Authors

  1. Schaum, Kathleen D. MS

Article Content

For many years, wound/ulcer management professionals have dreamed of technologies that could assist them in making accurate diagnoses and medical decisions. In the past 2 years, those dreams have begun to come true as various imaging studies have cleared the US Food and Drug Administration; received codes; and are starting to be covered and paid by Medicare, commercial payers, and private payers.

 

However, confusion reigns about the distinct types of codes that are assigned to these imaging studies, and how the codes are paid to (1) physicians and other qualified healthcare professionals (QHPs) in their offices and in facilities and (2) hospital-owned outpatient wound/ulcer management provider-based departments (PBDs). Therefore, let us review the 2022 coding and Medicare payment for each of the imaging studies currently available. Because each of the imaging codes is currently only affiliated with one product, the Table identifies the brand names of the products affiliated with the various codes. However, other similar brands may be manufactured and may qualify to use the same codes in the future.

 

SPATIAL FREQUENCY DOMAIN IMAGING OF SKIN

The code for spatial frequency domain imaging became effective in January 2019:

 

0061 U: Transcutaneous measurement of five biomarkers (tissue oxygenation [StO2], oxyhemoglobin [ctHbO2], deoxyhemoglobin [ctHbR], papillary and reticular dermal hemoglobin concentrations [ctHb1 and ctHb2]), using spatial frequency domain imaging (SFDI) and multi-spectral analysis

 

Although this code is paid under the Medicare Clinical Laboratory Fee Schedule,1 it is billable by physician/QHP offices and PBDs because 0061 U is excluded from the Clinical Laboratory Improvement Amendments edits.

 

CURRENT PROCEDURAL TERMINOLOGY (CPT)* CATEGORY III CODES

In the September 2021 Payment Strategies column, this author answered questions from wound/ulcer management professionals who did not understand the importance of reporting CPT Category III codes. Following are the main points to remember:

 

* CPT Category III codes are temporarily assigned (for 5 years) to emerging technology, services, and procedures. They allow collection of specific data vital for physicians/QHPs, payers, researchers, and health policy experts to determine the clinical efficacy, widespread usage, and outcomes of the various emerging devices, services, and procedures.

 

* At the end of 5 years, the CPT Category III codes may be assigned a CPT Category I code, or they may be archived and unavailable for use.

 

* Physicians, QHPs, and PBDs should report the CPT Category III codes every time they use the emerging technologies. That utilization is extremely influential in the American Medical Association's decision whether to convert the CPT Category III codes to CPT Category I codes at the end of the 5 years.

 

* The Medicare Physician Fee Schedule2 does not assign relative value units to CPT Category III codes. Therefore, Medicare payment rates and coverage are at the discretion of each Medicare Administrative Contractor (MAC). Physicians/QHPs who find value in these new imaging studies should take time to introduce each innovative technology to the MAC and other payers that processes her/his Medicare claims, to educate them about the medical necessity for their wound/ulcer patients, and to request adequate payment and coverage in her/his jurisdiction.

 

* The Medicare Outpatient Prospective Payment System (OPPS),3 used to pay PBDs, typically assigns CPT Category III codes to Ambulatory Payment Classification groups and assigns OPPS status indicators to the codes. The OPPS status indicators, assigned to the CPT Category III codes, clearly inform PBDs how Medicare will pay for the codes. The Medicare payment for codes with "T" status indicators will be reduced if the procedure is performed at the same encounter with another procedure assigned a "T" status indicator. Medicare will not pay separately for codes with "N" status indicators because payment for that code is packaged into payment for the primary procedure. Medicare will not pay for codes with the "Q1" status indicator if the code is billed on the same claim as a code assigned a status indicator of "S", "T", "V", or "X".

 

* Once a Category III code is released, physicians, QHPs, and PBDs should report it rather than unlisted CPT codes that may have been reported on prior claims.

 

 

Now let us review the three imaging studies that are currently assigned CPT Category III codes. Please note that two of the codes can be reported "per session for each anatomic site," another code can be reported "per extremity," and the last three codes can be reported "per each flap or wound" (Table).

  
Table 2022 - Click to enlarge in new windowTable

NONCONTACT REAL-TIME FLUORESCENCE IMAGING

The CPT Category III codes for this technology were effective July 2020 and will sunset in January 2026 unless physicians/QHPs use the imaging, report the codes, and take time to educate the MACs and other payers about the usefulness of the technology. The main description of these codes is:

 

Noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; 0598 T: First anatomic site (eg, lower extremity)

 

+0599 T: Each additional anatomic site (eg, upper extremity)

 

HYPERSPECTRAL IMAGING

The CPT Category III code for this technology was effective January 2021 and will sunset January 2026 unless physicians/QHPs use the imaging, report the code, and take the time to educate the MACs and other payers about the usefulness of the technology.

 

0631 T: Transcutaneous visible light hyperspectral imaging measurement of oxyhemoglobin, deoxyhemoglobin, and tissue oxygenation, with interpretation and report, per extremity

 

NONCONTACT NEAR-INFRARED SPECTROSCOPY

The three CPT Category III codes for this technology were effective July 2021 and will sunset January 2026 unless physicians/QHPs use the spectroscopy, report the codes, and take the time to educate the MACs and other payers about the usefulness of the technology. The main description of these codes is:

 

Noncontact near-infrared spectroscopy studies of flap or wound (for example, the measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation (StO2));

 

The first code should be used by physicians/QHPs when they own the equipment, take the image, and interpret and report the findings:

 

0640 T: Image acquisition, interpretation and report, each flap or wound

 

The second code should be used by PBDs who own the equipment and take the image. This code should not be reported in conjunction with 0640 T or 0642 T:

 

0641 T: Image acquisition only, each flap or wound

 

The third code should be used by physicians/QHPs who only interpret and report the findings. This code should not be reported in conjunction with 0640 T or 0641 T:

 

0642 T: Interpretation and report only, each flap or wound

 

SUMMARY

Professionals should take the time to (1) learn how these technologies can improve their outcomes, (2) identify the correct code(s) for each technology, (3) add the correct code(s) to their charging and billing systems, (4) report the codes on their claims, and (5) advocate to their MAC and other payers. As you know, payers often resist covering and paying for new CPT Category III codes until physicians/QHPs embrace the technology and take the time to educate the payers.

 

REFERENCES

 

1. Centers for Medicare & Medicaid Services. 2022 Medicare Clinical Laboratory Fee Schedule Files. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSche. Last accessed February 2, 2022. [Context Link]

 

2. Centers for Medicare & Medicaid Services. 2022 Medicare Physician Fee Schedule (updated January 2022). https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-rel. Last accessed February 2, 2022. [Context Link]

 

3. Centers for Medicare & Medicaid Services. 2022 OPPS and ASC Fee Schedule Addendum B. https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppsadd. Last accessed February 2, 2022. [Context Link]

 

* CPT is a registered trademark of the American Medical Association. [Context Link]