PBDs Should Select and Report Use of CTPs Carefully

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.

Medical directors, physicians, and other qualified healthcare professionals (QHPs) who work in hospital-owned outpatient wound/ulcer management provider-based departments (PBDs) continuously review innovative technology that will benefit their patients with chronic non-healing ulcers. Therefore, they get excited when sales representatives introduce them to new cellular- and/or tissue-based products (CTPs) for skin wounds and inform them that the Centers for Medicare & Medicaid Services (CMS) assigned HCPCS “Q” or “A2XXX” codes to the new CTPs.

In addition, program directors, coders, and billers who work in PBDs often acquire coding misinformation from well-meaning colleagues who share “what they code,” rather than “what they should code.” This is particularly prevalent with the coding for CTPs and for the application of CTPs.

Because coding misinformation is common, this consultant often receives calls from PBD stakeholders who report large volumes of denied CTP claims. The calls typically begin by the stakeholder saying, “We are never going to use [a particular brand of CTP] again because all of our claims were rejected,” or “We lose money every time the physicians/QHPs apply a CTP in our PBD.”

Because I have consulted on similar situations multiple times during the last few years, I decided to share my latest consultation with readers. Hopefully, this consultation will provide facts that will prevent PBDs from encountering the same Medicare payment problems.

Scenario

The chief financial officer (CFO) of a large multi-hospital system contracted with me to help him identify why their Medicare Administrative Contractor (MAC) denied 85% of the 2022 CTP claims, which were submitted by the 5 PBDs in the system. Because the MAC paid 95% of their CTP claims in previous years, the CFO was concerned about the 2022 revenue loss. He posed two questions to me: 1) “Why were the 2022 CTP claims denied?” and 2) “Should the CFO disallow the use of CTPs by the PBDs?

Facts to Consider

• The four Current Procedural Terminology (CPT^®1) codes (15271, 15272, 15275, and 15277) and the four Health Care Procedure Coding System (HCPCS) codes (C5271, C5272, C5275, and C5277) describe the application of “a skin substitute graft.” This means that sheet CTPs are grafted and anchored using the physician’s/qualified healthcare professional’s choice of fixation. The application codes should not be reported for application of other forms of CTPs (e.g., gel, powder, ointment, foam, liquid) or for injected skin substitutes. Therefore, if the CTP is not a sheet product, then the PBDs cannot report the application codes, and CMS cannot assign the CTP to the high-cost or low-cost skin substitute groups.
• The PBDs should separately report the appropriate product and application codes on the claim.

Consultation

First, I requested a complete list of CTPs that were applied in the 5 PBDs in 2021 and 2022. Even though the 2022 denied claims were the reason for the consultation, I wanted to see if the PBDs purchased the same brands of CTPs in both years, particularly because the MAC paid 95% of the 2021 CTP claims. That request and review proved to be especially important.

In 2021, the PBDs only purchased CTPs in the sheet form. In 2022, the physicians/QHPs began ordering new powdered and gel CTPs, in addition to the sheet CTPs. When I asked the physicians/QHPs why they began ordering the new CTP forms, they said “they were easier to apply and did not require fixation.” They also stated that the sales representatives assured them that CMS assigned HCPCS codes to the new CTPs.

Second, I requested to see ten deidentified claims, from each of the 5 PBDs, for CTPs that their MAC denied each month of 2022. I wanted to see if the claims were appropriately coded. This request and review also provided valuable information.

During the first 6 months of 2022, the PBDs’ claims reported the HCPCS code for the CTP that was ordered and applied by the physician/QHP, as well as the high-cost application codes. In the last 6 months of 2022, all 5 PBDs only reported the high-cost application codes: the claims did not include the HCPCS codes for the CTPs that were applied. When I asked the PBDs’ program directors why they stopped reporting the HCPCS codes on the claims, they said a well-known coder told them they should not report the HCPCS codes on the claims because payment for the CTPs is packaged into payment for the application.

Third, I used my research findings to develop an in-service education session for the CFO, the physicians/QHPs, the program directors, the coders, and the billers. The following are the main points that I included in their education.

If Coverage Criteria Are Met, MACs Will Pay for Sheet CTPs Assigned to the High-Cost Payment Group

• During the first half of 2022, the PBDs correctly reported the HCPCS code for the sheet CTPs and the high-cost application code on the same claim. I shared with the stakeholders the CMS table that identifies which CTPs that Medicare assigned to the high-cost and low-cost payment groups. They saw that CMS assigned all the sheet products, which they purchased, to the high-cost payment group. Their MAC paid the claims for the application of the sheet CTPs. Therefore, I encouraged the team to continue this correct coding in 2023.
• During the second half of 2022, the PBDs incorrectly reported only the high-cost application code on the claim; they did not report the HCPCS code of the sheet CTP. Their MAC did not pay for these claims because the HCPCS code for the sheet CTPs was missing from the claim. I encouraged the team to resume reporting the HCPCS code for the sheet CTPs on the same claim as the high-cost application codes.

Even If Coverage Criteria Are Met, MACs Will Not Pay for CTPs That Are Not in Sheet Form

• During the first half of the year, the PBDs correctly reported the HCPCS code for the powdered and gel CTPs, and incorrectly reported the high-cost application code on the same claim. However, just because a product has a HCPCS code, does not mean it is covered and paid.

         Once again, I shared with the stakeholders the CMS table that identifies which CTPs that CMS assigned to the high-cost and low-cost payment groups. They clearly saw that CMS did not assign the powdered and gel CTPs to any payment group. Therefore, their MAC could not, and did not, pay for these claims.
 
         In fact, the physicians/QHPs should have informed the patients that Medicare does not cover CTPs that are powders or gels. If the patients elect one of those CTPs to be applied by the physicians/QHPs, the patients should be informed that they will assume responsibility to pay the PBD for the product and the application and to pay the physician/QHP for the application.

• During the second half of 2022, the claims for the powdered and gel CTPs were even more incorrect. The PBDs did not report the HCPCS code for the product and only reported the high-cost application code on the claim. I reminded the stakeholders that CMS did not assign the powdered and gel CTPs to any payment group. Therefore, their MAC did not pay for these claims.

         As described above, the patients could elect to have a powdered or gel CTP applied, but they will assume responsibility to pay the PBD and the physician/QHP.

If Coverage Criteria Are Met, If Sheet CTPs Are Purchased, and If the Product Code and Application Code Are Correctly Reported, PBDs Should Be Allowed to Purchase Them

At the end of the in-service, I recommended that the CFO allow the 5 PBDs to continue using CTPs as long as they were thoughtfully selected, appropriately applied and fixated, and correctly coded.

Summary

To bill for the application of a CTP, the physician/QHP must fixate the CTP and must report the type of fixation in the patient’s medical record.

PBDs should verify if CMS assigned the CTPs, that the physicians/QHPs wish to use, to the high-cost or low-cost payment group. Then they should use the appropriate application codes for each CTP.

When physicians/QHPs apply CTPs in PBDs, the PBDs should always report two codes on the claim: 1) the HCPCS code for the product, and 2) the appropriate high-cost or low-cost application code.

Physicians/QHPs should only order and apply CTPs, that are not sheets, when they inform patients 1) that Medicare does not cover and pay for that form of CTP, and 2) that the patients will be responsible for paying the PBD for the product and the application, and for paying the physician/QHP for the application.
 
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.

Click here to download a PDF of this article.

Reference
1. CPT^® is a registered trademark of the American Medical Association. All Rights Reserved.