The Business of Wound CareThe Monetary Value of Durable Medical Equipment

Barbara Aung, DPM,CWS,CPMA,CSFAC

APAM Coding Committee Member

Vice President

AAPC-Tucson Chapter

Cactus Coders

Podiatric Surgery Attending - Tucson VA Residency

Disclosures

Speaker’s Bureau:

• Organogenesis

• Valeant Pharmaceutical - Jublia

• PharmaDerm – Kerydin

Grant/Research Support:

• Celegene

• Dipexium

• Alliqua Biomedical

• Tissue Regenix

Medical/Scientific Boards:

• OWM – Editorial Board

• APMA Coding Committee

What is Durable Medical Equipment (DME)?

CMS Def: Durable medical equipment is reusable medical equipment such as walkers, wheelchairs, or hospital beds. Includes Orthotics, Prosthetics and Supplies (Wound Dressings, Compression stockings, Diabetic Shoes,)

Practitioner must prescribe the type of equipment needed.

Medicare may also require a Certificate of Medical Necessity.

• To dispense Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), one must have a Durable Medical Equipment Regional Carrier (DMERC) license to dispense covered items for Medicare patients.

• National Supplier Clearinghouse at (803) 754-3951 or check out the CMS Web site, www.cms.hhs.gov

Examples of covered DME items

• pneumatic cam walker (L4360)

• non-pneumatic cam walker (L4386)

• CROW boot (L4631)

• compression garment (A6531-A6532 -AW)

• primary dressings used in the home (not in the office) – (A6000 through A6457)

• Primary dressings go right on the wound as opposed to other materials, which may cover the primary dressing or hold it in place.

Examples of non-covered items

• Ace bandage

• Coban

• OTC splints

• gauze, tape, Band-Aids, etc.

• Post-op shoes (L3260) are never covered by Medicare

Non-covered items are billable directly to the patient with no Advance Beneficiary Notice (ABN) or limiting charges restrictions.

Therapeutic Shoe Progam

• Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease

• The doctor who treats the diabetes must certify need for therapeutic shoes or inserts.

• A podiatrist or other qualified doctor must prescribe the shoes and inserts.

• A doctor or qualified pedorthist, orthotist, or prosthetistmust fit and provide the shoes.

• Medicare helps pay for one pair of therapeutic shoes and 3 pair of inserts per calendar year.

Therapeutic Shoes

• A5500 For diabetics only, fitting (including follow up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe

Allowable: $60.02 - $80.03

Possible Examples: Extra Depth Shoe

• A5501 For diabetics only, fitting (including follow up) custom preparation and supply of shoe molded from cast(s) of patient's foot (custom-molded shoe), per shoe

Allowable: $180.05 - $240.06

Possible Examples: Custom-Molded Shoe

Therapeutic Shoe Inserts• A5512 For diabetics only, multiple density insert, direct

formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each

Allowable: $24.49 - $32.65

Possible Examples: (diabetic insert, pre-fabricated)

• A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each

Allowable: $36.55 - $48.73

Possible Examples: (diabetic insert, custom-fabricated)

Wound or Surgical Dressings

• Both primary and secondary dressings are covered when :• 1) they are medically necessary for the treatment of a wound

caused by, or treated by, a surgical procedure; or • 2) they are medically necessary when debridement of a wound

is medically necessary.

• The surgical procedure or debridement must be performed by a physician or other health care professional to the extent permissible under State law.

• Surgical dressings must be ordered by a physician or a Nurse Practitioner, Clinical Nurse Specialist, Certified Nurse-Midwife or Physician's Assistant who was acting within the scope of his or her legal authority as defined by State law or regulation.

• Debridement of a wound may be any type of debridement such as; mechanical, surgical, autolytic or chemical.. Dressings used for mechanical debridement are covered.

Documentation Required• 1) A signed order by the physician or other health care provider

• 2) The order must specify:• A) type (category) of dressing• B) size of dressing• C) number / amount of dressings to be used at one time (if more than

one)• D) frequency of dressing changes• F) expected duration of need

• When is a new order required?• 1) a new dressing is added• 2) the quantity of an existing dressing INCREASES, not decreases.• 3) at least once every 3 months for each dressing being used, even if

the quantity has remained the same.

• the claim form must include the appropriate modifier, A1- A9, designates the number of wounds:

• A1 Dressing for one wound• A9 Dressing for nine or more wounds

DMERC Utilization Guideline

• Alginate wound cover...................... change once daily

• Alginate wound filler...................... change once daily, up to 2 six inch strips allowed per dressing change

• Composite dressing ........................3 times per week

• Contact layer ...................................once per week

• Foam dressing..................................up to 3 times per week

• Foam wound filler...........................once daily

• Gauze................................................3 times per day, no more than 2 pads on a wound

(non-impregnated)

• Gauze ...............................................once daily

(impregnated - other than water or saline)

DMERC Utilization Guideline

• Hydrocolloid cover and filler .........3 times per week

• Hydrogel wound cover.....................once daily (or 3 times per week if using adhesive border)

• Hydrogel wound filler.....................once daily, no more than 3 ounces per wound in a 30 day period

• Specialty absorptive dressing.........once per day (or every other day if using adhesive border)

• Transparent film..............................up to 3 times per week

• Wound filler not classified..............once per day

• Gauze, elastic...................................determined by the frequency of dressing change of the primary dressing

• Gauze, non-elastic............................determined by the frequency of dressing change of the primary dressing

Compression Stockings

• Patient Suffers from Chronic VLU’s or Chronic Phlebitic Syndrome – Active wound

• Wound debridement weekly by Dr…...

• A6530- Gradient compression stocking, BELOW KNEE,18-30 mmHg, Ea.

• A6531 - GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 mmHg, Ea.

• A6532 - GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50mmHg,Ea.

AW- Item furnished in conjunction with a surgical dressing

• L3260 Surgical boot/shoe, each

Possible Examples: PO shoe - not covered

• L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Possible Examples: Pneumatic-type

Allowable: $234.19 - $312.25

• L4386 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Possible Examples: CAM-Walker

Allowable: $128.12 - $170.83

• L3260 Surgical boot/shoe, each

Possible Examples: PO shoe - not covered

• L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Possible Examples: Pneumatic-type

Allowable: $234.19 - $312.25

• L4386 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Possible Examples: CAM-Walker

Allowable: $128.12 - $170.83

• L3260 Surgical boot/shoe, each

Possible Examples: PO shoe - not covered

• L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Possible Examples: Pneumatic-type

Allowable: $234.19 - $312.25

• L4386 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Possible Examples: CAM-Walker

Allowable: $128.12 - $170.83

Documentation for Dispensing – You as Supplier

• Rx for product(s) ordered

• PROOF OF DELIVERY ,AUTHORIZATION OF PAYMENT,WARRANTY/RETURN POLICY

• ON SHOES, COMPRESSION STOCKINGS, WALKER BOOT, WOUND CARE DRESSINGS AND BREAK-IN PROCEDURES

• (1) Return Policy form

• (2) Warranty form

• (3) DME Complaint Resolution Protocol

• (4) Current DMEPOS Supplier Standards for Medicare Enrollment sheet

• ABN if there is no coverage, charge patient for items

Closing Remarks / Thank You

The Business of Wound CareThe Monetary Value of Durable Medical Equipment

Barbara Aung, DPM,CWS,CPMA,CSFAC

APAM Coding Committee Member

Vice President

AAPC-Tucson Chapter

Cactus Coders

Podiatric Surgery Attending - Tucson VA Residency