Abstract
Wound care scientists, manufacturers, and wound care professionals should take time to visit the Centers for Medicare & Medicaid Services' website. It is easy to navigate and contains information for all wound care stakeholders. This article reviews some of the most popular Medicare website pages that should prove useful to wound care stakeholders. The links to those pages are also provided.
Kathleen Dianne Schaum, MS
Introduction
Scientists, manufacturers, and wound care professionals often seem mystified about the Medicare regulations and processes that pertain to the coding, payment, and coverage for the services, procedures, and products they develop, manufacture, distribute, and use for the management of acute and chronic wounds. In the early days of the Medicare program and before the Internet explosion, the dissemination of Medicare reimbursement information was cumbersome and costly. In fact, this author remembers receiving hundreds of pages of Medicare manual updates and local medical review policies in the mail each year. When these paper documents arrived in the mail on a quarterly basis, it took a significant amount of time to discard outdated material and read and insert the newly acquired material into the numerous binders of Medicare material. Many of the Medicare processes were only released upon request. However scientists, manufacturers, and wound care professionals and providers did not always know what materials to request.
Today, the dissemination of Medicare reimbursement information is very different. The Centers for Medicare & Medicaid Services (CMS) has a very comprehensive website that provides current information for all stakeholders. In fact, the Congress mandates certain information to be published on the CMS website well before its implementation date. CMS also requires the contractors who process the Medicare Part A and Part B claims to provide information and education to Medicare participating providers in their jurisdictions.
Let us take a look at just a few of the resources that provide invaluable information to wound care stakeholders.
Discussion
Medicare reimbursement resources for all wound care stakeholders
Wound care stakeholders need to understand how the Medicare program works. Visiting the Medicare page on the Centers for Medicare & Medicaid Services website1 is like walking into a huge library full of wonderful resources. The information found in the website will help stakeholders understand Medicare benefits, accurately bill for their services, procedures, and products, and provide quality care to the Medicare beneficiaries. The Medicare home page table of contents is very easy to read. If visitors to the website do not immediately find the section of information they need, they simply enter their topic into the search box and they will see a listing of all the Medicare documents, pertaining to that topic, that are available on the website.
CMS offers a multitude of outreach and education resources.2 Most wound care stakeholders are surprised when they visit this page: they usually cannot believe the resources that they have been missing. This author's favorite resource is the Medicare Learning Network® page (MLN, a registered trademark of CMS, is the brand name for official information healthcare professionals can trust),3 where wound care stakeholders can find a catalog of available MLN products, excellent informational documents called MLM Matters® Articles, web-based training courses (many offer continuing education credits), provider electronic mailing lists, and much more.
Medicare reimbursement resources for scientists
When scientists are preparing to conduct wound care-related clinical trials, one of the most common questions asked is: “Will Medicare pay for the service, procedure, product during the clinical trial?” The answers to this and many other clinical trial-related questions can be found at the Medicare Clinical Trial Policies4 web page. As registries become an important part of our data collection and reporting methodologies, scientists may want to learn how the government is currently using registries. They may begin by visiting the Registry Reporting page.5 Among many other valuable documents, scientists will find the list of participating registry vendors and the criteria to become a registry vendor.
Medicare reimbursement resources for manufacturers
When manufacturers are preparing to launch new services, procedures, or products, they must build a timeline for obtaining a code, for obtaining a published payment rate in their target site(s) of care, and for gaining coverage by the various Medicare contractors and Medicare Health Plans. The Healthcare Common Procedure Coding System (HCPCS) page6 contains the HCPCS Level II Coding Process and Criteria, the HCPCS application form and instructions, and announcements/summaries of the HCPCS public meetings. If a manufacturer needs a HCPCS code, this is the page to visit.
The Medicare Coverage Determination Process page7 tells manufacturers how to request a National Coverage Determination (NCD), includes Medicare Coverage Guidance documents similar to those used by the U.S. Food and Drug Administration, as well as, information about Local Coverage Determinations (LCDs).
Medicare reimbursement resources for wound care professionals and providers
Wound care professionals and providers need to understand the Medicare reimbursement side of their business to receive adequate payment for their excellent clinical work. Unfortunately, these professionals do not always take advantage of the enormous amount of information that CMS makes available to them.
The first thing that wound care professionals and providers should do is verify their business type, that is, acute care hospital, hospital-based outpatient wound care department, qualified healthcare professional (QHP) (in an office or in a facility), skilled nursing facility, home health agency, and durable medical equipment supplier. Next, they should identify the Medicare contractor that processes their claims and should go to that contractor's website and sign up for one or more of their mailing lists: then they will receive information about reimbursement topics that interest them. While visiting the contractor's website, wound care professionals and providers should note the wide variety of information that is available to them. For example:
Current news/updates
A/B Reference Manual information
Appeal guidelines
Comprehensive Error Rate Testing (CERT) Program reports
Claims and billing guidelines
Customer service center contacts
Electronic billing (electronic data interchange [EDI]) guidelines
Enrollment application process, reference materials, contact information, and education programs
Evaluation and management coding instructions and educational programs
Fee schedules for all separately payable professionals and providers in that jurisdiction
Forms available for download
Frequently asked Part A and Part B questions
Mailing list subscription
Medical policy directions for draft LCDs, open LCD meetings, current LCDs, LCD Reconsideration Process, etc.
