Mid-Year Reimbursement Updates for CTPs (Skin Substitutes) and PRP

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

Coding, payment, and coverage changes never stop! As we enter the second half of the year, let us take a look at some important reimbursement updates that pertain to several advanced technologies used by many wound/ulcer management physicians, other qualified healthcare professionals (QHPs), and hospital-owned outpatient wound/ulcer management provider-based departments (PBDs).

This article should be a reminder that wound/ulcer management professionals must continue to be vigilant about reimbursement changes throughout the year.

Cellular- and/or Tissue-Based Products (CTPs) for Skin Wounds

In the April 2022 Business Briefs, we reviewed the recent HCPCS coding assignments that have created an alphabet soup of CTP codes. However, we did not review the following coding and payment changes for CTPs that were announced in the April 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS):¹

• Nine new CTPs were assigned HCPCS codes that became effective on April 1, 2022:

       A2011      Supra SDRM, per square centimeter
       A2012      Suprathel, per square centimeter
       A2013      InnovaMatrix FS, per square centimeter
       A4100      Skin substitute, FDA cleared as a device, not otherwise specified
       Q4224      Human health factor 10 amniotic patch (hhf10-p), per square centimeter
       Q4225      AmnioBand, per square centimeter
       Q4256      MLG-complete, per square centimeter
       Q4257      Relese, per square centimeter
       Q4258      Enverse, per square centimeter

Per the usual OPPS policy for new CTPs, all nine codes were assigned to the low-cost group. Therefore, when reporting use of the new CTPs on claims, PBDs should use the low-cost application codes (C5271–C5278), plus the appropriate HCPCS code for the CTPs.

• One CTP was reassigned from the low-cost group to the high-cost group effective on April 1, 2022:

       Q4199      Cygnus Matrix, per square centimeter

Provider-based departments that are using these products should remember to stop reporting their application with the codes for low-cost products (C5271–C5278) and should begin reporting their application with the codes for high-cost products (15271–15278).

Now let us discuss the July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)², the Centers for Medicare and Medicaid Services (CMS) released some additional CTP coding and payment changes:

• Three new CTPs were assigned HCPCS codes that became effective on July 1, 2022:

       Q4259      Celera™ Patch, per square centimeter
       Q4260      Signature APatch, per square centimeter
       Q4261      Tag, per square centimeter
 
Per the usual OPPS policy for all new CTPs, all three products were assigned to the low-cost group. Therefore, when reporting use of the new CTPs on claims, PBDs should use the low-cost application codes (C5271–C5278), plus the appropriate HCPCS code for the CTPs.

• Four CTPs were reassigned from the low-cost group to the high-cost group effective on July 1, 2022:

       A2001      InnovaMatrix AC, per square centimeter
       A2002      Mirragen Advanced Wound Matrix, per square centimeter
       Q4229      Cogenex Amniotic Membrane, per square centimeter
       Q4258      Enverse, per square centimeter
 
Provider-based departments that are using these products should remember to stop reporting their application with the codes for low-cost products (C5271–C5278) and should begin reporting their application with the codes for high-cost products (15271–15278).
 

• One product was also reassigned from the low-cost group to the high-cost group, but its effective date is retroactive to April 1, 2022. The manufacturer correctly submitted their pricing prior to April 1, 2022, but a CMS error caused it not to be reassigned with the April 1, 2022 updates.

       A2001      InnovaMatrix AC, per square centimeter
 
Similar to the products above, which were reassigned from the low-cost group to the high-cost group, PBDs that are using InnovaMatrix AC should remember to stop reporting the application with the codes for low-cost products (C5271–C5278) and should begin reporting the application with the codes for high-cost products (15271–15278).
 

• One product, XCelliStem, is defined as a powdered skin substitute. As you know, CMS only assigns CTPs, that are available in sheets and that can be fixated with the physician’s/QHP’s choice of fixation during the surgical procedure, to the OPPS low- and high-cost groups. However, when CMS assigned the HCPCS code A2004 to XCelliStem, they incorrectly described it as “per square centimeter” and assigned it to the low-cost group. Once CMS recognized the mistake, they correctly described A2004 as XCelliStem, 1 mg, and removed it from the low-cost group. This change is retroactive to January 1, 2022. Therefore, PBDs should not report HCPCS code A2004 with C5271–C5278 on their claims.

Like all previous OPPS updates, the July 2022 Update of the Hospital Outpatient Prospective Payment System ends with a caution about coverage: “The fact that a drug, device, procedure, or service is assigned a HCPCS code and a payment rate under the OPPS doesn’t imply coverage by the Medicare Program, but indicates only how the product, procedure, or service may be paid if covered by Medicare. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage.” Therefore, before applying a CTP, physicians, QHPs, and PBDs should verify, with their MAC or any other payer, if a particular CTP is covered for that patient’s diagnosis.

Autologous Platelet-Rich Plasma (PRP)

In the December 2021 Business Briefs, we reviewed the new NCD 270.3 Blood derived products for chronic, non-healing wounds.³ At that time, the HCPCS code that applied to the newly covered service was G0460 Autologous plate-rich plasmas for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration, and dressings, per treatment. Shortly after New Year’s 2022, CMS began rescinding and issuing new transmittals about coverage of PRP. In case you missed them, following is an overview of the transmittals that affect providers. This is a perfect example of how coding and coverage are ever-evolving.

• January 12, 2022, Transmittal 11171 revised the description of HCPCS code G0460 and created a new code G0465:⁴

       G0460 Autologous platelet rich plasma for non-diabetic chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration, and dressings, per treatment
 
       G0465 Autologous platelet rich plasma for diabetic chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration, and dressings, per treatment
 
If you are using this technology for diabetic chronic wounds/ulcer, you should update your coding and charging systems from G0460 to G0465.
 

• January 20, 2022, Transmittal 11171 was replaced with Transmittal 11214, which:⁵

         o   Revised the implementation date to February 14, 2022, for the Medicare Administrative Contractors (MACs)
         o   Provided further claims processing direction, pertaining to G0460 and G0465, to the MACs
         o   Included a list of acceptable diagnosis codes for G0465
 

• May 4, 2022, Transmittal 11400⁶ expanded the list of covered diagnosis codes for G0465
• June 17, 2022, Transmittal 11460⁷ added still more covered diagnosis codes for G0465.

Because the list of covered diagnosis codes for G0465 has been expanded, now is an excellent time to educate your clinical team, your coders, and your billers. The MACs have been directed to implement the additional diagnosis codes by July 19, 2022. The new complete list of diagnosis codes, as well as other coding information, can be found at: https://3cpatch.com/reimbursement/
 
Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

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References
 
1. Centers for Medicare and Medicaid Services. April 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS). Last accessed July 6, 2022.
 
2. Centers for Medicare and Medicaid Services. July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS). Last accessed July 6, 2022.
 
3. Centers for Medicare and Medicaid Services. NCD 270.3[1] Blood Derived Products for Chronic, Non-Healing Wounds. Last accessed July 10, 2022.
 
4. Centers for Medicare and Medicaid Services. Transmittal 11711. Last accessed July 7, 2022.
 
5. Centers for Medicare and Medicaid Services. Transmittal 11214. Last accessed July 7, 2022.
 
6. Centers for Medicare and Medicaid Services. Transmittal 11400. Last accessed July 8, 2022.
 
7. Centers for Medicare and Medicaid Services. Transmittal 11460. Last accessed July 8, 2022.