Key Takeaways
- Documentation Drives Reimbursement. Providing excellent wound care is only part of the equation. Clinicians must clearly document wound severity, duration, prior treatments, medical necessity, and treatment plans to support reimbursement and withstand audits. As Dr. Gelly emphasizes, accurate documentation is often the difference between getting paid and receiving a denial.
- Coding Specificity Matters. Understanding the relationship between CPT codes (what you do) and ICD-10 codes (why you do it) is essential. Selecting the most specific diagnosis code and ensuring it aligns with the patient's condition and payer requirements can significantly reduce claim denials and improve reimbursement outcomes.
- Learn the Rules Before Problems Occur. Coverage policies, prior authorization requirements, LCDs, and payer-specific rules directly impact what treatments are covered. New wound care clinicians should develop the habit of reviewing insurance policies and documentation requirements proactively rather than learning through denials, audits, or lost revenue.
Transcript
Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text.
Jayesh Shah, MD:
Welcome to Wound Conversations, the podcast where wound care professionals come together to learn, share, and advance the practice of healing. I am Dr. Jay Shah and here each episode is going to bring you insights from leading experts across wound healing in spirit of learn today and apply tomorrow. Today's episode is one-on-one that many clinicians wish they had earlier in their careers known about it. Joining us today is Dr. Helen Gelly. Dr. Gelly has been involved in hyperbaric medicine and wound care since 1991. Dr. Gelly is boarded in undersea and hyperbaric medicine and is fellow of undersea and hyperbaric medicine. She's currently a medical director for hyperbaric physicians of Georgia. She has been actively involved in billing and reimbursement issues for both facilities and physician and is a co-chair for UHMS Quality Utilization Authorization and Reimbursement Committee. She's our president elect for undersea and hyperbaric Medical Society and she served as a faculty previously for WoundCon.
I and Dr. Helen Gelly were recently there for the UHMS annual meeting because we both were in the same board sitting on the same chair. So it's nice to see you again, Dr. Helen Gelly.
Helen Gelly, MD:
Thank you. It's an honor to be invited to speak with you, Jay.
Jayesh Shah, MD:
Yeah. Whether you are early in your wound care career or simply looking to strengthen your understanding of the reimbursement landscape, this conversation is designed to help build clarity and confidence. Wound conversation is brought to you by WoundSource, the trusted resource for wound care professionals and WoundCon, your connection to global virtual education in wound management. So let's get started. Listen today and apply tomorrow. One thing we love to explore on this podcast is what draws people into this field and keeps them passionate about it. So Helen, what's your wound care why?
Helen Gelly, MD:
Well, initially my practice was limited to hyperbaric oxygen treatments, but as more of my patients presented with wounds, I started becoming more involved in their wound care. At that time in the prehistoric age, wet-to-dry dressings were the standard of care for most of our referring physician offices. And as wound care became more sophisticated, the community standards didn't seem to change with the science. So I started doing more wound care as a service to my patients and to try and reduce the number of doctor visits they had because as you know, our patients are usually very complex and they see a lot of doctors. And if you can reduce one doctor visit per week, it's a huge advantage. But it also sort of started my path towards educating providers to get reimbursed for the care that they provide and not only to keep the lights on, but to also allow for cutting edge technology and innovations to be available to our most vulnerable patients.
Jayesh Shah, MD:
Helen, I accidentally entered into wound care (as well). I am an internal medicine physician and I became a wound care hyperbaric physician like you and got board certified. But I know you were emergency medicine physician and you got into hyperbaric medicine from emergency medicine. Is that correct?
Helen Gelly, MD:
Yes. Well, I think emergency medicine physicians are uniquely well suited to hyperbarics and wound care because we're not afraid of procedures. And we're also well-trained to observe patients and pick up on subtle physical abnormalities because a lot of times our patients in the ER can't tell us so we have to make clinical observations to find out what we need to do. So it really dovetails very well into wound care.
