Reimbursement Readiness

In Episode 32 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum welcomes Amiee Coriano to explain how Electronic Remittance Advice (ERA) and Explanation of Benefits (EOB) data can reveal hidden revenue opportunities within your organization.Amiee breaks down the differences between ERAs and EOBs, then shows how billing teams can move beyond simply posting payments and start using these documents as financial intelligence. She explains how underpayments, denial patterns, contractual adjustments, remark codes, patient responsibility, and payer variances can uncover revenue that might otherwise be missed.The episode also explores practical ways to turn ERA and EOB data into action, including denial trend analysis, monthly reporting dashboards, payer contract comparisons, and the use of practice management or revenue cycle technology to identify unusual payment patterns. The key takeaway: every denial, adjustment, and underpayment tells a story—and understanding that story can help protect and recover revenue.Download Handout

In Episode 31 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum and Donna Cartwright continue the Wound and Ulcer Management Audit Readiness Series with Part 4, focusing on the importance of accurately documenting and reporting the correct Place of Service (POS).Donna explains how Place of Service codes identify where care was provided and why they can directly affect payment, denials, and audit exposure. She reviews several of the most common settings in wound and ulcer management, including physician offices, homes, assisted living facilities, hospital outpatient departments, ambulatory surgery centers, skilled nursing facilities, nursing facilities, and independent clinics. Special attention is given to the often-confusing distinction between POS 31 and POS 32, including how Medicare Part A and Part B status, consolidated billing, and CTP payment responsibilities can change depending on the patient’s stay.The episode also explores how Place of Service affects facility versus non-facility payment rates and why clinicians and billing teams must understand how each facility is registered with Medicare. By verifying the care setting before submitting the claim, wound care professionals can reduce denials, avoid overpayments or underpayments, and strengthen their readiness for both pre- and post-payment audits.Click to Download Handout

In Episode 30 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum welcomes Amiee Coriano to clarify an important distinction that can directly affect reimbursement: the difference between an Additional Documentation Request (ADR) and a Medicare denial.Amiee explains that an ADR is a request for more information, while a denial is a payment decision that requires corrective action. She walks through why ADRs are issued, what documentation Medicare contractors may be looking for, and how revenue cycle teams should respond before a request escalates into a denial. The episode also reviews common denial reasons, appropriate next steps such as rebilling, recoding, redetermination, or appeal, and best practices for tracking recurring issues.The discussion closes with a broader look at the financial impact of poor ADR and denial management, including delayed payments, increased administrative costs, lost revenue, and higher audit risk. By recognizing the difference early, responding appropriately, and using trends to improve documentation and coding processes, wound care organizations can strengthen compliance and protect their revenue cycle.Downloads:Medicare ADR ResponseEpisode Survey:Click Here

In Episode 29 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum and Donna Cartwright continue the Wound and Ulcer Management Audit Readiness Series with Part 3, focusing on two of the most important components of the medical record: the plan of care and progress notes.Donna explains how a comprehensive plan of care supports medical necessity, communicates treatment goals, tracks changes over time, and helps auditors understand why specific services, procedures, and products were selected. She also reviews what should be documented for each wound or ulcer, including measurable goals, expected outcomes, barriers to healing, prior treatments, patient instructions, coordination with other clinicians, and changes made when treatment is not progressing as expected.The episode also takes a closer look at progress notes and how they should tell the ongoing story of each wound—from prior treatment results and clinical decision-making to measurements, wound appearance, signs of infection, overall assessment, and next steps. By keeping documentation consistent and showing how the patient is progressing from one encounter to the next, wound care teams can strengthen medical necessity and better prepare for payer audits.DownloadsPlan of Care and Progress Notes ChecklistEpisode SurveyClick Here

Episode SurveyIn Episode 28 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum turns the focus to a fundamental but often overlooked part of reimbursement: understanding the full descriptions behind CPT and HCPCS codes. As denials and audit failures continue to expose gaps between documentation and reported codes, Kathleen explains why knowing the code number alone is not enough.Using examples from debridement, CTP applications, autologous blood-derived products, negative pressure wound therapy, and wound care products, Kathleen breaks down the three key components of a code description: the service or product being identified, the clarifying information that defines its use, and the unit or measurement tied to reporting. She also highlights how seemingly similar codes can differ significantly based on anatomy, wound type, treatment method, or unit of measure.The episode reinforces one central principle: the documentation in the medical record must align with the code description reported on the claim. Kathleen also encourages clinicians, coders, and billers to review the codes they use most often, update their systems and workflows as needed, and use the provided checklist to strengthen coding accuracy and reduce denials, repayments, and compliance risk.Handout:Checklist for Selecting Wound and Ulcer Management Codes Based on Their Code Descriptions

