Vol. 15 Issue 12
What are the appropriate codes for wound care reimbursement?
Q: I work in a hospital-based outpatient clinic and have a question related to wound care reimbursement. Although there's an e-stim code, it seems to limit our use only to stage III and IV ulcers. Is that accurate?
A: For outpatient therapy under Medicare Part B, the Centers for Medicare and Medicaid Services reimburses for electrical stimulation to treat chronic stage III and IV arterial, diabetic, pressure and venous stasis ulcers that don't demonstrate measurable signs of healing after 30 days of conventional treatment. Conventional treatment consists of whirlpool, dressing changes and selective debridement, when appropriate.
The appropriate code to use is G0281 for electrical stimulation for chronic stage III and IV arterial, diabetic, pressure and venous stasis ulcers. If you use electrical stimulation for wound care other than described above, the appropriate code is G0282. However, this code isn't reimbursed by Medicare. You may use electrical stimulation prior to the 30 days, but you can't bill Medicare.
Q: My question has to do with wounds that don't require removing devitalized tissue. Is there any way for physical therapy to bill for the application of specialized dressing of complex wounds when debridement isn't needed?
A: When a physical therapist provides non-selective debridement under a therapy plan of care, this should be billed under CPT code 97602. Medicare currently reimburses zero dollars for this service.
Other payers besides Medicare may reimburse for this CPT code and for some complex dressings that use the appropriate "A" codes, which are located in the HCPCS Level II book. The best thing to do is to contact the specific payer or someone who provides wound care and has expertise in billing and reimbursement for wound care.
Q: My question is regarding the ICD-9 codes that Medicare accepts. I understand that only certain leg wound codes are reimbursable. Our facility is getting referrals for abdominal, chest, breast and scalp wounds (dehisced wounds, radiation necrosis or neoplastic wounds). Are there ICD-9 codes so we can be reimbursed in these cases?
A: To accurately answer your question, I'd need to know the policy of the Medicare contractor where you submit forms. In general, some Medicare contractors don't have a list of ICD-9-CM codes that support medical necessity; others have a list of ICD-9 codes, one of which must be on the claim form to support medical necessity of CPT codes. Or, contractors have a list of ICD-9-CM codes linked to each specific CPT code, one of which must be on your claim to support billing of that particular CPT code.
Contact your specific Medicare contractor for a policy on physical therapyif they have oneand check to see if they have ICD-9-CM codes that support medical necessity. For non-Medicare payers, check with the patient's specific insurance plan to verify coverage of diagnosis and services you want to provide prior to treatment.
Rick Gawenda, PT, is director of physical medicine and rehabilitation at Detroit Receiving Hospital in Michigan. He conducts national seminars on coding and reimbursement, along with other topics. If you have a tough coding issue you can't crack, e-mail firstname.lastname@example.org. To read more coding suggestions, go to www.advanceweb.com/REHAB and click on the Coding Clues tool bar.