As a representative for the Florida Society of Plastic Surgeons all of whom are certified by the American Board of Plastic Surgery, I attended the most recent Medicare Carrier Advisory Committee (CAC) meeting. This committee is composed of 31 members who are representatives of their corresponding organizations. These organizations include MD/ DO based societies of Anesthesiologists, Dermatology, Internal Medicine, etc. as well as representatives from the Florida Hospital Association, Podiatric Medical Association, Optometric Association, Association of Health Plans, etc. The CAC meets three times a year in Orlando.
First Coast Service Options, Inc presently is the contractor that administers Medicare payments in Florida.
One purpose of the CAC is to provide a mechanism to inform provider organizations in Florida of local coverage decisions (LCDs) and to participate in the development of LCD policies in an advisory capacity. As implied by the name, a LCD is a decision by the Medicare administrator (in this case FCSO) to cover a particular provider claim. The CAC influences what FSCO will have Medicare cover and how much Medicare will pay to providers of services to Medicare beneficiaries in Florida. What occurs in Florida significantly impacts discussions at the national level.
The role of the CAC member is to improve the communication between Medicare and the provider community. The representative is expected to communicate with their respective society members to disseminate proposed LCDs so as to solicit society member comments.
ACTIVITY AT THE MOST RECENT CAC:
An abridged review of the LCDs of importance to Plastic Surgeons discussed at the most recent CAC meeting follow:
For the purposes of this LCD entitled “Wound Care”, wound care is defined as care of wounds that are refractory to healing.
This LCD discusses the following:
- Use of E/M codes when wounds are the treatable condition
- Debridement codes
- Negative Pressure Wound Therapy
- MIST therapy
- Unna boot placement
- Requirement of documentation of the wound improving
- E/M codes:
- E/M codes include Wound Care Non-Selective Debridement E/M codes (CPT code 97602) since CPT code 97602 is a Status B code. This means that 97602 is bundled with other codes and generally is not payable separately.
- When an E/M code is billed with the other debridement codes it will be paid only when the documentation clearly establishes the E/M as a “separately identifiable service” that was reasonable and necessary, as well as distinct, from the debridement service provided.
- The following procedures are considered part of an E/M service and are not separately covered:
- removal of necrotic tissue by cleansing and dressing changes;
- cleaning and dressing small or superficial lesions;
- removal of coagulated serum from normal skin surrounding an ulcer.
- Debridement codes:
- Wound Care Selective Debridement (CPT codes 97597 and 97598) utilize sharp debridement of small wounds, usually without anesthesia or bleeding. Use of local anesthesia does not justify use of 110XX codes and use of local anesthesia is not separately billable.
- Wound Care Non-Selective Debridement (code 97602) includes dressing changes, hydrotherapy, and maggot therapy and is generally not payable as it is a Status B code (see above).
- Wound Care Surgical Debridement (CPT codes 11000, 11001, 11004, 11005, 11006, 11008, 11010, 11011, 11012, 11042, 11043, 11044, 11045, 11046, and 11047) (codes 11040 and 11041 are no longer used) are major debridement codes and should not be used for a circumscribed lesion. General anesthesia may be required.
- It would not be expected that an individual wound would be repeatedly debrided of skin and subcutaneous tissue because these tissues typically do not regrow very quickly. Such debridements performed more frequently than once a week could be subject to medical review.
- Negative Pressure Wound Therapy (NPWT):
- Disposable non-powered mechanical or single use non-electrically powered or battery powered Negative Pressure Wound Care (NPWT) (CPT codes 97607 and 97608) are not covered.
- NPWT, electrically powered (CPT codes 97605 and 97606), is considered medically necessary when at least ONE of the following conditions is met:
- There are complications of a surgically created wound
- There is a traumatic wound and a need for accelerated formation of granulation tissue not achievable by other topical wound treatments
- There is a chronic, non-healing ulcer with lack of improvement for at least the previous 30 days despite standard wound therapy and weekly evaluations with documentation of wound measurements (i.e., length, width, and depth) in ONE of the following clinical situations:
- Chronic Stage III or Stage IV pressure ulcer
- Chronic diabetic neuropathic ulcer
- Chronic venous ulcer
- Low-Frequency, Non-Contact, Non-Thermal Ultrasound (MIST Therapy)
- Low frequency, non-contact, non-thermal ultrasound describes a system that uses continuous low-frequency ultrasonic energy to produce and propel a mist of liquid and deliver continuous low-frequency ultrasound to the wound bed. This modality is often referred to as “MIST Therapy.”
- MIST Therapy is eligible for coverage by Medicare for:
- Wounds, burns and ulcers that have failed conventional debridement and meet Medicare coverage for debridement but which are too painful for sharp or excisional debridement.
- Wounds, burns and ulcers meeting Medicare coverage for debridement but with documented contraindications to sharp or excisional debridement.
- Wounds, burns and ulcers meeting Medicare coverage for debridement but with documented evidence of no signs of improvement after 30 days of standard wound care.
- MIST Therapy must be provided two to three times per week to be considered reasonable and necessary. Observable, documented improvements in the wound(s) should be evident after two weeks or 4 to 6 treatments. Wounds demonstrating no improvement after six treatments (two weeks) is considered not reasonable and necessary.
- Application of Paste Boot (Unna Boot) or Application of Multi-Layer Compression System (CPT codes 29580 or 29581). When both a debridement is done and an Unna boot is applied, only the debridement will be reimbursed.
- Documentation of Wound Improvement
- Since the overall goal of care is healing and not palliation, it is neither reasonable nor medically necessary to continue a given type of wound care if evidence of wound improvement as outlined in this LCD cannot be shown in two to four weeks.
- Medicare expects that with appropriate care:
- wound volume or surface dimension should decrease by at least 10 percent per month or
- wounds will demonstrate granulation tissue advancement of no less than 1 mm/week.
- Medicare requires documentation that the wound is improving due to the care provided. Evidence of improvement includes measurable changes in the following:
- Drainage Inflammation
- Swelling Pain and/or tenderness
- Wound dimensions (surface measurements, depth)
- Granulation tissue
- Necrotic tissue/slough
- Tunneling or undermining
For further information or if you have questions, please contact me or go directly to the FCSO site at www.fcso.com
The Vice President and Chief Medical Director of First Coast Service Options, Inc., James Corcoran, MD, MPH, can be reached at James.Corcoran@fsco.com or at 907‑791‑8211.
For the Florida Society of Plastic Surgery,
Donato A Viggiano, MD FACS