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New 2017 CPT® code updates and changes Cheat Sheet (DRAFT) by [deleted]

New 2017 CPT code updates and change

This is a draft cheat sheet. It is a work in progress and is not finished yet.


New 2017 CPT® code updates and changes for wound care and hyperbaric is right around the corner. These updates can result in new revenue opport­unities or reductions based on how your hospital is prepared. Here are 10 tips to avoid denials and keep your revenue cycle flowing.

Tips 1- 5

Tip 1: Know your Local Coverage Determ­ination (LCD) (if you have one) for hyperbaric treatments for medicare patients and review it often. Things change quickly in our industry. Most LCD’s will have a list of codes that support medical necessity and clearly state the docume­ntation requir­ements to justify treatment. Review the patient record prior to beginning treatment to ensure the docume­ntation meets those requir­ements.

Tip 2: Know your private insurers medical policy for hyperbaric treatm­ents. Medical policies are basically the LCD for commercial insurance. Search online for the payer’s hyperbaric medical policy and review the docume­ntation against the policy prior to starting patient treatm­ents.

Tip 3: Go beyond the author­iza­tion. You may gain author­ization but later discover the patient’s plan does not cover hyperbaric treatm­ents. After you receive the author­iza­tion, speak to someone in benefits to verify the patient’s financial respon­sib­ility. Ask to see: if the patient has hyperbaric benefits, their deductible amount and how much has been met, as well as their annual "out of pocket max".

Tip 4: Check CPT codes. When discussing author­iza­tions with a third party payer, ask if a reimbu­rsement amount is assigned to the CPT codes you intend to submit. In some cases, certain CPT codes are not assigned a reimbu­rsement amount, resulting in zero payment.

Tip 5: Single case agreem­ents. If the patient does not have benefits which cover hyperbaric treatm­ents, it is worthwhile to obtain a single case agreement. Your patient access office or patient billing office should know this process and have some acceptable reimbu­rsement values in mind to begin the negoti­ation process. It may take some back and forth between the two parties, but is worth the attempt to treat the patient in your center rather than sending to another facility. Remember to also get a single case agreement on behalf of the superv­ising physicians

Tips to Avoid HBOT Denials

Tips 6 - 10

Tip 6: Insura­nce. When asking for author­iza­tion, ensure that any superv­ising physician of hyperbaric treatm­ents, partic­ipates with the patient's insurance carrier.

Tip 7: Remember the 16th minute rule. Hyperbaric treatments for medicare are reimbursed in 30 minute segments beginning from the time the door of the chamber is closed and ending when the door of the chamber is opened. To justify billing the next subsequent segment, the time must reach into the 16th minute of the next 30 minute segment. Otherwise, you round down to the previous segment. The times noted on the treatment chart will justify the segmental billing.

Tip 8: DFU. The medical record for diabetic foot ulcers should have a statement regarding adequate glycemic control, offloa­ding, and debrid­ements.

Tip 9: Medical record­s.The medical record should have statements regarding the physician superv­ision, access­ibility and, in some cases, availa­bility of emergency and/or ICU services.

Tip 10: Review and re-eva­luate often. Utiliz­ation review is key to avoiding denials and excess expense to both the patient and the healthcare industry. This both justifies continued treatment (if improv­ement is seen) and discon­tin­uation (if the patient is not improv­ing). Patient reeval­uation is recomm­ended to occur after 20 treatments and then each 10 treatments after that. Most indica­tions should not exceed 60 treatm­ents.