Jayesh Shah, MD:
When I started my wound care career, I had no idea about reimbursement. I just thought I'm trying to help my patients and I want to do everything possible to get them healed, but I had no idea because this is really not taught. So tell me what does it mean by CPT codes?
Helen Gelly, MD:
So CPT code is the procedure code. It is the E&M code like 99205 or in hyperbarics 99183. What you have to know is what CPT codes reflect the work that you're doing, what defines that CPT code and what documentation is required for that particular code. So for example, a debridement code, 1104X, whichever level it is and those parameters need to be included within your clinical note.
Jayesh Shah, MD:
So how does then ICD-10 codes come into play? Like you said CPD code is mainly the work value like for debridement or hyperbaric oxygen therapy
Helen Gelly, MD:
Or the work that you're doing, whether it's an evaluation and management code, an initial consultation, a debridement, a negative pressure wound therapy application, whatever you're doing, it's procedural and physician work is CPT codes. Oh,
Jayesh Shah, MD:
Got it. Got it. So that's how they get paid based on what they're billing for CPD codes. But then what is this ICD-10 diagnosis coding? What is that?
Helen Gelly, MD:
ICD-10 is the actual diagnosis codes. ICD-10 came into effect in 2015 and you really need to be familiar with the code set for the problems that you are treating and you need to be coding as specifically as possible, but you also need to be aware of the limitations that ICD-10 coverage is mandated by the different insurance carriers. So some insurance carriers will give you a wider range of ICD-10 codes from which to pick. Other ones are perhaps more limited. So sometimes when you see your patient, you have to ask that dreaded question, "What's your insurance?" Because different insurance companies will cover different ICD-10 codes for the same problem. There's a little bit of give as to how you code them, but you absolutely need to know what the diagnosis code is that will get whatever you're planning on doing to the patient covered. So if you're planning on doing a negative pressure wound therapy or you're planning on putting on a compression wrap, you need to know that there has to be, for example, an edema code that you have documented so that you can get paid for putting on the compression.
Jayesh Shah, MD:
Let's go back because this is kind of a very basic but very important topic. So suppose if I do hyperbaric oxygen therapy in my clinic, like suppose if you do that, what will you put as a CPT code and what will you put it as ICD-10 codes? Well,
Helen Gelly, MD:
The CPT code would be for the physician supervision 99183 and for the facility code is G0277. And it depends on your site of service, whether you bill it or the hospital bills it, et cetera. The ICD-10 would be required depending on what the indication is and you would have to look at the medical policy of the insurance plan that the patient has. So for example, if you have radiation cystitis and you have bleeding, some people would just code that as hematuria, which wouldn't get covered, but if you coded it for radiation cystitis, it would get covered. So you have to pick the code that is specifically listed within the medical policy of the insurance carrier that your patient has.
Jayesh Shah, MD:
Now, so for diabetic foot ulcer though, there are so many codes about diabetes, but you need to be very specific, right? Suppose if I'm treating diabetic foot ulcer with hyperbarics, how will I do ICD-10 coding for that?
Helen Gelly, MD:
Well, it depends on the level of the diabetic ulcer. If it's a Wagner three, you can code it diabetes with ulcer and then osteomyelitis or diabetes with ulcer and then an ulcer code that is also to the level of where the depth of it is down to bone or not to bone, whether there was an abscess or not an abscess. So you have to look and read the codes. There are probably 25 or 30 options from each column in terms of what you're going to pick. But in that instance, it's a dual code. You have to pick the diabetes code and you have to pick the code that has either osteomyelitis or the ulcer.
Jayesh Shah, MD:
So now I know a lot of us who are in wound care and hyperbarics, they are not familiar with the coverage criteria or medical necessity, a documentation requirement. Where do they find that and how important is that?
