heir commitments reinforce the role of CMS in monitoring outcomes and promoting accountability.
Blog Posts About Wound Care Economics
Site Neutrality – a Looming Disaster or an Opportunity?
Now may be the time for academic programs and large hospital systems that still provide needed emergency hyperbaric services to start contacting their congressmen.
The Quality Payment Program (QPP) “Doctors and Clinicians Preview Period” for 2023 is Officially Open
Clinicians who reported data as part of the Quality Payment Program (QPP) in 2023 can preview their 2023 performance information before it appears on the Medicare.gov compare tool and in the Provider Data Catalog (PDC).
Providers Under Siege
The stakes go beyond money: reputational harm, exclusion from Medicare and Medicaid, and even criminal charges are on the table.
States Try to Limit the Use of AI in Prior Authorization
Read the complete article for more details on what individual states are doing to push back on the use of AI in Prior Authorization.
CTP-related LCDs Postponed at the Last Minute!
The LCDs that will directly impact CTPs (Skin Subs) have been postponed until January 1, 2026! Announcement came at the last minute!
Overzealous Medicare Audits
Be sure to read all of Ms. Emanuel’s article, which calls for radical reforms such as holding auditors accountable for mistakes.
Hospitals & Doctors Spend a Lot of Money Just Trying to Get Paid
No wonder practitioners in private practice have been tempted by the big dollars to be made from skin substitutes.
What Happened to “Innocent Until Proven Guilty? Check Out this Article on Medicare Recoupment
Check out Knicole Emanuel’s recent blog post about CMS monetary recoupment before full adjudication.
Fewer Regulatory Hoops but Continued Scrutiny on Fraud Under the Trump Administration
While the Trump Administration may be reducing the regulatory burden in many areas of government, they are NOT reducing their focus on reducing on fraud investigations.
The Cigna Group Launches Actions to “Drive Positive Change for Customers & Patients”
There are five key areas of focus, and several initial specific actions, to improve the health of its customers and the value it provides.
ACA Healthcare Plan “Just Say No” to 1 in 5 Claims
ACA insurers denied 1 in 5 medical claims in 2023, the highest rate since 2015.
Murphy Introduces Bipartisan Legislation to Preserve Medicare for Patients and Physicians
I worry that the misbehavior of a small percentage of practitioners will reduce enthusiasm for a bill to fix a huge physician reimbursement problem.
Noridian Surgical Dressings Webinar – 02/11/2025
The Noridian Provider Outreach and Education staff is hosting the Surgical Dressings webinar on 02/11/2025, 12:00 PM – 1:30 PM EST.
Landmark Antitrust Settlement Calls for Blue Cross Blue Shield to Pay $2.8 Billion into a Fund Designated for Physicians and Others
The fund is designated for settlement class members, including physicians, group practices, and health care facilities.
American Relief Act Extends Some Telehealth Waivers Including Audio-Only Telehealth
The continuation of Medicare telehealth flexibilities follows another recent telemedicine extension by the DEA and the Department of HHS.
Physicians Have Concerns Over the Implementation of Medicare’s Add-on Code for Complex Care (G2211)
The rules are complex, and a billing and coding expert may need to provide guidance to wound care practitioners.
Changes to the Administrative False Claims Act (AFCA) Mean That “Smaller” Medicare Fraud Cases (Up to $1 Million) Can Be More Easily Prosecuted
This legislation also makes it more likely that individuals who act as “whistleblowers” could realize the associated monetary rewards.
The New LCDs are (Almost Certainly) Coming to Town
I may post more information about the meeting later, but the general tone of the MAC medical directors was confident.
CGS Chief Medical Officer is Hosting a Meeting on the New Cellular Tissue Product / Skin Substitute LCD on December 20th
CGS J15 Webinar on Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
AMA sues MultiPlan Alleging Price-Fixing for Out-of-Network Physician Payments
The American Medical Association (AMA) and the Illinois State Medical Society (ISMS) have filed a lawsuit in federal court.
CMS Releases the Medicare Physician Fee Schedule Final Rule for 2025
The sad news is that CMS is going ahead with a 2.9% cut to Medicare physician reimbursements for 2025.
ICD-10 Changes
There were 252 new codes added, 36 code deletions, and 13 code revisions effective October 1, 2024.
CMS Releases 2025 Final Rule for the Hospital Outpatient Prospective Payment System (OPPS)
The short version, based on my cursory read, is that no old problems were fixed but no new problems were created by the final rule.
Breaking News! LCDs for Cellular Tissue Products / Skin Substitutes Released!
LCD – Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (L39756)
Bipartisan Bill Introduced That Would Provide a 4.7% Medicare Physician Payment Update
It would eliminate the 2.8% Medicare physician payment cut and provide a positive update that equals half of the Medicare Economic Index.
