Questions About the Application of CTPs Continue

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For the past 25 years, this author/consultant has been educating manufacturers and professionals about the coding, Medicare coverage, and Medicare payment for the application of cellular and/or tissue-based products (CTPs) for skin wounds. You are probably thinking, “Why have you kept educating about the same topic for such a long time?” The answer is simple: the codes, Medicare coverage, and Medicare payment systems keep changing. For several years, surgical, selective, and non-selective debridement reimbursement was the most-requested education topic, but the application of CTPs now tops this author/consultant’s list of requested education and frequently asked questions.

In last month’s Business Briefs column, I answered a frequently asked question: “Which new CTPs will be assigned HCPCS ‘A’ and ‘Q’ codes?” Also, in last month’s Consultation Corner column, I described a real-life consultation that emphasized why hospital owned outpatient wound/ulcer management provider-based departments (PBDs) should carefully select and report the CTPs they use.

Then, a few weeks ago at the 2023 Symposium on Advanced Wound Care (SAWC) Spring, I was honored to present “2023 Coding and Payment for Cellular and/or Tissue-Based Products for Skin Wounds (CTPs).” Because wound/ulcer management professionals and manufacturers are still confused about the appropriate codes for CTPs and their application, because the Medicare payment systems for the products and the procedure are in a state of flux, and because the Medicare Administrative Contractors (MACs) are continuing to refine their Local Coverage Determinations (LCDs) and Local Coding Articles (LCAs), I methodically explained:

• How physician/qualified healthcare professional (QHP) offices and PBDs should purchase the right size product for the wound/ulcer, should reduce the size of the product (if available) purchased as the wound/ulcer size decreases, and should report the correct CTP codes on their Medicare claim forms
• How physician/QHP offices should apply correct modifiers to the product code when they apply the entire sheet and when they waste a portion of the sheet
• How the application codes, which are surgical procedures, should be reported based on the anatomic location of the wound/ulcer, and the surface area of the wound/ulcer
• How the physician/QHP should report the application codes 15271–15278, regardless of the cost of the CTP
• How the PBDs should report the application codes 1) 15271–15278 when the physician/QHP applies a CTP assigned to the high-cost payment package, and 2) C5271–C5278 when the physician/QHP applies a CTP assigned to the low-cost payment package
• How physician/QHP offices are paid for 1) CTPs assigned HCPCS “A2XXX” codes, 2) CTPs with published average sales prices (ASPs), and 3) CTPs that do not have published ASPs
• How PBDs are paid less to apply CTPs to wounds/ulcers that are 100 sq cm or more on the feet than the same size wound/ulcer on the legs, and how PBDs can begin to fix this by assigning a correct charge for the application codes 15273, 15277, C5273, and C5277.
• How physicians, QHPs, and PBDs should pay attention to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits when they are performing another procedure at the same encounter as the CTP application
• How physicians, QHPs, and PBDs should verify the patient’s benefits and determine if a particular CTP and its application procedure is covered by the patient’s payer in that place of service and for that wound/ulcer type, and
• How thorough documentation is the “key” to receiving payment, and keeping your payment after an audit

Because the presentation contained more than 50 slides and was very thorough, I did not expect many questions. To my surprise, many attendees lined up at the microphones to ask questions. Because so many attendees had questions, and because another presentation was scheduled for that room, I offered to continue answering questions outside of the meeting room. To my surprise, a large group of attendees followed me out of the meeting room and asked questions for an additional 1½ hours.

The themes for most of the questions were similar and unexpected. In fact, I have not addressed these questions in previous Business Briefs and Consultation Corner articles and did not address them during my 2023 SAWC Spring presentation. Therefore, I am now sharing the unexpected questions in this article.

Q:       I am a physician and I provide wound/ulcer management in a skilled nursing facility (SNF). Can I purchase a CTP, take it to the SNF, and bill Medicare Part B for the product and the application?

A:        The answer is: It depends! To determine the answer, the physician should follow several steps:

1.         Verify if the product code and/or the application codes are considered part of the SNF Consolidated Billing (CB). NOTE: Currently the product codes are part of the CB, but the application codes are not. However, that does not guarantee that the product and procedure codes are covered: continue with the following steps.

