wound VAC change

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Does each wound VAC change note need to be signed by the attending physician to bill 97605? This patient has been coming into the family practice clinic for wound VAC changes every week, and there is an initial standing order, and each note says to come back in a week, but some notes are only signed by the wound care nurse, and there's no attending provider signature. Do these need to meet incident-to requirements? There's no documentation of the physician being available, but is would his cosignature be enough documentation? Also would the same rules apply for an Unna boot application 29580, or does this need to be done by the physician?

Wound: sacral pressure ulcer stage 4
Full thickness, granulation
Peri-wound red
Well defined edges
Length 4.1 cm, width 2.8 cm, depth 2.6 cm
Drainage moderate, serosanguineous
Cleansed with normal saline. KCI nondisposable wound VAC was changed, 2 pieces of black foam removed. Canister changed, 50 mL output noted in old canister. Target pressure 125 mmHg. Dressing changed, clean, dry, intact. Return in 1 week for wound VAC change.

This is what I found for references, but I want to make sure this is right before messaging the provider.

Article - Billing and Coding: Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services (A53296) (cms.gov)
Evaluation and Management (E/M) Coding Requirements
Only physicians and NPPs (Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) can provide and bill E/M and CPT 11000 series codes when the services are appropriate and state licensure allows. These services may not be provided as incident-to services by hospital staff.
• Services provided by qualified incident-to hospital staff, must meet both the incident-to service delivery requirements and the CPT descriptor requirements for the specific procedure.

Microsoft Word - Wound Care Charge Process - March 13 2012.docx (para-hcfs.com)
All Nursing and Therapist procedures require a physician order, detail progress notes and review and sign off of the progress notes by the attending Physician. (last page)

CPT Assistant, June 2005, Volume 15, Issue 6, pages 1-4
Active Wound Care Management
Negative Pressure Wound Therapy Treatment Codes
The Wound Care workgroup also recommended that new codes be created for the reporting of negative pressure treatment procedural services. Two new codes 97605 and 97606 have been established to report negative pressure wound therapy based on total surface area of wound(s) size. Negative pressure wound therapy is a procedure that manages wound exudates and promotes wound closure. A vacuum cleanses the wound, stimulates the wound bed, reduces localized edema, and improves the local oxygen supply. This places mechanical stress on the tissue that increases the rate of cellular proliferation, granular tissue formation, and new vessel growth. This procedure requires work and practice expense different than any of the procedures considered to be selective debridement in the 97000 series codes. Also, it is a procedure that has different clinical indications. The use of these codes is not limited to a specific setting but is dependent on the set-up by a trained provider. (I assume this includes a wound care nurse?)

Seven Incident-to Billing Requirements - AAPC Knowledge Center
Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.
If auxiliary personnel perform services outside the office setting, e.g., in a patient’s home or in an institution (other than hospital or SNF), their services are covered incident to a physician’s service only if there is direct supervision by the physician [e.g., the physician must be physically present to oversee the care].
 

thomas7331

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Wound vacs, Unna boot and other non-surgical wound care services are commonly performed by nursing staff - I'm not aware of any requirement that these must be performed by a physician. As long as the staff members are acting within the scope of their license and training, there shouldn't be a problem with this. 'Incident to' requirements must be met, as indicated in the sources you've cited. This includes the requirements that there be a valid physician order for the services in the care plan, and that the services be provided under the required level of supervision. A physician co-signature on the note is not one of these requirements - simply having the physician sign the note does not document that they supervised the service or that any of the other 'incident to' requirements have or have not been met.

Some organizations may have internal requirements for a co-signature, or an attestation by the physician stating that they were present in the office and available at the time of the service, but to the best of my knowledge, a co-signature is not something that payers require in the documentation for 'incident to' services. The guidelines state that the record must reflect the physician's continued involvement in the patient's care but in my opinion, for what it's worth, requiring the physician to co-sign every single nursing note is a bit of a waste of the physician's time and adds little of value to the record.
 
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