Will Reimbursement Changes Adversely Affect Preventative Wound Care?
- Volume 24 - Issue 2 - February 2011
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This author details recent changes to the CMS physician fee schedule and what lower reimbursement may mean for wound care centers and the high-risk patients they treat.
The 2011 update in the Centers for Medicare and Medicaid Services (CMS) physician fee schedule can be projected to reduce reimbursement for wound care services in facilities by 22 percent. While Congress called for a 0 percent update in the fee schedule for 2011, the CMS cut the conversion factor from $36.8729 to $33.9764, which is an approximate -7.8 percent reduction. The conversion factor cut is designed to help keep the relative value unit (RVU) changes budget neutral.
Physicians who specialize in wound healing have a unique practice and represent a heterogeneous group of physician specialties, including general surgery, podiatry, vascular surgery, plastic surgery, infectious diseases, endocrinology, pulmonology and general surgery. Some practice in private offices but given the nature of the work, many practice in hospital-based wound centers.
Updates in the 2011 fee schedule particularly impact codes that are used by wound specialists. Wound debridement codes were completely revised both in definition and value, and some common skin substitute application codes were drastically reduced. Changes in RVU and fee schedule for common codes from 2010 to 2011 for facility sites are illustrated in the tables below.
A Closer Look At The Coding Changes
Debridement reimbursement (1104x) is no longer based on the number of wounds debrided but rather on the total area of the debridement in increments of 20 cm2. Partial (11040) and full thickness (11041) skin debridement codes were deleted and replaced with removal of devitalized tissue (97597). There are now add-on codes to report additional increments of 20 cm2. The add-on codes are inherently reduced in value and should not be modified by -59.
Why the drastic impact in wound services? It is all about the requirement to bill by surface area and not number of wounds. Under 2010 guidelines, if there were two wounds that each measured 9 cm2 and were debrided into the subcutaneous tissue, one would bill 11042 and 11042-59. The -59 modifier results in a 50 percent reduction of reimbursement for the second code.
In the 2011 guidelines, one only bills 11042, adding the surface areas together to total <20 cm2. Even if adding the surface areas together is sufficient to bill another unit, the RVU of the add-on code is 40 percent of the value of the first code.
The debridement of subcutaneous tissue (11042) code was the only frequently used wound care code that increased in value from 1.17 RVU to 1.4 RVU. This increase is offset by the requirement to code by area and not number of wounds. If this were debridement of muscle, the reduction would be even greater. The RVU of the parent code for muscle debridement (11043) dropped 42 percent and the add-on code for muscle debridement (11046) is 31 percent of the parent code. It is difficult to directly calculate the impact on reimbursement since it depends on the 2011 square area scenarios and the number of wounds debrided in the 2010 scenarios.
In our wound center, 67 percent of the patients have more than one wound. The average number of wounds in those patients is 2.35.