New 2017 CPT® code updates and changes for wound care and hyperbaric is right around the corner. These updates can result in new revenue opportunities or reductions based on how your hospital is prepared. Here are 10 tips to avoid denials and keep your revenue cycle flowing.
Tip 1 – Know your Local Coverage Determination (LCD) (if you have one) for hyperbaric treatments for medicare patients and review it often. Things change quickly in our industry. Most LCD’s will have a list of codes that support medical necessity and clearly state the documentation requirements to justify treatment. Review the patient record prior to beginning treatment to ensure the documentation meets those requirements.
Tip 2 – Know your private insurers medical policy for hyperbaric treatments. Medical policies are basically the LCD for commercial insurance. Search online for the payer’s hyperbaric medical policy and review the documentation against the policy prior to starting patient treatments.
Tip 3 – Go beyond the authorization. You may gain authorization but later discover the patient’s plan does not cover hyperbaric treatments. After you receive the authorization, speak to someone in benefits to verify the patient’s financial responsibility. Ask to see: if the patient has hyperbaric benefits, their deductible amount and how much has been met, as well as their annual “out of pocket max”.
Tip 4 – Check CPT codes. When discussing authorizations with a third party payer, ask if a reimbursement amount is assigned to the CPT codes you intend to submit. In some cases, certain CPT codes are not assigned a reimbursement amount, resulting in zero payment.
Tip 5 – Single case agreements. If the patient does not have benefits which cover hyperbaric treatments, it is worthwhile to obtain a single case agreement. Your patient access office or patient billing office should know this process and have some acceptable reimbursement values in mind to begin the negotiation process. It may take some back and forth between the two parties, but is worth the attempt to treat the patient in your center rather than sending to another facility. Remember to also get a single case agreement on behalf of the supervising physicians.
Tip 6 – Insurance. When asking for authorization, ensure that any supervising physician of hyperbaric treatments, participates with the patient’s insurance carrier.
Tip 7 – Remember the 16th minute rule. Hyperbaric treatments for medicare are reimbursed in 30 minute segments beginning from the time the door of the chamber is closed and ending when the door of the chamber is opened. To justify billing the next subsequent segment, the time must reach into the 16th minute of the next 30 minute segment. Otherwise, you round down to the previous segment. The times noted on the treatment chart will justify the segmental billing.
Tip 8 – DFU. The medical record for diabetic foot ulcers should have a statement regarding adequate glycemic control, offloading, and debridements.
Tip 9 – Medical records.The medical record should have statements regarding the physician supervision, accessibility and, in some cases, availability of emergency and/or ICU services.
Tip 10 – Review and re-evaluate often. Utilization review is key to avoiding denials and excess expense to both the patient and the healthcare industry. This both justifies continued treatment (if improvement is seen) and discontinuation (if the patient is not improving). Patient reevaluation is recommended to occur after 20 treatments and then each 10 treatments after that. Most indications should not exceed 60 treatments.