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Application of Wound Vac - Patient had an I&D and wound

  1. #11
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    Medical Coding Books
    AAOS didnt address the non-physician versus physician. The AMA clearly states that those codes are to be billed by non-physician providers.

    I will stick the the AMA guideline on this one since the are the KING/QUEEN of CPT.


    I have actually put an e-mail out to Margie Vaught to see what her response is to the conflicting information. I will update once I have received it.
    Last edited by mbort; 05-28-2009 at 11:24 AM.

  2. Default
    This is to answer if physicians can bill for wound vac. It says yes they can.
    http://www.kci1.com/88.asp

    I would be interested to know Margie's answer on that, but I used to bill 97605 out for podiatrists and plastic surgeons. I never had a problem. I think that rule changed.
    Thanks

  3. Default
    Rules changed from medicare as of 1/1/2006, physicians can bill see links:

    http://www.wpsic.com/medicare/part_a...2006030100.pdf
    starts on page 27

    “Always” versus “Sometimes” Therapy
    CMS defines an “always therapy” service as a service that must be performed by a qualified
    therapist under a certified therapy plan of care, and a “sometimes therapy” service as a service
    that may be performed by a non-therapist outside of a certified therapy plan of care.
    Effective January 1, 2006, CMS is reclassifying CPT codes 97602, 97605, and 97606 as
    “sometimes therapy” services that may be appropriately provided either as therapy or nontherapy

    http://www.cms.hhs.gov/manuals/downloads/clm104c05.pdf
    starts on pg 30.
    ع+ 97605

    ع If billed by a hospital subject to OPPS for an outpatient service, these HCPCS codes –
    also indicated as “sometimes therapy” services - will be paid under the OPPS when the
    service is not performed by a qualified therapist and it is inappropriate to bill the service
    under a therapy plan of care. The requirements for other “sometimes therapy” codes,
    described below, apply.
    + These HCPCS/CPT codes sometimes represent therapy services. However, these codes always represent therapy services and require the use of a therapy modifier when performed by therapists.

  4. #14
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    Default Margies response
    Here is Margie Vaughts response....since the AMA rates higher than the AAOS, I'll be sticking to the AMA guidelines.

    Today I just received more information where they are being told not only to report the wound vac after doing debridement but to also report for the dressing change 15852. I don't know where this is coming from and it is driving me crazy.. And today has been hateful as the majority of my day has been fighting 'we were told' situations.

    I best I can give you is what you have from CMS and CPT and CCI and then you will have to decide.


    CPT® Assistant June 2005 Volume 15 Issue 6
    "Question: Is it appropriate for PHYSICIANs to report codes from the active wound care management series 97597-97606?

    AMA Comment: Codes in the active wound care management series provide a mechanism for reporting interventions associated with active wound care as performed by licensed nonPHYSICIAN professionals. These codes are to be reported by nonPHYSICIAN professionals (eg, PHYSICIAN assistants, nurse practitioners, enterostomal therapy nurses, wound care nurses, physical therapists) licensed to perform these procedures. Only those individuals licensed by a particular state to perform the described services should use the codes to report services. As licensure varies from state to state, the applicable state laws and requirements determine who may perform specific types of services. For wound debridement performed by PHYSICIANs, see codes 11040-11044."

    Here is what CMS appears to indicate:
    Orthopedic Coder's Pink Sheet
    Effective Date 09/01/2007
    Publish Date September 2007
    "Question:Can PHYSICIANs bill for negative pressure wound therapy codes 97605 and 97606?

    Answer: Not according to CPT. The WOUND VAC codes are part of the active wound care management series, which “provide a mechanism for reporting interventions associated with active wound care as performed by licensed nonPHYSICIAN professionals” (CPT Assistant, June 2005).

    “These codes are to be reported by nonPHYSICIAN professionals (e.g., PHYSICIAN assistants, nurse practitioners, enterostomal therapy nurses, wound care nurses, physical therapists) licensed to perform these procedures,” CPT says. Further, CPT tells you to check your state laws for licensure requirements and restrictions on who may perform specific types of services. PHYSICIANs should refer to the surgical debridement codes, 11040-11044 , CPT directs.

    That should take care of some of the confusion generated by a parenthetical note in the CPT manual that tells you not to report codes 97597-97602 with 11040-11044, with no mention of whether the restriction also applied to the WOUND VAC codes, 97605 and 97606. Now, with the June 2005 CPT Assistant, we see that the AMA's intent is that PHYSICIANs not bill these codes.

    Medicare may be different: You'll have to keep a close eye on your Medicare local coverage determination for its specific wound care billing policy. Medicare added work RVUs for the WOUND VAC codes in the 2006 PHYSICIAN fee schedule (Nov. 21, 2005 Federal Register). This year, for 97605, Medicare pays $33. For 97606 it pays $35.62 (both fees in the office setting, par, not adjusted for locality). Coverage, however, is tightly restricted:

    “When the negative pressure wound therapy service does not encompass selective debridement, we consider the service to represent a dressing change and will not make separate payment,” CMS states in the 2006 Medicare fee schedule.
    “When the negative pressure wound therapy service includes the need for selective debridement, we consider the services represented by CPT codes 97605 and 97606 to be bundled into CPT codes 97597 and 97598, meaning that we would not make separate payment for these services.” (2006 Medicare PHYSICIAN fee schedule)
    Still, starting last year, Medicare changed the status for 97605 and 97606 from “bundled” to “active” in the PHYSICIAN fee schedule relative value file. Also, in April 2006, Medicare introduced CCI edits bundling the WOUND VAC codes as components of 11040-11044, but it later removed them, retroactive to April 1, 2006 .

