If you have a question about Medicare reimbursement you would like the authors to address, send your question and contact information to Medicare Advisor, c/o Linda Jones, ADVANCE for PTs & PTAs, 2900 Horizon Dr., King of Prussia, PA 19406; fax (610) 278-1425; ljones@merion.com.

Question: I am a physical therapist working in the SNF setting. I am still unclear about the issue of Medicare reimbursement for wound care by physical therapy.

It is my understanding that Medicare Part A will reimburse for wound care by PT only if the patient has rehab potential and is receiving other PT treatments. Can you shed some light on the issue of wound care (i.e., electrical stimulation) administered to a bedridden patient who has no functional rehabilitation potential?

The wound care minutes of treatment would qualify them as "skilled" and classify the resident in a Rehab RUGS level. Is it appropriate to qualify a patient for Part A Medicare when the only skilled treatment they receive is wound care?

Even if the patient can be qualified for skilled care due to medical reasons, is it appropriate for PT wound care minutes to classify them into a Rehab RUG?

Also, are the Part B guidelines the same for wound care? I hope you can assist me with this dilemma. Thanks for your help!

Answer: Medicare does not specifically define when it will or will not cover the provision of services by a P.T. for wound care. What HCFA states in both the Intermediary Manual and the Skilled Nursing Facility Manual is that, to constitute skilled PT, the services provided:

1. "must be reasonable and necessary for treatment of the patient's condition,

2. must be provided with the expectation that the condition will improve materially in a reasonable and generally predictable time,

3. must be of a level of complexity and sophistication, or the condition of the patient must require the judgment, knowledge and skills of a P.T., and

4. must be considered under accepted standards of medical practice to be specific and effective treatment for the patient's condition."

So, ask yourself if these requirements apply to the patient, and you should be able to identify whether or not your intervention is appropriate.

Each patient must be considered individually. The wound care team needs to ask such questions as:

• What are the lab values? Do they predict non-healing?

• What are the caloric needs for healing in this patient? What is the actual intake of the patient?

• How old is the wound?

• What other interventions have been attempted, such as medication, dressings, etc.? What has been the result of these interventions?

• Has the patient had other wounds and how have they responded to treatment?

• Have all of these things been documented in the patient's chart?

By combining the answers to these types of questions with the answers to the four coverage requirements, as a professional, you will be able to judge whether or not you should be involved in the patient's wound care, and to what extent you should be involved. Documentation throughout the patient's medical record must substantiate the need for physical therapy intervention, and will be what the Intermediary will consider in its review of medical necessity.

Part of your question refers to wound care minutes contributing to a RUG-III category. Wound care constitutes a skilled level of care for nursing so a Part A beneficiary would automatically qualify for a non-rehab RUG-III category. The amount of time that physical therapy spends in treatment, provided that it is appropriate based on the four coverage requirements, would legitimately place the patient in a Rehab RUG-III category.

There are no differences in requirements for Part A or Part B coverage as they both carry the same requirements for qualifying as a skilled service. However, under Part B, when you exceed the published edits, the claim will automatically go for Level II Medical Review. This should not be a cause for either concern or discontinuation of service if the four coverage requirements are met AND there is thorough substantiating documentation in the patient's medical record and in any other facility documentation such as Wound Care Team minutes.

It should be noted that in June of 2000, HCFA issued a continuance of Transmittal No. AB-00-53, National Coverage Policy on Electrostimulation for Wound Healing, which prolongs the policy that each case of electrical stimulation utilization will be individually reviewed.

References

1. HCFA. (November 1999). Skilled nursing facility manual. Washington, DC: Department of HHS.

2. HCFA. (July 1999). Intermediary manual. Washington, DC: Dept. of HHS.

3. HCFA. (June 2000). National coverage policy on electrostimulation for wound healing. Transmittal No. AB-00-53. Washington, DC.

Pauline Watts and Danna D. Mullins are the co-founders of Encompass Education, Inc. of Palm Harbor, FL. They are the "Medicare Advisor" columnists for the ADVANCE online family of newsmagazines. You may contact the authors at encompasseducation@worldnet.att.net.