Medical policy search site by keyword(s), LCD number, CPT® (CPT is a registered trademark of the American Medical Association) code, ICD-9-CM code, HCPCS code, etc.
Medical review guidelines for a successful medical review
Newsletters and bulletins from Medicare contractors and CMS
Specialty guides
Training events schedule: workshops, webinars, teleconferences, self-service education, CMS education, etc.
Links to other Medicare sites
The CMS website also contains many valuable references for wound care professionals and providers. For example:
Coding information can be found at the HCPCS Release and Code Sets page,8 at the ICD-9-CM page,9 at the ICD-10-CM page,10 at the National Correct Coding Initiative (NCCI) Edits page,11 and at the Outpatient Code Editor (OCE) page.12
Provider-specific billing and payment information can be found at the Medicare home page, under the section entitled Medicare Fee-For-Service Payment. There wound care professionals and providers will find the links that pertain to their particular payment system.
QHPs often say they cannot find the Medicare allowable payment rates for products such as cellular and/or tissue-based products (CTPs) for wounds (outdated term “skin substitutes”). That is because they try to find that information in the Physician Fee Schedule. Instead, QHPs should refer to the Medicare Fee-For-Service Part B Drugs page and open the link for the Medicare Part B Drug Average Sales Price page.13
Coverage information for all Medicare Administrative Contractors (MACs) can be found in the Medicare Coverage Database.14 By visiting this database, wound care stakeholders can view all the NCDs and LCDs for the entire country.
Quality healthcare for Medicare beneficiaries is a high priority for CMS. Therefore, CMS has created a Quality of Care Center page,15 where wound care stakeholders can read about the various site-specific quality initiatives, demonstration projects, patient assessment instruments, roadmaps for quality measurements, etc. For those who are unfamiliar with quality measures, CMS has published an entire page dedicated to Quality Measures.16
Laws and regulations
This author has received many phone calls from frustrated wound care stakeholders who believe that the laws and regulations that pertain to them are secret. Actually, that perception is far from the truth. In fact, the Laws and Regulations page17 includes all the CMS guidance documents, such as manuals, rulings, and transmittals. It also has links to provider-specific laws and regulations. Wound care professionals and providers should visit this webpage before spending a lot of time searching for laws and regulations. The one Internet site will most likely contain the information you are seeking.
Abbreviations and Acronyms
- CERT
Comprehensive Error Rate Testing
- CMS
Centers for Medicare & Medicaid Services
- CPT®
Current Procedural Terminology
- EDI
electronic data interchange
- HCPCS
Healthcare Common Procedure Coding System
- ICD-10-CM
International Classification of Diseases, 10th Edition—Clinical Modification
- ICD-9-CM
International Classification of Diseases, 9th Edition—Clinical Modification
- LCD
Local Coverage Determination
- MLN
Medicare Learning Network®
- NCCI
National Correct Coding Initiative
- NCD
National Coverage Determination
- OCE
Outpatient Code Editor
- QHP
qualified healthcare professional
Acknowledgments and Funding Sources
No funding sources to acknowledge.
Author Disclosure and Ghostwriting
K.D.S. is the President of her own consulting firm, Kathleen D. Schaum & Associates, Inc., and is the Director of Medical Products Reimbursement for Healthpoint Biotherapeutics. This article was written by its author; no ghostwriters were used.
About the Author
Kathleen D. Schaum, MS, is the President and founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net
References
- 1.CMS Medicare page. www.cms.gov/Medicare/Medicare.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Medicare.html
- 2.CMS Outreach and Education page. www.cms.gov/Outreach-and-Education/Outreach-and-Education.html. [Oct 6;2013 ]. www.cms.gov/Outreach-and-Education/Outreach-and-Education.html
- 3.CMS Medicare Learning Network® page. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html. [Oct 6;2013 ]. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html
- 4.CMS Medicare Clinical Trial Policies page. www.cms.gov/Medicare/Coverage/ClinicalTrialPolicies/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Coverage/ClinicalTrialPolicies/index.html
- 5.CMS Registry Reporting page. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.html
- 6.CMS HCPCS General Information page. www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html
- 7.CMS Medicare Coverage Determination Process page. www.cms.gov/Medicare/Coverage/DeterminationProcess/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Coverage/DeterminationProcess/index.html
- 8.CMS HCPCS Release and Code Sets page. www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/index.html
- 9.CMS ICD-9-CM page. www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/index.html
- 10.CMS ICD-10-CM page. www.cms.gov/Medicare/Coding/ICD10/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Coding/ICD10/index.html
- 11.CMS National Correct Coding Initiative Edits page. www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
- 12.CMS Outpatient Code Editor page. www.cms.gov/Medicare/Coding/OutpatientCodeEdit/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Coding/OutpatientCodeEdit/index.html
- 13.CMS Medicare Part B Drug Average Sale Price page. www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html
- 14.CMS Medicare Coverage Database. www.cms.gov/medicare-coverage-database. [Oct 6;2013 ]. www.cms.gov/medicare-coverage-database
- 15.CMS Quality of Care Center page. www.cms.gov/Center/Special-Topic/Quality-of-Care-Center.html. [Oct 6;2013 ]. www.cms.gov/Center/Special-Topic/Quality-of-Care-Center.html
- 16.CMS Quality Measures page. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html. [Oct 6;2013 ]. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html
- 17.CMS Laws and Regulations page. www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html. [Oct 6;2013 ]. www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html