Business Briefs: Application of Skin Substitute Graft Procedure Codes Are Changing Again – For Physicians and Facilities!

  Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. 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.

  The 2012 CPT® manual has been released. One of the biggest surprises in the manual pertains to the application of skin substitute grafts. If you have not ordered a 2012 CPT® manual, please do so immediately. If you received your copy of the 2012 CPT® manual, but have not read it, do yourself a BIG SERVICE and read the Skin Replacement Surgery subsection of the Integumentary System section.

  On November 1, 2011 the Centers for Medicare & Medicaid Services (CMS) published their 2012 Medicare payment rates for physicians and hospital-based outpatient wound care departments (HOPDs). If you have not updated your charging system to reflect the new skin substitute graft procedure codes and accompanying payment rates, you must do so before January 1, 2012. Remember, CMS no longer has a grace period for new ICD-9-CM, CPT®, or HCPCS codes. The 2012 ICD-9-CM codes became effective on October 1, 2011. The 2012 CPT® codes and HCPCS codes will become effective on January 1, 2012. Most importantly, the new Medicare payment rates will also go into effect on January 1, 2012.

2012 CPT® Code Changes for Skin Substitute Grafts

  The American Medical Association deleted 24 application of skin and dermal substitute CPT® codes that have been in existence since 2006. In addition, CMS deleted the two temporary HCPCS codes that they created for use by physicians on January 1, 2011. See Table I for a list of the deleted application of skin and dermal substitute CPT® and HCPCS codes and for some examples of brands that are affected by the code changes.

  Eight new skin substitute graft codes were created to replace the 24 deleted CPT® codes and 2 deleted HCPCS codes. See Table II for a list of the 8 new CPT® codes. Unlike the deleted codes that were distinguished by product category description, the 8 new skin substitute graft codes will be used for all types of skin substitute grafts. The 8 new codes have a two-tier structure, which is based first on the size of wound surface area, and second on the anatomic location of the wound. Please note that the wound surface area applies to the size of the recipient site, not to the size or amount of product used.

  For multiple wounds, providers should sum the wound surface area of all anatomic sites that are grouped together into the same code descriptor. For example, providers should sum the wound surface area of all wounds on the trunks and legs, but should not sum the wound surface area of the feet and legs. Also note that wrists are considered part of the arm, and ankles are considered part of the leg.

  When wound surface areas are smaller than 100 sq cm, select either CPT® code 15271 or 15275, based upon the anatomical location of the wound. CPT® code 15271 should be selected when the skin substitute graft is applied to the wound surface area of the trunk, arms, or legs that is 25 sq cm or less. CPT® code 15275 should be selected when the skin substitute graft is applied to the wound surface area of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits that is 25 sq cm or less. Use the appropriate new add-on CPT® codes, 15272 and 15276, for each additional 25 sq cm of wound surface area, or part thereof. Please note: If the wound surface area is 100 sq cm or more, do not use 15271-15272 and 15275-15276.

  Instead, when the wound surface area is greater than or equal to 100 sq cm, select either CPT® code 15273 or 15277, based upon the anatomical location of the wound. CPT® code 15273 should be selected when the skin substitute graft is applied to the wound surface area of the trunk, arms, or legs that is greater than or equal to 100 sq cm, or 1% of body area of infants and children under the age of 10. CPT® code 15277 should be selected when the skin substitute graft is applied to the wound surface area of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits that is greater than or equal to 100 sq cm, or 1% of body area of infants and children under the age of 10. Use the appropriate new add-on CPT® codes, 15274 and 15278, for each additional 100 sq cm of wound surface area, or part thereof; or each additional 1% of body area of infants and children or part thereof. Please note: If the wound surface area is less than 100 sq cm, do not use 15273-15274 and 15277-15278.

2012 Medicare Payment Rates for New Skin Substitute Graft Codes

  The 2012 Medicare Physician Fee Schedule (MPFS) Final Rule was released on November 1, 2011 and listed 1) the relative value units (RVUs) that are assigned to the new skin substitute graft codes when physicians perform the work in their offices and in facilities, and 2) the global surgical periods assigned to the new codes. The new reduced RVUs and CMS’s assignment of zero global surgical days to all of the new codes resulted in an overall decrease in physicians’ 2012 payment when they perform these procedures. Remember that global surgical periods only pertain to physicians. Global surgical periods are not applicable to HOPDs.

  The RVUs and national average Medicare payment rates for physicians are higher for wounds with larger surface areas than for wounds with smaller surface areas. (See Table III) Please note that the rates in Table III reflect the current law, which reduces the MPFS by 27.4%, when this column went to press in early November 2011. This drastic reduction may be softened before the payment rates actually take effect on January 1, 2012.

  The 2012 Medicare Outpatient Prospective Payment System (OPPS) Final Rule was also released on November 1, 2011. The RVUs that set the physicians’ fee schedule are not relevant to the OPPS payment system. Instead, CMS assigns the CPT® codes for the clinic visits and procedures performed in HOPDs to ambulatory payment classification (APC) groups based on the similarity of resources required.

  The new application of skin substitute codes for wound surface areas smaller than 100 sq cm are assigned to APC Group 0134 and their respective add-on codes are assigned to APC Group 0133. The new application of skin substitute codes for wound surface areas larger than 100 sq cm are assigned to APC Group 0135 and their respective add-on codes are assigned to APC Group 0134. Similar to the MPFS, the APC payment rates are higher for wound surface areas larger than 100 sq cm. When you review the 2012 vs 2011 APC payment rates for the HOPDs, you will find that the 2012 rates for wound surface areas less than 100 sq cm are slightly lower than last year, and the rates for wound surface areas greater than 100 sq cm are slightly higher than last year. See Table IV.

Medicare Coverage

  As we have discussed many times before in this column: the existence of a CPT®/HCPCS code and a payment rate does not guarantee that the payer will cover and actually pay for the service, procedure, or product. Everyone who is reading this article should pay close attention to the local coverage determination (LCD) written on this topic by the Medicare contractor that processes their claims. Now that the same CPT® codes are used to represent the work of applying all skin substitute grafts, the Medicare contractors will be forced to specify the brands that they wish to cover by their HCPCS “Q” or “C” codes. In addition, the Medicare contractors must remove the 24 deleted CPT® and 2 deleted HCPCS codes from their LCDs. In addition, the Medicare contractors must use the 8 new CPT® codes for application of skin substitute grafts in their LCDs.

  Any time the Medicare contractors revisit LCDs to make required coding changes, they may take the opportunity to make other LCD coverage changes. If the coverage changes restrict coverage in any way, the Medicare contractors are required to post the DRAFT LCD for public comment. All wound care professionals should monitor their Medicare contractor’s LCDs on a monthly basis. Print each revised LCD and its attachments and share the changes with each member of your wound care team. Pay attention to additional LCD guidance regarding medical necessity, utilization, frequency of application, documentation, coding, etc. Most importantly, all wound care professionals should take the opportunity to comment on any DRAFT LCDs during the public comment period.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net.

1. CPT is a registered trademark of the American Medical Association.