1. Schaum, Kathleen D. MS

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Surprise! Surprise! When I was writing the January 2014 column, entitled 2014 Procedure Code Changes, I never dreamed that I would be writing about more procedure code changes in this month's column. However, the Centers for Medicare & Medicaid Services (CMS) proved that they can rapidly create new procedure codes for use by facilities.


In last month's column, we discussed the revised definition for CPT(R)* code 15777 "Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (list separately, in addition to code for primary procedure)." We also mentioned that the application of skin substitute graft CPT codes (15271-15278) is still relevant for the topical application of cellular and/or tissue-based products for wounds (CTPs) (old term "skin substitute"). This is still true for qualified healthcare professionals (QHPs) who apply CTPs in any site of service. This may also still be true for hospital-based outpatient wound care departments (HOPDs) and ambulatory surgical centers (ASCs) that bill to non-Medicare payers. This is now partially true for HOPDs and ASCs who submit bills to Medicare fee-for-service plans. The following text details what transpired.


On Thanksgiving Eve, when most wound care professionals were traveling to be with family and friends or were preparing a holiday feast, CMS released the 2014 Medicare Hospital Outpatient Prospective Payment System (OPPS) and ASC payment system Final Rule: And just that quick, HOPDs and ASCs had new procedure codes to use when they bill for the application of some CTPs in 2014.


The CMS decided to package the payment for the CTPs into the payment for the work to apply the products. Because of the wide variation in average sales price of the CTPs and the claims data for the CTPs, CMS found that it was nearly impossible to select a single dollar value, which represents all the CTPs, to package into the OPPS and ASC procedure payments. Therefore, CMS decided to separate the CTPs into 2 groups: "low cost" CTPs and "high cost" CTPs. Table 1 shows the CTPs assigned to the low-cost group and Table 2 illustrates the CTPs assigned to the high-cost group.

Table 1 - Click to enlarge in new windowTable 1. "Low-Cost" CTPs Packaged by Medicare in HOPDs and ASCs in 2014
Table 2 - Click to enlarge in new windowTable 2. "High-Cost" CTPs Packaged by Medicare in HOPDs and ASCs in 2014

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The Final Rule directs HOPDs and ASCs to use new HCPCS codes to represent the application of the low-cost products. Those codes are C5271-C5278. On January 1, 2014, HOPDs and ASCs should have added the C5271-C5278 codes to their charge sheets, electronic medical records, and Charge Description Masters (CDMs). The Final Rule also directs HOPDs and ASCs to continue using the CPT codes 15271-15278 to represent the application of the high-cost products and the products with pass-through codes. Table 3 depicts the CTPs with pass-through codes. See the HCPCS and CPT procedure code descriptions in Table 4 for the application of low-cost products and the application of high-cost products. Important tip: It is imperative that HOPDs and ASCs continue to report the "Q" codes and appropriate charges, for the products, on their Medicare claims. Those charges will be used to set the HOPD and ASC packaged application rates in future years. If HOPDs and ASCs cease billing and charging for the Q codes, the packaged payment rates will certainly decrease in the future. In addition, non-Medicare payers may continue to pay separately for the product and the procedure.

Table 3 - Click to enlarge in new windowTable 3. CTPs with Pass-Through Codes in HOPDs and ASCs Effective January 1, 2014
Table 4 - Click to enlarge in new windowTable 4. Medicare Procedure Codes for HOPDs and ASCs To Report for the Application of "Low-Cost" and "High-Cost" CTPs

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The CMS is very clear that the separation of low-cost and high-cost products into packaged procedure codes was effective on January 1, 2014. However, HOPDs and ASCs must check with the non-Medicare payers who insure their patients to determine if they intend to continue using the 15271-15278 codes for the application of all CTPs, or if they intend to use the new C5271-C5278 codes for the application of low-cost CTPs and the 15271-15278 codes for the application of high-cost CTPs. HOPDs and ASCs can accomplish this task in several ways:


* Assign someone in your HOPD and/or ASC to proactively contact the top 10 to 20 non-Medicare payers of your wound care patients.


* Ask every non-Medicare payer when you verify each patient's insurance benefits prior to application of CTPs.



You should share this information with all stakeholders who are in your revenue cycle management (eg, coders, billers, CDM director) because they can often set up your billing software to handle payer-specific procedure codes for the same procedure.


You should also remember that QHPs who apply the CTPs in HOPDs and ASCs will continue to use 15271-15278 for the application of all CTPs. The concept of low-cost and high-cost products does not apply to QHPs.


Final note: If you take the time to read the 2014 Final Rule, you will learn that CMS has not yet accepted the term "Cellular and/or Tissue-Based Products for Wounds (CTPs)," which was carefully created by the Alliance for Wound Care Stakeholders. Wound care scientists and professionals must continue to educate CMS, the Medicare Administrative Contractors, the American Medical Association, and other major stakeholders that the term "skin substitute" does not appropriately describe the products that have been assigned Q codes by CMS. Therefore, this author will continue to use the term "Cellular and/or Tissue-Based Products for Wounds (CTPs)" in this column.


In the next Payment Strategies column, we will discuss some additional new HCPCS codes and the Medicare payment changes for the CTPs and many other services and products provided by wound care professionals in HOPDs and ASCs.