10 Preparation Steps for Charge Description Masters in 2015

  Information regarding coding, coverage, and payment is provided as a service to readers. Every effort has been made to ensure accuracy of all information. However, HMP Communications and the authors do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  As you prepare for this holiday season with family and friends, don’t forget to also prepare for the coding and Medicare payment system changes that will affect your wound care hospital-based outpatient department (HOPD) beginning Jan. 1. To assist with this preparation, let’s review the major charge description master (CDM) changes that HOPD program directors should make and schedule for implementation when the clock strikes midnight Jan. 1.

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2015 CDM Coding Changes

  Preparation Step 1: Twelve new Healthcare Common Procedure Coding System (HCPCS) codes have been awarded to 16 new cellular and/or tissue-based products for wounds (CTPs) [outdated term “skin substitutes”]. See Table 1. It is hard to believe that 61 CTPs are now assigned “Q” or “C” codes. As always, do not forget that the “existence of a code does not guarantee coverage and payment by Medicare.” HOPD program directors should always refer to any CTP-pertinent local coverage determination (LCD) that is released by the Medicare Administrative Contractor (MAC) that processes one’s claims (www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx). If you plan to incorporate one or more of the new products into your CTP formulary, and if the new product(s) are covered by your MAC, you should add the appropriate “Q” or “C” code(s) to the 2015 CDM.

  Preparation Step 2: The descriptions for negative pressure wound therapy (NPWT) Current Procedural Terminology (CPT) codes (97605 and 97606) have been revised. The descriptions now include the phrase “utilizing durable medical equipment (DME).” In addition, the temporary CPT codes (G0456 and G0457) for “mechanically powered” NPWT have been deleted. Two new codes (97607 and 97608) have been created to report NPWT “utilizing disposable, nondurable medical equipment.” Like 97605, the new code 97607 should be used for the treatment of wounds with a total wound surface area ≤ 50 sq cm. Similarly, like 97606, the new code 97608 should be used for the treatment of wounds with a total wound surface area > 50 sq cm. In addition, the dressing is included in the new codes (97607 and 97608) and should not be reported separately. Finally, the 2015 CPT manual clearly states that 97607/97608 should not be reported in conjunction with codes 97605/97606.

  If HOPDs use one or more of the disposable NPWT systems, the HOPD program director should delete G0456/G0457 and add 97607/97608 to the 2015 CDM. Program directors should also make a special effort to educate the coding staff about the existence of unique codes for the disposable NPWT systems. In 2014, when consulting with HOPDs and reviewing their CDMs, this author learned that many lost revenue when they used disposable NPWT because the coders reported 97605/97606 rather than the appropriate codes G0456/G0457. See Table 2.

  Preparation Step 3: HOPDs that provide hyperbaric oxygen therapy (HBOT) services should use the new code that the Centers for Medicare & Medicaid Services (CMS) created for reporting HBOT to Medicare. The new HBOT code is G0277 Hyperbaric oxygen, full-body chamber, 30 minutes. Because this code is unique to Medicare and because 99183 is still in the 2015 CPT manual, HOPDs should still use 99183 on their claims to private payers. Therefore, HOPDs should establish an internal system that reports G0277 on Medicare claims and 99183 on private payer claims. HOPD program directors should work closely with the CDM directors and the coding/billing director(s) to accomplish this very important step.

2015 CDM HOPD Charge Changes

  HOPD program directors should update their charges in the CDM when one or more of the following situations occur:
    1. new products, procedures, and/or services are added to the HOPD offerings;
    2. manufacturers adjust their sales prices to the HOPD;
    3. CMS adds, deletes, and/or revises HCPCS codes;
    4. the American Medical Association adds, deletes, and/or revises CPT codes; and/or
    5. the Medicare Outpatient Prospective Payment System (OPPS) Final Rule reflects Medicare national average payment rate changes.

  While the first two situations are beyond the scope of this article, let’s take a look at the preparation steps for situations 3-5.

