Addressing FAQs Related to New & Misunderstood Codes

  Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure information accuracy. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  This author has received hundreds of emails and phone calls from qualified healthcare professionals (QHPs) who provide wound care within hospital-based outpatient departments (HOPDs) and other settings since the start of the New Year. All parties ask similar questions about new 2015 codes and about misunderstood codes. As part of this issue of Today’s Wound Clinic (TWC) taking a specific focus on wound care reimbursement, this article offers a review of the most frequently asked questions (FAQs) our dedicated readers have about new codes and misunderstood codes through question-and-answer format.

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New Code FAQs for HBOT

  Q: Is it true that Healthcare Common Procedure Coding System (HCPCS) code C1300 Hyperbaric oxygen under pressure, full-body chamber, per 30-minute interval has been deleted?
  A: Yes, the Centers for Medicare & Medicaid Services (CMS) deleted HCPCS code C1300 as of Dec. 31, replacing it with HCPCS code G0277 Hyperbaric oxygen under pressure, full-body chamber, per 30-minute interval, which became effective Jan. 1, 2015.

  Q: Which sites of care can use the new code G0277?
  A: Unlike code C1300, which was only used in HOPDs and ambulatory surgery centers (ASCs), code G0277 can be used in the following sites of care when hyperbaric oxygen therapy (HBOT) is provided on the premises:
    • HOPDs
    • ASCs
    • Offices of QHPs.

  Q: When QHPs supervise HBOT in an HOPD, should they also report code G0277 on the claim form?
  A: No. QHPs who supervise HBOT in HOPDs should continue to use Current Procedural Terminology (CPT®) code 99183 Physician or other qualified healthcare professional attendance and supervision of hyperbaric oxygen therapy, per session.

  Q: Is it true that QHPs who purchase HBOT chambers and provide the service in their office can code for both CPT code 99183 and HCPCS code G0277?
  A: Yes, effective Jan. 1, 2015, QHPs who have HBOT chambers in their offices may now code for 1) their HBOT attendance and supervision (CPT code 99183), and 2) each 30-minute interval of HBOT (HCPCS code G0277) provided to the patient.

FAQ for CTPs

  Q: Is it true that CMS assigned HCPCS codes to additional cellular and/or tissue-based products (CTPs) [outdated term “skin substitutes”] effective Jan. 1, 2015?
  A: Yes, CMS continues to assign new HCPCS codes for CTPs that meet the new coding qualifications. See the January/February 2015 Business Briefs for a list of products assigned new HCPCS codes. Reminder: The assignment of an HCPCS code does not guarantee Medicare payment: The product must be covered in order to receive Medicare payment.

FAQ for NPWT

  Q: I work in an HOPD and have begun using disposable negative pressure wound therapy (NPWT). I am concerned because the hospital charge description master (CDM) director insists we should use the same CPT codes (97605/97606) for both traditional NPWT and disposable NPWT. When I attended the Wound Clinic Business seminar, I thought we learned that if a specific code exists for a service/procedure/product that it should be used. Did I misunderstand?
  A: You understood perfectly! Let’s take a look at the correct CPT and HCPCS codes for 2014, and the revised and new CPT codes for 2015. In 2014 the correct CPT codes for traditional NPWT were:
    97605 NPWT (eg, vacuum-assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area ≤ to 50 sq cm.
    97606 NPWT (eg, vacuum-assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area > 50 sq cm.

  In 2014, the correct HCPCS codes for disposable NPWT were:
    G0456 NPWT, (eg, vacuum-assisted drainage collection) using a mechanically powered device, not durable medical equipment (DME), including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area ≤ 50 sq cm.
    G0457 NPWT, (eg, vacuum-assisted drainage collection) using a mechanically powered device, not DME, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area > 50 sq cm.

