Medicare

“This past summer, one of my patients who was suffering from a diabetic foot ulcer was admitted to a skilled nursing facility (SNF) following a hospital discharge. During her admission to the SNF, I continued to care for her in my office, including ulcer debridement and radiographs. Medicare is denying payment for her ulcer debridements (CPT 97597) as well as the technical component of her radiographs (CPT 73630-TC) on the grounds that “all SNF Part A inpatient services are paid under a prospective payment system (PPS)” and that “services that are considered within the scope or capability of SNFs are considered paid in the PPS rate.” In other words, Medicare considers the care that I rendered to be bundled with the payment to the SNF for admission, and therefore the SNF should have been doing it themselves, and that if I want payment I need to bill the SNF since they–in Medicare’s view–outsourced the ulcer care to me. While I fully expect the SNF to balk at any requests for payment from me, and I believe it might still be worth my time to appeal to an Administrative Law Judge, I would like to know if anyone has experienced this? In the future, if I am going to care for the ulcers of my patients when they are admitted to SNFs, is there anything I can arrange with the SNF or with the patient to ensure I am compensated for their care?”

“I am reading conflicting information regarding the dispensing of a post-operative/cast shoe. Medicare never seems to pay for this but commercial carriers usually do. I am reading that this shoe is NOT separately payable when it is dispensed in conjunction with a surgical procedure code. You cannot have the patient sign an ABN and charge the patient for the shoe. Please clarify the dos and don’ts of using the L3260 HCPCS code.”