  Preparation Step 4: HOPDs should carefully review the 2015 OPPS changes outlined in the OPPS Final Rule for CTPs and for their application. For 2015, all of the application of the “high cost” CTP codes (15271-15278) and all of the application of the “low cost” CTP codes (C5271-C5278) track to the same ambulatory payment classification (APC) groups as 2014. CMS increased the OPPS packaged payment allowable (2%-5%) for the application of both “high cost” and “low cost” CTPs.

  Speaking of “high cost” and “low cost” CTPs, CMS changed the methodology for determining which products are in each group. In 2014 the average sales price reported by the manufacturers was the main determinant of the high/low cost group assignment. Not so in 2015. HOPD claims submitted from 2013 are very important: The new methodology for determining which products are in the 2015 high cost and low cost group are based on the weighted average mean cost reported on 2013 HOPD claims. This new claims-based methodology reduced the threshold level to enter the high cost group from $32 per sq cm to $25 per sq cm. HOPD program directors should watch for the January 2015 OPPS quarterly updates to view the final list of products assigned to the high cost group and to the low cost group. In addition, HOPD program directors should review the January 2015 OPPS Addendum B to identify which CTPs’ pass-through status has ended and the CTPs that have pass-through status for 2015. CAUTION: Pass-through status does not guarantee Medicare coverage. The HOPD program director should review the LCD, if one exists, to determine if a particular CTP is covered.

  Similar to the 2012 HOPD claims data, the 2013 HOPD claims data (which CMS used to set 2015 OPPS rates) for the application of CTPs to wounds ≥ 100 sq cm (on the smaller anatomic locations such as the feet) still did not reflect higher costs/charges than to wounds ≤ 100 sq cm (on the same smaller anatomic locations). Therefore, the 2015 OPPS allowable rate for the application of CTPs to wounds ≥ 100 sq cm (on the smaller anatomic locations) is the same as for wounds ≤ 100 sq cm (on the smaller anatomic locations), even though the HOPDs must purchase a greater amount of CTPs for the larger wounds.

  Because claims from 2014 will determine the OPPS payment rates for 2016, it is too late to influence the 2016 OPPS payment rates. However, HOPDs can influence the 2017 OPPS payment rates by submitting charges on their 2015 claims that better represent their actual costs to purchase each unique brand of CTP, to purchase the amount of CTP needed to cover the wound surface area (especially for wounds on the smaller anatomic locations that are ≥ 100 sq cm), and to support the qualified healthcare professional (QHP) who performs the procedure. Updating HOPD charges in the CDM is the first step toward correcting 2017 packaged allowable rates for CTPs. As we have discussed many times before in Business Briefs, the HOPD program director should also audit all the claims processing steps to verify that the correct number of CTP units applied and the correct charge for the application of each unique brand of CTP are reflected on the submitted claims.

  Preparation Step 5: See Table 3 for a review of the 2015 OPPS changes for NPWT. Note that NPWT utilizing DME for wounds ≤ 50 sq cm (97605) has moved from APC Group 0013 to APC Group 0012 while NPWT utilizing DME for wounds > 50 sq cm (97606) remained in APC Group 0015. In addition, the new code (97607) assigned to the NPWT utilizing disposable, nondurable medical equipment for wounds ≤ 50 sq cm and the code (97608) for wounds > 50 sq cm are both assigned to APC Group 0015. This is a reduction from the APC group to which the deleted codes (G0456/G0457) were assigned in 2014.

  The APC group reduction discussed above is another example of HOPD claims data from 2013 causing the 2015 APC group assignment to drop. This author has spoken to many HOPD program directors who reported that they did not add G0456/G0457 to their CDMs: They just reported disposable NPWT with the DME negative pressure codes and charges. Other program directors reported that even though they added G0456/G0457 to their CDMs, they kept the same charges as 97605/97606: In those cases the HOPDs did not receive adequate reimbursement for the disposable products they purchased and the claims unfortunately provided to CMS incorrect data about the costs/charges associated with purchasing/applying disposable NPWT. If HOPDs use DME negative pressure and/or disposable NPWT, it is essential that the program director updates the CDM with the correct charges, as well as the correct codes, and sets the implementation date as Jan. 1.

  Preparation Step 6: HOPDs should carefully review the 2015 OPPS changes for surgical and medical debridement. In 2015 the surgical debridement codes (11042-11044) will remain in the same APC groups as 2014. The medical debridement code (97597), better known as the “selective debridement” code, also remains in the same APC group (0015) in 2015 as in 2014.