Helen Gelly, MD:
Well, all those fall within the same framework. You have to first look into the insurance plan that the patient has, look at their medical policy and see what their requirements are for them to define medical necessity or what is covered and what isn't or what needs to be documented and what doesn't. But you really need to tell the story of what has been done, what has and hasn't worked and why if you can identify the reason. If you can figure out what was missed, then you need to decide what the plan is going forward. So as we all know, plenty of very smart people have already seen these patients. So it's our job to dig deeper and to find out what's not been considered. In some instances, it's a zebra, but in many instances it's obvious that they should have gotten, for example, vascular screening, however, somehow it got missed.
And so you need to look at the medical policies of every single insurance plan because they're not all uniform and then look to see what needs to be documented. Even if you are not in control of that particular aspect of medical care, for example, hemoglobin A1C, you need to document what it was and then refer them to their endocrine physician or their primary care physician for management, but you need to look at it. You need to look at parameters for nutritional assessment, protein and albumin, for example, and document it. So what they want is listed in their medical policies. You just need to read them to make sure that you're covering all the bases when you do your dictation.
Jayesh Shah, MD:
And this is for hyperbaric oxygen therapy.
Helen Gelly, MD:
Oh, it's all for wound care as well.
Jayesh Shah, MD:
For wound care as well. Okay.
Helen Gelly, MD:
Absolutely. It's the same thing as necessary for wound care. For example, in some of the LCD that was retired, and I know that we'll talk about LCDs later, they basically said that you had to have adequate compression and it needed to be more than 20 millimeters of mercury. So a tubigrip didn't work. So they're telling you what you have to do or what you have to document and that's uniform throughout wound care, all aspects of wound care as well as hyperbaric medicine.
Jayesh Shah, MD:
Where will they find all this information?
Helen Gelly, MD:
It's online.
Jayesh Shah, MD:
Where online? Where can they go?
Helen Gelly, MD:
Well, you have to just search for Blue Cross Blue Shield Anthem medical policy on wound care or CMS wound care policy or which if there's a national coverage decision policy or if it's local specific to every single intermediary, which I guess we'll discuss a little bit further along the line, but these are almost all uniformly available online.
Jayesh Shah, MD:
What is this prior authorization? Because a lot of times when you're treating patients, they will say, "My secretary says, Oh, you can't do this because we don't have prior auth. What's that?
Helen Gelly, MD:
Well, prior authorization is a process in which a physician or a provider requests a review by the insurance company and then they review whether or not the patient has the coverage appropriate, the policy has appropriate coverage for what you're requesting because every policy has different coverage. So the same, if you have Blue Cross Blue Shield and the patient is employed by Coca-Cola, they may have slightly different coverage than somebody who's the local gardener who may have the same Blue Cross Blue Shield, but the policy covers different things. So you fill out a form, it's usually online and you submit it to the insurance company. Traditional Medicare does not have a prior authorization process. Medicare Advantage, almost all of them do, as well as all the commercial plans. The thing to remember is prior authorization is not a guarantee of payment. It just tells you that this procedure or this product or this treatment is covered.
It does not say that you have met medical necessity.
Jayesh Shah, MD:
What does it mean by global periods?
Helen Gelly, MD:
Well, global periods are usually assigned to surgical procedures and it's either a 10-day global or a 90-day global. Almost all of the ... So the surgeon does the appendectomy and then for 90 days after that, all of the visits are covered under the initial payment. I would say that most all of the codes that we use in wound care have a zero global period.
Jayesh Shah, MD:
That's awesome. So even if someone does surgery and they send to wound care, you're able to see them?
Helen Gelly, MD:
Yes. We're a specialist.
Jayesh Shah, MD:
Okay, got it. And how about denials? A lot of times physicians or providers do debridements or do total contact cast or negative pressure therapy and then they get denial. What is that?
Helen Gelly, MD:
Well, denials are really a business plan for the insurance companies. You do the procedure that you think is appropriate for the patient and some of them have routine denials of up to 15%. And so this is a business plan for them. If they deny, they know that only 10% of those denials are going to get appealed. And so by denying it, they're not having to pay it out and they know that most people won't appeal. However, if you do appeal, the overturn rate is significantly higher than 50 to 60%. So it's worth trying to appeal the denial if you have the documentation to support the payment.