  Effective Jan. 1, 2015, the CPT codes for traditional NPWT remain the same, but the descriptions are slightly revised. Please note the revisions are in bold:
    97605 NPWT (eg, vacuum-assisted drainage collection), utilizing DME, including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area ≤ 50 sq cm.
    97606 NPWT (eg, vacuum-assisted drainage collection), utilizing DME, including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area > 50 sq cm.

  Effective Jan.1, 2015, HCPCS codes G0456 and G0457 were deleted and replaced by two new CPT codes for disposable NPWT. HOPDs should list the two new codes in their CDM and use them when these disposable products are purchased by the HOPD and applied in the HOPD. Following are the two new CPT codes. Please note the bold code descriptions that vary from the descriptions of the deleted HCPCS codes.

    97607 NPWT, (eg, vacuum-assisted drainage collection, utilizing disposable, nondurable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area ≤ 50 sq cm.

    97608 NPWT, (eg, vacuum-assisted drainage collection, utilizing disposable, nondurable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area > 50 sq cm.

  Q: When I reviewed the list of active HCPCS codes, I noticed A9272 Wound suction, disposable, includes dressing, all accessories and components, any type, each. I wanted to report that code on our HOPD Medicare claims for disposable NPWT systems that we purchase. The hospital coders and billers told me the code was not covered by Medicare. Is this true? If so, why did CMS create the code?
  A: Your hospital coders and billers are correct that HCPCS code A9272 is not covered by Medicare. When HOPDs purchase disposable NPWT systems for use on Medicare patients, HOPDs should report the new CPT codes 97607/97608.

  Now, let’s answer your second question. CMS has different departments that create HCPCS codes, set payment rates, and determine coverage. The regulations that are used to establish HCPCS codes are very different than the coverage regulations. For example, many HCPCS codes exist for pediatric products because other payers need those codes to process claims for those products. These pediatric product codes are not covered by Medicare because Medicare is not usually the payer for children. Similarly, when disposable NPWT systems are used in the home, some private payers may cover the product under their DME benefit or other benefit category. In those cases, private payers may need HCPCS code A9272 to process claims for the disposable NPWT systems. When conducting insurance benefit verifications with private payers, be sure to verify if they pay for HCPCS code A9272 and/or CPT codes 97607/97608.

FAQ for Modifiers

  Q: Is it true that modifier -59 was deleted and that new modifiers were created to replace modifier -59?
  A: Modifier -59 Distinct procedural service was not deleted. However, new modifiers (called –X [EPSU] modifiers) were created to provide greater specificity in situations where modifier -59 was previously reported and may be utilized in lieu of modifier -59 whenever possible.

  Note: Providers may continue to use the -59 modifier in any instance in which it was correctly used prior to Jan. 1, 2015. The initial CMS notice that established the –X [EPSU] modifiers was designed to inform system developers that healthcare systems need to accommodate the new modifiers.

  In addition, the National Correct Coding Initiative (NCCI) is not yet requiring use of the new –X [EPSU] modifiers. Nevertheless, wound care professionals may begin using the new –X [EPSU] modifiers for Medicare claims with dates of service on or after Jan. 1, 2015, but it is incorrect to include both Modifier -59 and an –X [EPSU] modifier on the same claim line. This author recommends using the new –X [EPSU] modifiers now — before being forced to use them.

  Reminder: The CPT manual instructions state that Modifier -59 should not be used when a more descriptive modifier is available. See the new –X [EPSU] modifiers and descriptions in Table 1.

  Q: Modifier -59 has been in use for a long time and we are very accustomed to using it. Do you have any recommendations about steps we should take to implement the new –X [EPSU] modifiers?
  A: Sure. HOPDs and QHPS should follow the –X [EPSU] modifier implementation steps in Table 2.

  Q: I heard that off-campus HOPDs and QHPs (who perform services, procedures, and surgeries at off-campus provider-based outpatient departments) must use modifiers on all of their claims? Is this true. If so, why?
  A: Yes, and let’s answer the “why” first. Because the Medicare Payment Advisory Commission (MedPAC) questioned the appropriateness of the increased payments made to physician offices that become HOPDs, CMS is collecting data about the frequency and types of services furnished in provider-based departments in off-campus locations.