FDA Approves Changing the Expiration Date of Some IV Fluids Made by Baxter to Help Alleviate Shortages
Baxter International is one of the largest suppliers of IV fluids in the United States with its North Cove facility providing 60% of IV fluid in the USA.
Check Your Final 2023 MIPS Scores Available Online – Scores Will Impact 2025 Physician Payment!
Should an error be found, the deadline to request a review is Oct. 11 at 7 pm CT.
“To Self-Disclose or Not to Self-Disclose”: Check Out Attorney Knicole Emanuel’s Blog
Self-disclosure is better than waiting to get caught. Lives can be ruined if you wait to get caught.
Templated Notes and Medicare Audits
If practitioners encounter denials by auditors based on the use of note templates, they should probably seek legal counsel.
Reminder: Final Scores for the 2023 Performance Year of Medicare’s Merit-Based Incentive Payment System (MIPS) are Now Available Online and the Deadline to Request a Review is October 11 at 8 PM ET
Check your scores soon as they will impact your 2025 Medicare payment!
UnitedHealthcare Launches a “Gold Card” Program in October to (Hopefully) Reduce Prior Authorization Woes
The program will be offered across its commercial, individual exchange, Medicare Advantage and Medicaid business lines.
Due to the Impact of Beryl, CMS Has Automatically Applied a Hardship Exemption Within the 2024 Merit-Based Incentive Payment System (MIPS) Performance Period to Eligible cC Areas
The extreme and uncontrollable circumstances (EUC) policy will apply in affected Texas counties as identified by federal public health emergency and disaster declarations.
Check Out the New Article in TWC “I’m Getting Audited – Now What?” by Stephen Bittinger
Mr. Bittinger’s article explains the various types of audits, what’s at stake, and how an attorney might help.
Aetna to Cut Payment for Urgent Care Surgical Services and Payments for NPs and PAs
Wound Care practitioners who bill site of service 49 (independent clinic) take note!
The Average Cyberattack Breach Costs ~$11 Million – and the Number of Attacks Per Week is Increasing
Ransomware attacks have dominated, accounting for over 70% of successful cyberattacks on healthcare organizations in the past two years.
In 2025, Physicians Face a 2.8% Pay Cut While Mandatory Participation in an MVP Looms
In 2024, physicians had a 1.68% pay cut and they remain the only Medicare providers to not receive an inflationary update.
Does Which EHR a Doctor Uses Impact the “Cost” Category of MIPS?
Wound care practitioners have higher TPCC costs when compared to their peers. To CMS, they look like they spend too much money.
Global Internet Outage Continues to Impact Many Healthcare Systems
Human error may be just as much of a risk as hacking, ransomware and other intentionally malicious assaults.
2025 Medicare Physician Fee Schedule is Out (and CMS Did Not “Package Price” Cellular Tissue Products / Skin Substitutes in the Doctor’s Office)
The billing of CTPs in the doctor’s office is unchanged. The 2025 Medicare conversion factor is set to decrease for the fifth straight year.
Breaking News! OPPS Proposed Rule is Out!
At first glance, there are no changes to Cellular Tissue Product /skin substitute payment, which remain under package pricing in this site of care.
Accelerated and Advance Payment (AAP) for Medicare Ends on July 12
CMS announced that Medicare payments under the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption (CHOPD) will end on July 12.
CMS Adds 76 New Items to its Master List of DME Supplies That May Be Subject to Prior Authorization (and Some Surgical Dressings are on the List)
The Centers for Medicare & Medicaid Services (CMS) added 76 new items and deleted three from its master list of durable medical equipment (DME), prosthetics, orthotics, and supplies.
How to Subscribe to the NGS Self Service Plus Newsletter
If NGS is your MAC, you might want to subscribe to the Self-Service Plus newsletter, accessed online.
Physicians Have Until Dec. 31 to File a MIPS Hardship Exemption Due to the Change Cyberattack
The 2024 MIPS EUC portal is now open, and physicians have until Dec. 31 to file a hardship application and avoid a 2026 MIPS negative payment adjustment.
What Doctors Wish Patients Knew About Prior Authorization
Maybe if I’d let patients read this article, I could have discussed the issue with my patients honestly, rather than just running away from it.
CMS Explains its 2024 Value-Based Care Strategy
CMS ALWAYS tell us what they are going to do before they do it. Then they do it, and we are surprised.
A Little Reprieve for Physician Pay Cuts
A 3.4% Medicare physician pay cut took effect on January 1, 2024. However, thanks to the passage...
CMS Announces Flexibilities in the Wake of the Change Cyberattack
CMS is encouraging MA plans to offer advance funding to health care professionals most affected by the cyberattack.
CMS Announces Reopening of 2023 MIPS EUC Application in Response to Change Healthcare Cyberattack
I am reposting the entire message from the CMS about the extension of the Extreme and Unavoidable...
