A Potpourri of Outpatient Prospective Payment System (OPPS) Updates

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.

Not only have the Centers for Medicare & Medicaid Services (CMS) been very busy making hundreds of regulatory changes to ensure that Medicare beneficiaries have access to health care throughout the COVID-19 public health emergency (PHE), but they have not missed a beat in releasing draft rules, reviewing HCPCS code applications, and providing quarterly updates to the various Medicare payment systems. The 31-page July 2020 Outpatient Prospective Payment System (OPPS) update is an example of the huge volume of work that the CMS staff is doing in addition to managing the PHE.¹ This update has a potpourri of topics that pertain to wound/ulcer management professionals who work in hospital owned outpatient provider-based departments (PBDs).

Cellular and/or Tissue-Based Products for Skin Wounds (CTPs)

All outpatient wound/ulcer management PBDs should be aware that the CTPs that do not qualify for pass-through status are packaged into the OPPS payment for the appropriate application procedure.

The 2020 CPT^® Manual reminds us that the application codes “are not to be reported for application of non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid) or injected skin substitutes.”² That explains why only 13 of the 21 CTP HCPCS codes, established on July 1, 2020, were assigned into the high cost or low-cost groups for OPPS packaging purposes: 8 of the products cannot be reported with the application codes. Twelve of the 13 new CTPs are assigned into the low-cost group because the CMS does not have pricing data, which demonstrates that the cost of the CTP is above either the mean unit cost (MUC) of $48 or per day cost (PDC) of $790 for calendar year 2020. Table 1 includes all 21 newly established CTP HCPCS codes and the low-cost or high-cost group assignments for the 13 CTPs, which can be reported with the appropriate application procedure code(s).

Also effective on July 1, 2020 is a CTP HCPCS code description change for Q4176. See Table 2 for that change.

Non-Contact Real-Time Fluorescence Wound Imaging

In the February 2020 Business Briefs, this author explained that 2 new Category III codes would become effective on July 1, 2020 for non-contact real-time fluorescence wound imaging using MolecuLight i:X (MolecuLight).³ Now that the codes 0598T and 0599T are effective, physicians and other qualified healthcare professionals (QHPs) who use the technology should report the appropriate Category III code(s) instead of the Category I unlisted codes that they may have been reporting prior to July 1, 2020. Because Category III codes are not assigned relative value units, they do not have published allowable rates on the Medicare Physician Fee Schedule (MPFS). Therefore, payment rates for the physician performing the imaging, as well as coverage, will be determined by each Medicare Administrative Contractor (MAC) and each private payer. Because these claims will not only determine payment rates for the imaging performed now, but will also contribute to the relative value unit assignments to future Category I codes, physicians/QHPs should use their normal mark-up process to determine their charge for 0598T and 0599T.

In the July OPPS update and in the July 2020 OPPS Addendum B, the CMS assigned 0598T to APC Group 5722 (Level 2 Diagnostic Tests and Related Services) with a status indicator of “T” and packaged the 0599T add-on code (just like all add-on codes are packaged in the OPPS).⁴ Therefore, if the imaging is covered by the patient’s MAC, it will receive separate payment in PBDs, if 0598T is not part of a National Correct Coding Initiative edit. Because 0598T has a status indicator “T,” the multiple procedure reduction will apply if it is performed at the same encounter when another procedure with status indicator of “T” is performed. The national average payment rate for APC Group 5722 is $253.10 and the minimum unadjusted copayment rate is $50.62.

For information about documentation requirements and frequently asked questions pertaining to coding, coverage, and payment, see the article written by Leah Amir in the June 2020 issue of Today’s Wound Clinic.⁵

Telehealth and Communication Technology-Based Services (CTBS)

Throughout the COVID-19 PHE, this author has been updating the wound/ulcer management professionals about the various waivers for telehealth and for CTBS.^6–9 Prior to the COVID-19 PHE, wound/ulcer management professionals rarely used these digital technologies because their business model did not include them and because the various regulations restricted their use. After the COVID-19 PHE recommendations to stay-at-home and to maintain social distancing were released, wound/ulcer management professionals quickly found the various digital technologies and waivers to be essential to their new way of managing patients from afar.

Once the telehealth and CTBS waivers were released, the CMS found it had to tweak coding, payment systems, and coverage for these services. The July OPPS update included many of these adjustments that are retroactive to March 1, 2020. Table 3 includes a few of telehealth and CTBS adjustments that may be of interest to PBD, as well as physicians/QHPs.

Reminder from the CMS

As usual, at the end of the July 2020 OPPS update, the CMS reminded all stakeholders: “the fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”¹

Reminder from This Author

Reimbursement is comprised of three parts: coding, coverage, and payment. If any component is missing, the service, procedure, or product will not be reimbursed.

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

1. July 2020 Update of the Hospital Outpatient Prospective Payment System: https://www.cms.gov/files/document/mm11814.pdf. Last accessed June 16, 2020.
2. CPT is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT^®) is copyright 2019 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.
3. Schaum KD. Share new codes with your clinical and revenue cycle teams. Today’s Wound Clinic. 2020; 14(2):6–9.
4. July 2020 OPPS Addendum B: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates. Last accessed June 17, 2020.
5. Amir L. New Category III CPT codes now active for MolecuLight i:X fluorescence imaging of bacteria. Today’s Wound Clinic. 2020; 14(6):24–30.
6. Schaum KD. June 2, 2020 update: telehealth waivers during COVID-19 public health emergency. Today’s Wound Clinic. https://www.todayswoundclinic.com/articles/june-2-2020-update-telehealth-waivers-during-covid-19-public-health-emergency. Last accessed June 17,2020.
7. Schaum, KD. Test your knowledge: coding for telehealth performed during the COVID-19 PHE. Today’s Wound Clinic. 2020; 14(6):4–8
9. Schaum KD. COVID-19 reimbursement depends on what was performed: telehealth or communication technology-based service? Today’s Wound Clinic. https://www.todayswoundclinic.com/articles/june-2-2020-update-telehealth-waivers-during-covid-19-public-health-emergency. Last accessed June 17, 2020.
10. Kathleen D. Schaum, April 30, 2020 update: communication technology-based services during the COVID-19 pandemic. Today’s Wound Clinic. https://www.todayswoundclinic.com/articles/april-30-2020-update-communication-technology-based-services-during-covid-19-pandemic-0. Last accessed June 17, 2020.