  Now let’s discuss the “who,” “what,” and “when.”
    • Effective Jan. 1, 2016, off-campus HOPDs will be required to report modifier –PO Services, procedures and/or surgeries furnished at off-campus provider-based outpatient departments on every claim submitted to Medicare. Off-campus HOPDs should take advantage of this advanced notice to adjust their claims-processing systems to append modifier –PO to their Medicare claims. Note: Use of the modifier –PO is voluntary during 2015. If the off-campus HOPD is ready to begin using modifier –PO on their Medicare claims in 2015, feel free to do so.

    • For QHPs who work in off-campus provider-based HOPDs, CMS is going to create two new place-of-service (POS) codes that must be used on Medicare claims. These codes will replace POS code 22 Hospital outpatient. One of the new POS codes will identify outpatient services furnished in on-campus, remote, or satellite locations of a hospital. The other new POS code will identify services furnished in an off-campus, provider-based hospital setting. Note: These two new POS codes are not yet available. Once the new POS codes are released, QHPs will be expected to use them immediately without a voluntary reporting period. We will discuss this when the new POS codes are released.

FAQs on Misunderstood Codes

  Evaluation & Management (E&M)
  Q: I am a QHP who works in an HOPD. I continue to have disagreements about E&M coding with my coders and the HOPD coders. Here is what I believe:

  1) The level of E&M coding that I report does not have to align with the level of clinic visit level coding that the HOPD reports.

  2) If I perform an E&M and order the HOPD to perform a procedure such as application of multilayer compression or enzymatic debridement, I should report the appropriate E&M code and the HOPD should report the appropriate procedure code.

  3) If I do not manage a separate identifiable new problem, I should not report an E&M on follow-up visits when I perform a procedure.

  4) If I perform a procedure for which there is a code, I should report the code even if the Medicare payment rate for the procedure is less than the Medicare payment rate for E&M.

  Please tell me if I am correct.

  A: Fabulous, you are correct!

  HBOT
  Q: I am a QHP who attends and supervises HBOT in the HOPD. I always submit 4 units of service on my claims, just like the HOPD does. However, I only get paid for 1 unit. Why?
  A: The answer can be found in the description of the two different codes that must be reported by the QHP and the HOPD. The description of the QHP’s code 99183 is “per session.” The description of the HOPD’s code C1300 (in 2014) and G0277 (in 2015) is “per 30-minute intervals.”

  Q: Several of the QHPs who attend and supervise HBOT in our HOPD are complaining that their claims are being denied. Will you please help them understand why?
  A: In some instances, QHPs were using the HCPCS code C1300, which only pertained to HOPDs (not to QHPs). In a few instances, the payer’s medical policy and/or the lack of hospital privileges did not cover the medical specialty of the provider who performed the service. In other instances, the QHPs were reporting 4 units of service for CPT code 99183 Physician or other qualified healthcare professional attendance and supervision of HBOT, per session. Either the QHP or the coders/billers did not understand that CPT code 99183 should be reported “per session,” not per 30-minute intervals.

  Q: Starting in 2015, when QHPs provide HBOT in their offices, which codes and how many units of service should the QHP report to Medicare? My office manager and I are already disagreeing on this issue.
  A: In 2015, QHP offices that provide HBOT should continue to report 1 unit of CPT code 99183 on their Medicare claim forms. In addition, they should report HCPCS code G0277, 1 unit per 30-minute interval.