CMS Removes the Requirement for AUC From the 2024 Medicare Physician Fee Schedule
Implementing the AUC program would have been a time consuming and expensive lift for practitioners.
Resources from CMS and the AMA to Help You Implement Changes to Physician Documentation & Billing
There have been two major changes in the regulations pertaining to physician documentation during ambulatory visits, both of which are favorable for wound care practitioners.
Medicare Audits on Pneumatic Compression & Surgical Dressings – “It’s About the Documentation…”
I am a huge fan of attorney Knicole Emanuel’s blog and her most recent post is directly relevant to the field of wound care.
Be Careful Billing the New CMS G2211 Add-on Code for Visit Complexity
It is intended to “better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.”
Claims Disruptions Continue After Cyberattack on Change Healthcare
This is yet another blow to hospitals and physicians that are struggling to make ends meet in the face of payment reductions.
Ransomeware Cyberattack on Change Healthcare is Affecting Individual Physician Practices Too
United Health-owned Change Healthcare has confirmed the ransomware group “ALPHV/Blackcat” is...
Noridian Has Begun Requesting “Documentation to Support Credentialing of the Provider Performing the HBO Service”
If there are super-secret requirements that Noridian has now decided to impose, then they should be enshrined in a public document somewhere.
New Coding When Caring For a Complex Condition
G2211 should be added to an office or other outpatient evaluation and management CPT® code. It should never be submitted alone.
Surgical Dressing Webinar by Noridian on March 7th
On Thursday, Mar 7, 2024 from 12:00 PM – 1:00 PM CST, Noridian is offering a webinar on Surgical Dressings. It is intended for DME suppliers.
Novitas Releases Top Ten Reasons for Claims Denials…and Wound Centers Should Especially Check Out Reason #7
Reason #7 for claim denials is especially relevant to hospital-based outpatient wound centers (HOPDs).
MIPS Revenge!
The MIPS program has continued to evolve with penalties increasing and the participation threshold needed to avoid a penalty also increasing.
Noridian is Offering a Feb 13th Webinar on the Lymphedema Compression Benefit Category
On February 13th, 2024, Noridian is offering a Webinar for DME suppliers about lymphedema compression benefits.
Pneumatic Compression Devices Webinar by Noridian on Feb 13th, 2024
On Tuesday, Feb 13, 2024 from 2:00 PM – 3:00 PM CST, Noridian is offering a webinar intended for DME suppliers about pneumatic compression devices (PCDs).
The Deadline to Submit MIPS Data for 2023 is April 1 at 6 pm EST to Avoid up to a 9% Penalty on Medicare Revenue
The data submission period for Medicare’s Merit-Based Incentive Payment System (MIPS) 2023 performance year is underway.
Time Sensitive! It’s Not Too Late to Sign the Letter to CMS Protesting the 41.5% Reduction of HBOT Facility Fees!
I know the holidays are busy – but most of us would like to have a job to go back to in January…
CPT® Change for 2024
There are major changes to CPT coding associated with noncontact near-infrared spectroscopy.
Without Warning – the Outpatient Prospective Payment Final Rule Cuts HBOT Facility Fees by 40%
What we need is for people to submit a comment, and to spread the word that hyperbaric oxygen therapy is in a crisis.
Modifications Needed to Wound Center EHR to Support DME Orders for Dressings
Your EHR will need to be modified to meet the DME documentation requirement burden (and if you think the list below is ridiculous – it is, but it’s still required).
Listen to a Podcast with Dr. Helen Gelly, “How to Get Your Wound Clinic Through an Audit”
On your drive home, check out this podcast with Helen Gelly MD, FUHM, FACCWS, UHM/ABPM, “How to Get Your Wound Clinic Through an Audit.”
HBOT Facility Payments are Under Attack (Physician Supervision is Next…)
We need individuals at all training levels to comment on the proposed changes that CMS is proposing in the Medicare Physician Fee Schedule (MPFS) for the technical payment of HBOT.
PRESS RELEASE: New Study in Journal of Medical Economics Shows Decrease in Chronic Wound Medicare Costs Amid Increase in Chronic Wound Prevalence
Over 2014-2019, the number of Medicare beneficiaries with chronic wounds increased 13% to 10.5 million amid a surprising 20% reduction in chronic wound expenditures. Researchers seek to explain why, and what the policy implications may be.
The Lymphedema Treatment Act Passed!
The LTA will improve insurance coverage for the medically necessary, doctor-prescribed compression supplies that are the cornerstone of lymphedema treatment.
Medicare Posts Final Rule for 2024 Policy Changes to Medicare Advantage Plans – Review of Medical Necessity Requirements
Undersea and Hyperbaric Medicine IS a recognized medical subspecialty so that might help patients obtain necessary HBOT treatments.
