, which covers injectable drugs, CMS approved Q4122 (Dermacell, per square centimeter) to be billed under 636 or 278* (other implants). For Medicare, Q4122 has a “high” assignment, which means it is separately payable. You can now assign this HCPCS code to revenue code 278 in your ChargeMaster.As soon as possible, you should proactively meet with your contracting department and review current managed medicare or commercial contracts for language stipulating additional reimbursement for revenue code 278. Historically, many contracts with acute care hospitals in California had “exclusions,” which identified revenue code 274-278 for a separate reimbursement from the procedure. Contracts vary, but typically implant reimbursement is at “cost +5%” or a percentage of billed charges. TWO: The Office of Inspector General (OIG) will audit more Hyperbaric Oxygen Therapy (HBOT) service providers. You can bet on it.This is huge news in the wound care industry, and for good reason. The OIG’s latest report focused on First Coast Service Options, Inc., which paid the second largest amount for HBOT services in 2013 and 2014. And earlier this year, the OIG audited Wisconsin Physician Services (WPS). In both cases, the providers did not comply with Medicare requirements.All Medicare Administrative Contractors (MACs) should expect to be scrutinized more closely and operate as if they will be audited by the OIG at any time.Start having regularly scheduled meetings with your business office and ask about additional documentation requests from your local MACs. Find out if there are any non-payments or delays in payment for HBOT services. Conduct a self-audit of payment turnaround times.Based on the actions of CMS and OIG, it won’t be long before managed Medicare plans follow suit. Even though they require prior authorization for HBOT, they may begin to investigate more into the entire approval process. THREE: There’s a new specialty code for HBOT. Use it.CMS has established a new Physician Specialty code - D4 - for Undersea and Hyperbaric Medicine. MACs will recognize Undersea and Hyperbaric Medicine (D4) as a valid specialty type for the following edits:-Ordering/Referring -Critical Access Hospital (CAH) Method II Attending and Rendering -Attending, operating, or other physician or non-physician practitioner listed on a CAH claimProviders should update their specialty by submitting a change of information application to their local MAC. Providers should submit an enrollment application to initially enroll or update their specialty by March 6, 2019 with the new specialty. Alert your billing staff to make sure they’re aware of these changes.BONUS TIP: MACS are focusing on providers with higher denial rates and billing practices that vary from their peers. Do everything you can to avoid Targeted Probe & Educate (TPE). If your claims are compliant, you are much less likely to be selected.If you need help, contact WCA for a free 20 Point Onsite Assessment so we can help determine your needs.*Please Note: The revenue code we identified (278) when used with HCPCS code Q4122 (Dermacell) is specifically used for breast reconstruction. The intent of drawing your attention to the new usage of this revenue code was to prompt discussions with your contracting department.For further reference please review MLN Matters MM11099 (section 13):

We Support
Wound Centers.

It's just that simple.