2.         Verify if the Medicare Administrative Contractor (MAC), who processes the physician’s claims, covers the application (which is a surgical procedure) when it is performed in a SNF and when it is performed on that patient’s type of wound/ulcer.

3.         Verify if the MAC covers the brand of CTP that the physician wishes to apply.

4.         Ask the SNF’s administration if the patient is in a Medicare Part A–covered SNF stay.
            a.    If the answer is yes, the SNF must purchase the CTP because it is included in the SNF’s CB. If the patient also has Medicare Part B coverage, the physician may charge the MAC for the procedure—if it is covered in a SNF and—if it is covered for that patient’s type of wound/ulcer.
            b.    If the answer is no, and the patient has Medicare Part B coverage, the physician may purchase the CTP (if it is covered), may apply it (if the surgical procedure is covered in a SNF, and if it is covered for that type of wound/ulcer), and may charge the MAC for the product and the procedure.

Q:       What place of service should the physician report on the Medicare claim when a CTP is applied to a patient who is in a Medicare Part A covered SNF stay?

A:        The correct place of service code is: 31 Skilled Nursing Facility.       

Q:       What place of service should the physician report on the Medicare claim when a CTP is applied to a patient in a nursing facility (not in a Medicare Part A–covered stay)?

A:        The correct place of service code is: 32 Nursing Facility.

Q:       I am a podiatrist who spends 100% of my time managing wounds/ulcers for patients in skilled nursing facilities and nursing facilities. On my Medicare claim, I report the place of service code 11 Office because I do not have an office. Is that OK?

A:        No, that is not OK. Medicare requires podiatrists, physicians, and QHPs to report the appropriate place of service code for the place where the patient received the service.

Q:       I am a nurse practitioner who works for a mobile wound/ulcer management service. All my work is performed in skilled nursing facilities and nursing facilities. Because I do not have an office, I was told that I should report the place of service code 11 Office. Is that correct?

A:        No, that direction is not correct. You are required to report the appropriate place of service code for the place where the patient received the service.

Q:       I am a wound/ulcer management physician who sees patients in my office, in PBDs, in SNFs, and in their homes. My MAC does not normally cover surgical procedures, such as the application of CTPs, when performed in SNFs and in patients’ homes. Therefore, I normally schedule those patients to receive their CTPs applied in my office.

However, during the COVID-19 public health emergency (PHE), SNF patients were not prohibited to leave the SNF, and many other patients were fearful to leave their homes and/or to enter medical offices. Luckily, the PHE waivers allowed physicians to provide procedures (that could safely be performed) in SNFs and in patient homes. In addition, if I normally managed that patient in my office, I was permitted to report the place of service 11 Office if I also included the CR Catastrophe/disaster related modifier on the claim.

Now that the PHE has ended, may I continue to perform the application of CTPs in SNFs and in patients’ homes, add the CR modifier to the procedure code, and be paid based on the Medicare allowable rate for the office?

A:        Ever since the end of the COVID PHE was announced, CMS and the MACs have been releasing guidance documents and conducting webinars about waivers that ended on May 11, 2023, and about waivers that will be extended past May 11. To the best of this author’s knowledge, the waiver that allowed the physician to perform a surgical procedure, which was usually not covered in a SNF or in a patient’s home, and the waiver to pay out-of-office services and procedures at the in-office Medicare allowable rate ended on May 11, 2023. In addition, the May 4, 2023 MLN Connects Newsletter clearly stated that the CR modifier should only be reported during a PHE when a formal waiver is in place.¹ Therefore, professionals should plan to discontinue adding the CR modifier to claims with dates of service on/after May 12, 2023. That direction also makes this author believe that this scenario is no longer allowed. However, this author’s belief does not matter. What matters is your MAC’s coverage and payment policy. Therefore, if this situation pertains to you, please present the scenario to the MAC that processes your claims.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.

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Reference
1. Centers for Medicare and Medicaid Services. MLN Connects Newsletter. May 4, 2023. Last accessed May 7, 2023.