    Resources

    Download the 2006 Medicare PHYSICIAN fee schedule payment policy for negative pressure wound therapy from the Nov. 21, 2005 Federal Register at: www.access.gpo.gov/su_docs/fedreg/a051121c.html

    To see Medicare's RVUs, etc. for negative pressure wound therapy download the PHYSICIAN fee schedule relative value file at: http://tinyurl.com/2po4da"

    Margie Scalley Vaught, CPC, CPC-H, CCS-P, MCS-P, ACS-EM, ACS-OR
    Healthcare Consultant

  5. Default
    The AMA guidelines are from 2005 and the rule changed in 2006. Refer to my last response with the websites.
    It states that those codes are referred to as "sometimes therapy" and in an outpatient setting physicians can bill for those codes.
    And the original question that was asked, 97605 denied for dx only not any other reason.
    I've billed these before in an outpatient setting and there was never a problem. Not sure why you are going with 2005 info when it changed in 2006, but that's up to you.
    Thanks for sharing what Margie had to say.

  6. #16
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    I posted the bulletin about "always" versus "sometimes" to Margie and asked her how this plays into it ...we will see what she says. I'll post her response when received.

  7. #17
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    Margies response:

    I don't think it affects it as it states 'performed by non-therapist' - which can be NPPs when not part of a therapy treatment plan

    Then it goes on to talk about hospital issues:
    "In order to pay hospitals accurately when delivering these “sometimes therapy” services
    independent of a therapy plan of care, CMS is establishing payment rates for CPT codes 97597, 97598, 97602, 97605, and 97606 under the OPPS when performed as non-therapy services in the hospital outpatient setting.
    Table 9 below lists the APC assignments and status indicators for these codes when delivered independent of a therapy plan of care in a hospital outpatient setting.

    Margie Scalley Vaught, CPC, CPC-H, CCS-P, MCS-P, ACS-EM, ACS-OR
    Healthcare Consultant
    Coding Content Specialist for DecisionHealth

  8. Default
    That last comment doesn't really answer anything.
    Here is where it says MD's can bill. I really don't want to keep going on and on about this. I just want people to know it is fine to bill this code for physicians. I used to bill this numerous times. It is ok to bill.
    http://www.kci1.com/88.asp




    6. Is there currently a CPT code that can be used to bill for application of V.A.C.® Dressings?

    Effective January 1, 2005, Negative Pressure Wound Therapy (NPWT) was assigned two CPT codes for wound treatment by the American Medical Association (AMA):

    CPT Code
    Wound Size

    97605
    < or = 50 cm2 in surface area

    97606
    > 50 cm2 in surface area


    CMS changed the payment status in the 2006 Medicare Physician Fee schedule to "A" (active status) for the NPWT CPT codes. CMS assigned 0.55 work Relative Value Units (RVUs) to code 97605 and 0.60 work RVUs to code 97606. Relative Value Units are used to calculate the payment to providers. This means that healthcare practitioners such as MDs, PTs, PAs, DPMs and NPs, who prescribe V.A.C.® Therapy may be eligible for reimbursement for certain covered services related to NPWT. Healthcare practitioners who are eligible to seek reimbursement under the NPWT CPT codes are determined by state regulations that dictate what types of procedures each practitioner can perform. The dollar amount of the payment will vary, depending on the geographic location within the US and practice costs within that location. It is approximately $30.00 for 97605 and $40.00 for 97606.

  9. #19
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    BUT keep in mind...KCI is the company/REP that supplies them...they will tell you anything to get you to use their product. Because you have done it in the past and have received payment isnt a good enough reason for me to do it. Each to their own, I just wont risk it it until I see something SOLID from the AMA/CPT. Right now everything still point to a "NO GO" for me.

    I still believe that the AMA/CPT are the higher authority and take presidence over everyone else. The CMS Bulletin from 2006 addresses OPPS, not physicians.

    Mary, CPC, COSC

  10. #20
    Default wound vac
    We haven't had a lot of luck with wound vac's either. Medicare refuses to pay. Most other private carriers also. When we started researching this a couple of years ago, we could not charge a wound vac and anything else on the same date of service. This was mainly for wound care. We were allowed either an E/M or a wound vac or a debridement. If the patient had a wound vac placed and a debridement on the same wound, the debridement was charged. If an E/M and a wound vac, a decision had to be made as to whether the E/M or a vac would be charged unless the documentation was over and above having the vac placed, as in a first time visit (but not usually because the vacs are usually ordered) then we would add a 25 modifier to the E/M, but as I said this was rare.. So, as I have read this, also, is mostly coder choice. We do not charge vacs and anything else on the same date of service. Documentation hasn't been sufficient for us to change that yet. This is one of those gray areas in our black and white world. Good luck!

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