  The big 2015 OPPS debridement news is that the nonselective debridement code (97602) will be moved to the same APC group (0015) as selective debridement, as traditional NPWT for wounds > 50 sq cm, and as disposable NPWT for all sizes of wounds. The OPPS allowable for 97602 will increase from $83.73 to $146.08 on Jan. 1. NOTE: This year, when we discussed debridement at Wound Clinic Business seminars, this author was always surprised at the number of HOPDs that used enzymatic debridement, but did not list 97602 on their CDMs and did not report it on their claims. Therefore, it is paramount that program directors update their CDMs to reflect the correct debridement codes/charges effective Jan. 1.

  Preparation Step 7: Another piece of big 2015 OPPS news pertains to 97610 Low-frequency, noncontact, and non-thermal ultrasound. This code will be moved to APC Group 0015: In 2014 it was in APC Group 0013. That APC group move increases the 2015 OPPS allowable from $83.73 to $146.08. If the HOPD uses this technology, the program director should update the CDM to reflect the correct code/charge for 97610 effective Jan. 1.

  Preparation Step 8: The 2015 OPPS Final Rule provides some interesting payment directions regarding epidermal autografts and split-thickness skin grafts (STSGs). The APC group (0329) assigned to STSGs will remain the same in 2015. Likewise, the APC group (0328) assigned to epidermal autografts performed on smaller anatomic locations (such as feet) will remain the same in 2015. However, the 2015 APC group for epidermal autografts performed on larger anatomic locations (such as trunk, arms, and legs) moved from APC Group 0329 ($2260.46) to APC Group 0327 ($429.95). This is another example of the importance of HOPD claims because this APC group change was also based on claims data submitted in 2013.

  It is hard to understand why in 2013 HOPDs charged a significantly smaller amount for work performed on the same size wounds on trunk, arms, and legs than they charged for work performed on the same size wounds on smaller anatomic locations. If QHPs perform epidermal autografts and/or STSGs in HOPDs, the HOPD program director should examine the CDM codes and charges for these procedures and update them by Jan. 1.

  Preparation Step 9: HOPDs always have questions about Medicare payment for compression applied to venous stasis ulcers. In 2015, three of the most common compression codes moved to new APC groups:
    • 29445 for application of rigid leg cast moved from APC Group 0426 ($138.21) to APC Group 0058 ($223.20);
    • 29580 for application of paste boots moved from APC Group 0426 ($138.21) to APC Group 0059 ($127.82); and
    • 29581 for application of multilayer compression to lower leg moved from APC Group 0058 ($121.00) to APC 0059 ($127.82).

  If the HOPD uses one or more of these compression systems, the program director should review the CDM to ascertain if the correct compression codes and the appropriate charges are implemented on Jan. 1.

  Preparation Step 10: To the surprise of many, the 2015 Medicare Physician Fee Schedule Final Rule and the 2015 OPPS Final Rule created a new code (G0277 hyperbaric oxygen, full-body chamber, 30 minutes) for reporting HBOT to Medicare. CMS assigned G0277 to the same APC group (0659) that was assigned to the deleted code C1300.

  The 2015 national average OPPS allowable rate decreased slightly from $110.93 per 30 minutes to $109.24 per 30 minutes.

  HOPD program directors should carefully update their CDM with this new code for Medicare and should verify the 2015 charge is set appropriately for each 30-minute increment.

  SUMMARY: Preparation of the HOPD’s 2015 CDM is more important than preparing New Year’s celebrations. If HOPDs take time before 2014 ends to meticulously delete old codes/add new codes/update charges on the CDM you should be paid correctly by Medicare when 2015 begins.

  As a big bonus, correct 2015 HOPD claims data will positively influence 2017 national average OPPS allowable rates. In other words, preparing 2015 CDMs is the “gift that keeps giving” - correct OPPS payments in 2015 and correct OPPS allowable rates in 2017. From this author to all readers: “Have a wonderful holiday season and a great New Year - especially after preparing your CDM.”

  For author info and disclosures, see page 4.