  Example: Effective Jan. 1, 2015, if a QHP office provides 120 minutes of HBOT on the office premise, the Medicare claim may look like this:
    99183 1 unit
    G0277 4 units

  CTPs
  Q: The hospital coding department told our HOPD program director to remove the HCPCS codes for CTPs used in the HOPD from our charge sheet and from our CDM. When I asked why, the coders said it was “extra work to code for products that are packaged.” I thought CMS requires HOPDs to code both the CPT code for the application of the CTP and the HCPCS code for the product. Who is correct?
  A: Congratulations, you win the coding-knowledge prize! If the HCPCS code for the product does not appear on the same claim with the application code, CMS has created edits that will deny the packaged Medicare payment for the application of CTPs. Do not remove the product HCPCS codes from the HOPD charge sheets and CDM. Important: Be sure the CPT code for the application and the HCPCS code for the product appear on the same HOPD claim. Otherwise, the Medicare Administrative Contractor (MAC) will not pay the claim.

  Q: Our HOPD has been reporting on our charge sheets the total number of sq cm of CTPs purchased for each application. The coders have been changing the units to “1” because they said the number of units of the product had to match the number of units of the application code. Is that correct?
  A: No. The HOPD should always report the total number of sq cm of CTPs purchased for each application. The coders should then report the same number of sq cm on the claim form “units” field. The reason for this is simple: The descriptor for most CTPs is “per sq cm” while the descriptor for the application of the CTPs is either in 25 sq cm increments or in 100 sq cm increments.

  Q: When CMS created the new HCPCS codes (C5271-C5278) for the application of products they designated “low cost” CTPs, we added those HCPCS codes to our HOPD CDM. However, some claims for private payers were rejected when we used those HCPCS codes. How can we rectify this?
  A: Following are two tips that have worked for HOPDs throughout the country:

    Tip 1: Always verify insurance benefits before performing the procedure. While verifying benefits, ask the payer if the claims-processing system recognizes C5271-C5278 or if you should report 15271-15278 for the application of all CTPs. Note: At the beginning of 2014, very few private payers recognized C5271-C5278. As we enter 2015, many more private payers now recognize C5271-C5278.

  Tip 2: Meet with the hospital coding and billing departments. Decide which department will determine when C5271-C5278 should be reported on the claim.
    • Some HOPDs successfully use the application code information they receive during insurance benefit verification to help them enter the correct code into their charging system.
    • Other HOPDs enter 15271-15278 into their charging system for the application of both “high cost” and “low cost” CTPs. The coding or billing department then changes the codes to C5271-C5278 for traditional Medicare patients and for other payers who recognize the new codes.

  Q: QHPs who work in our HOPD are telling our program director that the HOPD coders are incorrectly coding for CTPs applied to wounds that are on the foot and that extend into the ankle. The QHPs contend that two base codes should be reported for the application of CTPs. Our coders say that we should only use one base code because the CTP is applied to one wound. Will you please help us with this dilemma?
  A: Hooray for the QHPs! They are correct. For coding purposes, the ankle is connected to the leg. Therefore, the QHP should measure the portion of the wound that is on the foot and report the application code(s) for the foot (either CPT codes 15275/15276, HCPCS codes C5275/C5276; or CPT codes 15277/15278, HCPCS codes C5277/C5278) and the portion of the wound that is on the ankle and report the application code(s) for the leg (either CPT codes 15271/15272, HCPCS codes C5271/C5272; or CPT codes 15273/15274, HCPCS codes C5273/C5274). Remind your HOPD coders and billers that these CPT and HCPCS codes are not per wound; they are based on anatomic location.

  ICD-10-CM Implementation
  Q: When do you think QHPs should begin to think about ICD-10 implementation?
  A: All medical professionals, most importantly QHPs, should have begun preparing to implement ICD-10 4-5 years ago. Not only do QHPs have processes to change and people to train, but QHPs must refine their documentation to capture the specificity that medical policies as well as ICD-10 requires.

  In the end, the true winners will be the patients, the medical providers, and the QHPs: Everyone will be able to prove the level of work that the patient required and the outcomes that were achieved. If any readers have not begun refining their documentation, this author highly recommends that you utilize the ICD-10-documentation tools and case studies that have appeared throughout 2014 and 2015 in TWC. Also, be sure to read through our May 2015 issue, which will be devoted to preparing for ICD-10 implementation.