Cath Lab Digest

Dr. Fife and Mr. Walker disclose they have financial interest in Intellicure, Inc. and the Intellicure Clinical Documentation & Facility Management Software. This article was developed and submitted for publication with the generous volunteer support of the Association for the Advancement of Wound Care members.

Outpatient wound center facility reimbursement for Medicare beneficiaries is defined by the Centers for Medicare and Medicaid Services (CMS) in the Hospital Outpatient Prospective Payment System (HOPPS). (Physician reimbursement by the CMS is determined by the 1995–1997 Medicare guidelines for physician documentation and will not be discussed in this paper.) The HOPPS, published on April 7, 2000 in the Federal Register,¹ was intended to revise the outpatient payment system for hospital clinic and emergency departments, as well as for all hospital outpatient departments that did not have an existing billing schedule, such as outpatient cancer centers or pain management clinics. Wound care centers were instructed to use three sets of the five Evaluation and Management (E&M) Codes: new patients — codes 99201 to 99205; consults — codes 99241 to 99245; and established/follow-up — codes 99211to 99215.¹ Although the CMS directed facilities to bill using all of these classes of codes, only three payment groups existed. They are known as Ambulatory Patient Classification (APC) Codes 600, 601, and 602; the assigned payments were approximately $44, $52, and $82, respectively (approximate because several other factors impact the actual payment, such as wage index and locality).

In addition, as specified in the 2000 Federal Register,¹ each wound facility was expected to “develop a system for mapping the provided services furnished to the different levels of effort represented by the codes.” Provided that the services were medically necessary and properly documented and that the facility was following its own developed system, the CMS would assume the facility was in compliance with reporting requirements. At the same time, the CMS emphasized that the intensity of facility visits and reporting codes should be based on “an internal assessment of the relevant charges for those codes as opposed to failing to distinguish between low- and mid-level visits because the payment is the same.” One of the CMS goals through HOPPS was to study billing information to establish a database for revising weighing factors and other payment adjustments in future years.

“Time” was readily adopted by wound care clinics as a means of assessing the charged level of service for each patient visit. While a time-based analysis is an easy system to develop and subsequent billing codes are easy to calculate, this system rewards inefficiency. Although more complex wound care activities require more time, a system based on a subjective assessment of time spent could result in healthcare workers justifying a billed level of service that is inappropriately high compared to the actual work provided.