In Episode 27 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum and Donna Cartwright continue the Wound and Ulcer Management Audit Readiness Series with Part 2, focusing on wound and ulcer measurements and descriptions. Accurate documentation in these areas is essential not only for clinical continuity, but also for demonstrating medical necessity and supporting reimbursement during pre- and post-payment audits.Donna explains what auditors expect to see in the medical record, including consistent wound measurements, clear documentation of changes over time, complete descriptions of each wound’s origin and condition, and the results of previous treatments. She also reviews common documentation problems that can lead to denials or repayments, such as mismatched wound descriptions, missing post-procedure measurements, incomplete tissue percentages, unsupported treatment continuation, and incorrect CTP sizing or wastage reporting.The episode closes with practical guidance for conducting an internal self-audit and improving documentation workflows. Donna also provides a checklist that wound care teams can use to evaluate whether their wound measurements and descriptions clearly tell the story of each wound and support the medical necessity of the care provided.Episode 27 Evaluation Link: CLICK HEREDOWNLOADS:Checklist for Measurements and Wound Description

In Episode 26 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum addresses a common coding practice that can create serious repayment risk during audits: reporting an evaluation and management service with Modifier 25 when a minor wound or ulcer management procedure is performed during the same encounter.Kathleen reviews the 2026 NCCI Manual guidelines and explains why the decision to perform a minor procedure—and the related pre-, intra-, and post-procedure work—is generally included in the procedure payment. She clarifies that an E&M service may only be reported separately when the medical record supports a significant, separately identifiable service that goes beyond the work required to evaluate and perform the procedure, regardless of whether the patient is new or established.The episode also examines the proposed 2027 Medicare Physician Fee Schedule change that could reduce payment for one of the two services when a legitimate E&M visit and global procedure occur on the same day. Kathleen separates that proposal from misinformation circulating online and encourages practices that frequently use Modifier 25 to conduct a self-audit before unsupported billing leads to denials or recoupments.DOWNLOADS:Appropriate Use Of Modifer -25 with Minor Procedures2026-ncci-medicare-policy-manual-all-chapters.pdf

In Episode 25 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum and Donna Cartwright launch a new Wound and Ulcer Management Audit Readiness series focused on the documentation auditors expect to find in the medical record. This first installment examines the history and physical, showing how incomplete, inconsistent, or overly broad documentation can undermine medical necessity and place reimbursement at risk.Donna explains how to make each record self-contained, clearly identify the origin and location of every wound, document prior treatments and their effectiveness, and connect underlying conditions to the patient’s ability to heal. She also addresses common audit concerns such as inconsistent wound counts, contradictory physical-exam findings, missing results from previous therapies, and cloned or outdated information pulled forward by the electronic health record.Listeners will also receive a practical checklist they can use to self-audit their own history and physical documentation. The goal is simple: help the auditor understand the patient’s condition, the progression of each wound, and why the selected treatment was medically necessary.Download History & Physical Checklist

The 2027 OPPS and MPFS proposed rules are here. Sheet CTPs hold steady, non-sheet CTPs move to a size-based payment model, ABDP rates rise in OPPS only, and SCSA gets a whole new coding structure. Comments due August 31 (OPPS) and September 14 (MPFS). Watch for full update and view links below.2027 Proposed Rule for Medicare Physician Fee Schedule (MPFS): https://www.cms.gov/medicare/payment/fee-schedules/physician/federal-regulation-notices/cms-1848-p2027 Medicare Proposed Rule for Outpatient Prospective Payment System (OPPS): https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/regulations-notices/cms-1850-p

Coding correctly is about more than selecting the right CPT code. Understanding National Correct Coding Initiative (NCCI) edits is essential to avoiding denied claims, preventing compliance issues, and ensuring accurate reimbursement.In this episode of Reimbursement Readiness, Kathleen Schaum welcomes reimbursement expert Yesenia Banks to explain the fundamentals of NCCI edits in practical, easy-to-understand terms. Together, they discuss why NCCI edits exist, how they impact claims, the three major categories of edits, when modifiers may be appropriate, and where to find the official CMS resources your team should be using.Whether you're a clinician, coder, biller, or revenue cycle professional, this episode provides a practical foundation for understanding one of Medicare's most important coding safeguards—and how applying it correctly can improve reimbursement accuracy while reducing audit risk.