When it comes to healing, sometimes our skin needs a little more than a kiss it and make it better approach. Complex, non-healing, or chronic wounds require clinical interventions to jump start the body’s natural healing process. These specialized procedures are referred to as Active Wound Care Management and are much more in depth than routine Nursing Services and/or Evaluation and Management. When these services are billed separately despite being part of a single clinical episode, it can lead to significant overpayments.
What to look for
Active Wound Care Management (AWCM) (CPT codes 97597–97610) describes procedures used to promote healing by removing devitalized tissue and promoting the growth of new tissue. This typically involves high-level clinical decision-making and physical intervention.
Nursing Services (like those provided in a SNF) and/or Evaluation and Management (E&M) entails wound care that is more routine – such as cleaning a wound, applying topical ointments, and changing dressings. Those services are considered an inherent part of a standard nursing visit or E&M service and are not separately reimbursable as active management.
AWCM codes are often depth-specific. Medical record documentation must support the specific layer of tissue removed, include precise measurements before and after the procedure and should specify the instruments used. Routine nursing care rarely involves the same instruments required for active debridement codes. Active wound care is also generally expected to show progress. If there is no change in the wound status or the treatment approach, it may indicate transition back to routine care.
Frequent or routine claim submissions that include both an E&M code and an AWCM code should be reviewed. Unless a significant, separately identifiable service was performed, the evaluation of the wound is considered part of the wound care procedure itself. Additionally, dressing changes are included in any debridement codes, so a provider shouldn’t bill for both on the same wound during the same session.
HCFS Has You Covered
Combating unbundled codes requires a multi-layered approach. Payers need to leverage advanced data analytics to identify suspicious billing patterns and inappropriate services. If you’re using the HCFSPlatform™, we’ve got you covered. Our Artificial Intelligence (AI) models can identify spikes and other anomalous billing patterns. We can also help identify outlier provider billing patterns and peer comparisons to potentially catch any inappropriate billing quickly. Some examples of our alerts include:
[2641-30] – OUTLIER, WOUND DRESSINGS AND SUPPLIES (INDIVIDUAL TIER)
[2893-01] – UNBUNDLING, ACTIVE WOUND CARE MANAGEMENT WITH NURSING FACILITY E/M SERVICES
[2893-20] – MISREPRESENTATION OF SERVICES/SERVICES NOT RENDERED, ACTIVE WOUND CARE MANAGEMENT WITH NURSING FACILITY E/M SERVICES (PEER COMPARISON)
[2893-30] – MISREPRESENTATION OF SERVICES/SERVICES NOT RENDERED, ACTIVE WOUND CARE MANAGEMENT WITH NURSING FACILITY E/M SERVICES (INDIVIDUAL TIER)
If you’re not using the HCFSPlatform™ and you’re interested in knowing more, email us at [email protected].
If you have questions or comments, you may email us at [email protected].
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