Jayesh Shah, MD:
Wow. A lot of people may say, okay, they denied and I'm just going to let the money go. But you think you say you should fight for it, right?
Helen Gelly, MD:
Well, doesn't keep the lights on if you don't get paid.
Jayesh Shah, MD:
Well, there's so much to talk about on business side of wound care learning about things that you kind of briefly mentioned it in the last conversation that we had. You mentioned about LCD, you mentioned about MAC, but they're rarely explained clearly. And really the physician who is just coming out of training or provider coming out of the training, they really don't know. Can you break down what they are and why they have such a direct impact on what we do?
Helen Gelly, MD:
So MACs or Medicare administrative contractors are the administrators of traditional Medicare plans. In the United States, there are seven and you really need to find out what MAC covers your state, but they're basically insurance companies that are supposed to follow the Medicare or CMS guidelines, but they're in fact owned by commercial insurance plans. For example, Neridian is owned by Blue Cross Blue Shield of North Dakota. Palmetto and GCS are owned by Blue Cross Blue Shield of South Carolina. Guidewell Mutual Holding Corp owns Novotas, First Coast, and Blue Cross Blue Shield of Florida. So these are very integrated systems between commercial plans, traditional Medicare MACs, and then many of these are also in the Medicare Advantage arena. Now, national coverage determinations or NCDs are policies that are developed by CMS on a national level. Local coverage determinations are providing guidance, but for every single MAC can have a different local coverage decision on the same topic.
So they may have different requirements, they may have different coverage to a certain extent and you have to find out whether or not there is a local coverage determination policy on wound care, on hyperbarics, on whatever compression dressings that you're going to put on lymphedema care, for example. And these are available online. So if you know that it's Novitas, you can go to the Novitas website, you go into the LCD, NCD tab, and then you type in what you want to get to and then it pulls up the policy and then you can read the policy and they're quite extensive and they'll tell you all the requirements for documentation, what they'll cover and then they have something called an article and that article is more focused towards billing and documentation. So they're there, you just have to be aware that you have to find them.
If however, there is no local coverage decision or there's no national coverage decision, then your MAC is going to revert to reasonable and necessary, whether the procedure is safe and effective, whether or not it has FDA approval and it's not experimental, et cetera. If you have a Medicare Advantage patient and there is no NCD or LCD, they revert to the commercial plan. So that's why you need to be aware of all the commercial plans because let's say for example, in the instance of skin substitutes or CTPs or CAMPS, whatever you want to call them, there is no national coverage decision policy, there is no local coverage decision policy. So all the Medicare Advantage plans revert to their commercial medical policy and that may be very limited. So you have to know what the policy is so that you can pick the appropriate product and also make sure you have the appropriate documentation.
Jayesh Shah, MD:
Wow, that's just so much information for a doctor or a provider to know. That's really helpful context because many clinicians experience the consequences of these policies before they fully understand how they work.
Helen Gelly, MD:
Well, and you have to review them on a regular basis because they change. And so my recommendation, our practice, we look at least every six months at the major carriers in our area to make sure that we're being compliant.
Jayesh Shah, MD:
Helen, what are the most common documentation or coding mistakes you see from newer wound care clinicians that lead to denials or lost revenue or even audits?
Helen Gelly, MD:
Well, there's usually a lack of specificity as to the duration of the wound or ulcer, what the etiology is and what prior treatments have been provided. So you have to build the story that this has been a wound that has not responded to conventional or standard care and that they're seeing you as a specialist to provide advanced therapeutics, right? The documentation should include photo documentation with a ruler and a date on it. I know that a lot of people are using computer-based programs to do wound measurements, but if there's a little green dot or whatever, the auditors are saying that because the size of the wound can only be verified if you have something that has a standard measure, they're asking for that in the photo. So again, free and post any kind of procedure to show that something has been done and that the other thing that they want is a defined plan for the treatment of whatever problem you're addressing that can be tracked over time.
