Collagen Dressings

Question:

Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?

Answer:

Thank you for your inquiry.  Several factors have to be considered.

First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.

Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.

Per Medicare Claims Processing Manual, Chapter 12, Section 40.1

o   Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket.  Depending on medical necessity, the dressings may or may not be covered under a home health benefit.

Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.

Per Medicare LCD L33831:

Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)

A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal.  They can stay in place for up to 7 days.  Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.

To justify payment for DMEPOS items, suppliers must meet the following requirements:

• Standard Written Order Criteria (SWO)

• Medical Record Information (including continued need/use if applicable)

• Correct Coding

• Proof of Delivery

Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.

Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.

LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings. 

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831

As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).

*This response is based on the best information available as of 10/17/24.

Fall Risk Prevention Program: Part 2

Question:

We read and received your recent Coding Coach on the Fall Risk Prevention Program and directive to report Category II CPT codes for this service. We have a follow-up question.  Why would we not be able to report CPT code 97750 for this service, and can this code be billed incident- to the physician if the MA performs the work?   

Answer:

Per CPT coding guidelines, many parameters are associated with reporting CPT code 97750. CPT code 97750 is not used for a MIPS tracking code. Reporting this code requires that the work be performed by an MD, DO, or PT. An MA may not perform the work associated with this code and bill incident - to, as an MA is not a Qualified Healthcare Professional (QHP). 

*This response is based on the best information available as of 9/16/24.

Fall Risk Prevention Program: Part 1

Question:

We want to institute a Fall Risk Prevention Program in our practice to take advantage of CMS's Merit-based Incentive Payment System (MIPS). Based on CMS’s 2024 Quality Measures List, what codes should we report, and can our practice's medical assistant (MA) capture this work? 

Answer:

It is great that your practice will institute a Fall Risk Prevention Program to capture MIPS. According to CMS’s 2024 Quality Measures list, are 2 measures reportable in this category. 

Quality measure number 155 - Falls: Plan of Care.  This measure is designed to capture the percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months. 

Quality measure number 318 – Falls: Screening for Future Fall Risk.  This measure is designed to capture the percentage of patients 65 years of age and older screened for future fall risk during the measurement period. 

Per CPT, these quality measures should be reported with Category II tracking codes, which are used for performance measurement. 

The applicable category II CPT codes for these MIPS measures are as follows: 

1100F: Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER). 

1101F: Patient screened for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the past year (GER). 

An MA can capture the work to assist the clinician when reporting these Category II CPT codes. 

*This response is based on the best information available as of 9/5/24.

Coding For Arthroscopic Subacromial Decompression

Question:

We received a denial from one of our payors saying the documentation did not support CPT code 29286. The surgeon documented bursectomy, release of ligament and removal of anterior osteophytes. Does this support CPT code 29826? 

Answer:

Thank you for your inquiry. Unfortunately, the payor is correct. The removal of osteophytes with or without the bursectomy and ligament release does not support CPT code 29826. To report the subacromial decompression, documentation must support an acromioplasty, which is a reshaping of the acromion. Typically, surgeons will document the work and state they took the acromion from a Type III to a Type I.  

*This response is based on the best information available as of 7/11/24.

CPT and ICD-10-CM Codes in Operative Notes

Question:

What is KZA’s perspective when a surgeon documents the CPT codes within the clinical operative note? 

Answer:

KZA discourages using CPT and ICD 10 codes within the operative notes. While documenting details of each procedure is key within the operative report (both the header and within the body of the note), adding CPT and ICD 10 diagnosis codes creates an issue if the coding is incorrect. The operative report is part of the legal medical record, and payors may question the accuracy and validity of the entire report if the codes documented within the record are different than the codes billed. For this reason, we advise against documenting the specific CPT and ICD 10 codes within the operative report to prevent other denial and stall tactics. 

*This response is based on the best information available as of 6/20/24.

Assistants at Surgery

Question:

We have surgeons who use their “Fellows” per their program as “Assistants at Surgery” and want to bill the corresponding codes under the “Fellow” with the “80” modifier. Is this OK?  

Answer:

Under the current CMS guidelines, fellows are considered residents when practicing within their GME program, so their services as surgical assistants would not be billable. However, there are certain circumstances where a fellow may bill for their own services when practicing outside their GME program (e.g., in the Emergency Department, seeing patients as a primary physician (not in an orthopedic capacity). A Fellow in a private Fellowship and employed by the group practice is billable as a Fellow. These are non-GME-funded fellowships. 

 In an academic setting, we suggest that questions regarding fellow reporting be referred to Compliance for discussion and direction. CMS has very specific guidelines regarding moonlighting that can be found here: https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf 

*This response is based on the best information available as of 6/6/24.