Medicare Posts Final Rule for 2024 Policy Changes to Medicare Advantage Plans
The rule goes into effect Jan 1, 2024. Whether this will make MA less of a Medicare DIS-advantage is yet to be seen.
Are Verbal Orders Prohibited?
There are no federal regulatory prohibitions on the use of verbal orders, although CMS frowns upon verbal orders in the context of medications.
Give Yourself the Gift of an Audit
A self-audit is a miserable “gift” to give yourself, but a real audit is a gift that just keeps on giving when you are not prepared.
Reminder: 10 Days Until the Close of the 2022 MIPS Data Submission Period
The Centers for Medicare & Medicaid Services (CMS) has opened the data submission period for Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2022 performance year of the Quality Payment Program (QPP).
RAC Provider Audits and Why You Need to Worry
If you want to know what topics the Centers for Medicare and Medicaid Services (CMS) are auditing,...
Watch Session 4 of the Intellicure Webinar Series: Keeping Your Payments — After An Audit — Is In Your Control
On Wed., Oct. 26, Dr. Caroline Fife and Kathleen D. Schaum presented the fourth and final session...
Watch Session 3 of the Intellicure Webinar Series: Keeping Your Payments — After An Audit — Is In Your Control
On Wed., Oct. 19, Dr. Caroline Fife and Kathleen D. Schaum presented the third session of...
Watch Session 2 of the Intellicure Webinar Series: Keeping Your Payments — After An Audit — Is In Your Control
On Wed., Oct. 5, Dr. Caroline Fife and Kathleen D. Schaum presented the second session of...
Homework from Audit Session One
Kathleen Schaum provided the first of 4 free sessions on "Keeping your Payment after an Audit."...
Watch Session 1 of the Intellicure Webinar Series: Keeping Your Payments — After An Audit — Is In Your Control
On Wed., Sept. 28, Dr. Caroline Fife and Kathleen D. Schaum held the first session of...
Join Our Integral 4-Part Webinar Series on Audits!
Please join Dr. Caroline Fife and Kathleen D. Schaum as they discuss the keys to keeping your...
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 5
In case you think you are safe because you live in another MAC jurisdiction, it’s the same as the First Coast policy and it won’t surprise me to see all the MACs adopt the same (flawed) policies.
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 4
This is Part 4 of the list of what you need to document (per the proposed rule) if you want to use a skin substitute (CTP) for a DFU or VLU.
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 3
Novitas is going to limit clinicians to 2 applications of a “specific skin substitute” over the 12-week period defined by the date of the first application.
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 2
I am not even halfway through the details of the proposed policy, so stay tuned for more.
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 1
If you want to present comments on any of the proposed policies in the Novitas LCD, sign up to attend the Open Meeting.
Wound Repair CPT® Codes
When it comes to CPT® coding, wound repair is typically classified as simple, intermediate, or complex.
Is Collagen Billable Following Elective Procedures?
Some providers dispense surgical dressings to patients and submit coding for the dressings to third party payers in exchange for payment.
The MACs are Back… With TPE Audits
Targeted Probe and Educate (TPE) audits were briefly suspended for COVID-19, but now they are back.
The Future of Wound Infections – at the APWCA Meeting This Week in Philadelphia
Great opportunities to advance wound care knowledge, this week in Philadelphia!
Coding During the Postoperative Global Period
Many wound care – related procedures, including some amputations and certain incision and drainage services, carry with them a 10 or 90-day postoperative global period.
CMS Releases the Final Rules of the Medicare Physician Fee Schedule and the Hospital Outpatient Payment System
CMS has released the final rules of the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Payment System (HOPPS).
Debridement Auditing – It’s All About the Benchmarking
Benchmarking allows you to visualize whether you might raise a red flag with an auditor, since we know they have been auditing debridement services.
WATCH THIS: Trends in Wound Care Audits & Denials, with Dr. Caroline Fife and Dr. Helen Gelly
Last week, Dr. Caroline Fife and Dr. Helen Gelly enjoyed a relaxed, unscripted conversation about...
How the Tiniest Details Impact Wound Care Revenue & Revenue Cycle Management
In the world of Revenue Cycle Management, attention to detail is no laughing matter. A seemingly minor error can lead to decreased reimbursement, cash flow delays, patient dissatisfaction and complete denial of payment.
The 2022 Physician Fee Schedule Proposed Rule is Open for Comment
These proposed “rules” are hundreds of pages and filled with jargon. However, the details will control how physicians get paid in 2022.
What Exactly is a Separately Identifiable Evaluation & Management?
When a significant and separately identifiable E&M and a procedure are both performed, the documentation of the encounter must clearly reflect two separate services with no overlap in work between the E&M and the procedure.