So step one is edema control, step two is infection control, step three is debridement. And then as you go along, you're addressing what you've done and how it's responded and what the next step is. So the better and more comprehensive your electronic medical record is, the better your chances are getting paid and not be made to return money. If you get enough audits, you get put on double secret probation where they're doing a hundred percent prepayment review so you're not going to get paid unless every medical record is sent and we don't want people going to jail. So if you do something, if you document it accurately, you have a defense for what you've billed. If you don't have any documentation, then you're really opening up yourself to some pretty severe consequences because if Medicare is not paying you on a regular basis because you're on prepayment review, you may be six months behind in the revenue cycle.
Jayesh Shah, MD:
Yeah. Yeah. I think thanks for all the knowledge because we don't want any wound care person to be in orange. We don't want them in jail for sure. But tell me what's one thing clinicians can do tomorrow that will immediately strengthen their documentation? Well,
Helen Gelly, MD:
I think that the medical record really needs to reflect the severity of the wound and the ulcer and the complexity of the patient. So for example, in a diabetic foot ulcer, 20% of those go to amputation. So a diabetic foot ulcer is limb threatening and that needs to be documented in the chart. If they are being seen by podiatry and then referred to the wound center and they say it's a Wagner two and then you see them and it probes to bone and you think it's a Wagner three, you need to change the diagnosis from two to three and then you need to explain why. So even if you started seeing the patient with a Wagner two and then it goes to a Wagner three, you need to change the coding because all the things that you're going to do for the Wagner three ulcer would not be substantiated if it was a Wagner two.
So you have to make sure that the coding is accurate so that all your interventions are deemed appropriate and medically necessary. So don't be lazy and just allow the electronic medical record to pre-populate over and over again a missed code or a misdiagnosis because those are the things that are going to get you into trouble if there's ever an audit.
Jayesh Shah, MD:
Oh, and that's so commonly find in the audits that because of the EHR, the prepopulated codes and no one takes an effort to make it correct and sometimes they get into trouble. But the question is, does PROPE-2 bone alone satisfy to be Wagner grade three or they need to do more to support that in the documentation?
Helen Gelly, MD:
Well, it depends on what part of the country you are. Probably you need some imaging in most places, you would need some kind of imaging or laboratory values, inflammatory markers, potentially bone biopsy, bone culture. It depends where the infection is and how appropriate it is for the patient to get that particular intervention, but at least imaging I think would be appropriate.
Jayesh Shah, MD:
So you'll need some supportive documentation. Thank you. So as we start wrapping up this episode, we love to hear your wound to the wise. At WoundCon, we use that phrase to highlight a practical takeaway we hope clinicians truly remember. So from today's discussion, what is one business or reimbursement pool you believe every wound care clinician should take too heart early in their career?
Helen Gelly, MD:
Much like the scouts, you have to be prepared, right? So always be prepared, pay attention to the details of documentation because truly that's a life and career saver. It's worth the extra few minutes to make sure that everything has been done appropriately.
Jayesh Shah, MD:
Absolutely. Great advice. That's a great takeaway, especially because confidence in this area doesn't happen overnight. It's built by understanding the systems around clinical care little by little. A lot of times a lot of providers learn by mistakes and it's better to not make mistakes or not make too many mistakes in getting to jail. So you want to know about this business of medicine before you start seeing patients. Thank you, Dr.Gelly, it's so much fun having you on the podcast and joining us today and helping make this concepts more approachable and practical for clinician. And thank you to all listeners for tuning in. In our next episode, we'll continue this conversation by exploring how clinicians balance excellent patient care with the business realities of modern wound management. Until then, be sure to explore the educational resources available at woundsource.com and accredited virtual education opportunities available through WoundCon.
You can find this and future episodes on woundcon.com, SoundCloud, Apple Podcast, and Spotify. So be sure to follow us on your favorite platform. We look forward to continue to help you listen today and apply tomorrow.