There Is No Such Thing as a Dumb Question!

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.

During the past month, this author has received numerous calls from wound/ulcer management professionals who began by saying, “I have a dumb question, but I hope you can provide the answer for me or tell me where to find the answer.” This author reminded each caller that there is no such thing as a dumb question and that she would do her best to answer the question. In fact, the callers’ questions were interesting and covered a variety of topics. Therefore, this author is sharing some of those questions and answers in this month’s column.

Q: Our Medicare Administrative Contractor (MAC) retired its hyperbaric oxygen therapy (HBOT) Local Coverage Determination (LCD) and Local Coverage Article (LCA). Does that mean our MAC no longer covers HBOT?

A: To answer this question, let us remember 4 important facts about Medicare coverage:

1.    MACs do not write LCDs/LCAs for every service, procedure, and/or product they cover. In fact, not all MACs have an LCD/LCA that pertains to HBOT. In those cases, physicians and other qualified healthcare professionals (QHPs) are expected to thoroughly document the medical necessity for the service, procedure, and/or product based on clinical practice guidelines and published clinical evidence. In addition, the physicians and QHPs are expected to completely describe the work they performed.

2.    When MACs release active LCDs/LCAs, the physicians and QHPs still must thoroughly document as described above. In addition, they must follow all the utilization, documentation, and coding guidelines provided in the LCDs/LCAs.

3.    If MACs retire their LCDs/LCAs, they still cover the services, procedures, and/or products that were the subjects of the retired LCDs. However, the physicians and QHPs must be meticulous about their documentation.

4.    If an active National Coverage Determination (NCD) exists for a service, procedure, and/or product, physicians and QHPs must follow the NCD guidelines, even if their MAC retires their LCD/LCA that pertains to the same topic.

We know that Medicare does have an active hyperbaric oxygen therapy NCD. Therefore, the national coverage regulations exist even after a MAC retires its HBOT LCD/LCA. In addition, the NCD includes a thorough list of covered single ICD-10-CM code and dual diagnosis code requirements.¹ The latest revision of the covered diagnosis codes for hyperbaric oxygen therapy was implemented on July 1, 2019.²

Q: I thought that the Centers for Medicare & Medicaid Services (CMS) implemented new HCPCS codes on January 1 of every calendar year. Some of the physicians who work in our hospital-owned outpatient wound/ulcer management provider-based department (PBD) want to use a cellular- and/or tissue-based product (CTP) for skin wounds that is not on the list of CTPs that was released on January 1. The physicians insist that the CTP they want to use has been assigned a new HCPCS code effective October 1, 2020. Can the physicians be correct that a new code was assigned in October rather than January?

A: You are correct that the CMS implements new HCPCS codes on January 1 each year. However, you may have missed the fact that the CMS is now releasing new HCPCS codes for drugs, biologics, and CTPs on a quarterly basis: January 1, April 1, July 1, and October 1. If the CTP that your physicians want to use is listed in Table 1, it has received a new HCPCS code effective October 1, 2020, and your physicians are correct.
You may be interested to know that all the CTPs that received new HCPCS codes effective October 1, 2020 were assigned to the low-cost payment package for PBDs. Please keep in mind that assignment of a HCPCS code and a payment rate under the Outpatient Prospective Payment System (OPPS) does not imply the CTP is covered by the Medicare program; it only indicates how the CTP may be paid if it is covered by the Medicare Administrative Contractor(s)(MAC) that processes the PBD and the physicians’ claims.

ou may also be interested to know that CTPs that are currently assigned to the low-cost payment package could be reassigned to the high cost payment package in the future. Those reassignments are also announced on a quarterly basis. See Table 2 for a list of CTPs that were reassigned to the high cost payment package effective October 1, 2020.

Q: Is it true that the pass-through status for PuraPly and PuraPly AM (Organogenesis) ended on September 30, 2020? If so, how should our PBD now code for the products, and how will the PBD now be paid for the products?  

A: Yes, the pass-through status ended for PuraPly and PuraPly AM on September 30, 2020. PBDs should continue to use Q4195 to report PuraPly and Q4196 to report PuraPly AM. They should also continue to report the number of sq cm purchased for the patient along with the PBD’s charge. In addition, PBDs should continue to report the correct code for the application of high cost CTPs (15271–15278), with the correct number of units, and the PBD’s charge. Because payment for the products is now packaged into payment for the application, your MAC will only pay the PBD for the appropriate application code(s). Even if the PBD’s cost of PuraPly/PuraPly AM exceed the device offset cost included in the application code(s), your MAC will no longer make a pass-through payment for the products. REMINDER: PBDs must include the HCPCS code for the CTP on the claim along with the application code. Even though Medicare payment for CTPs is packaged into the PBD’s payment for the application, the claim will not be paid if the HCPCS code for the product is not on the same claim as the application code.

Q: I am a surgeon and have several questions about the use of negative pressure wound therapy (NPWT), both disposable (dNPWT) and durable medical equipment (DME).
1.    Where do I go to research if I can bill and be paid by Medicare for the application of dNPWT and NPWT DME applied in the operating room immediately after a surgical procedure?
2.    If I performed a surgical procedure with a 90-day global surgical period and I applied either a dNPWT or a NPWT DME at the same time, can I bill and be paid by Medicare for the reapplication of the dNPWT or the NPWT DME during follow-up office visits?

A: The answer to question number 1 is simple: you can determine if one procedure is a component of another by searching the appropriate National Correct Coding Initiative (NCCI) Edit files.³ These procedure-to-procedure (PTP) edit files are updated on a quarterly basis and are easily located on the CMS website. If you do not know how to sort the PTP files quickly to find your answer, the Medicare Learning Network has published an excellent booklet, entitled How to Use the Medicare National Correct Coding Initiative (NCCI) Tools, that shows you step-by-step how to use the NCCI tools and that has some additional resources that may be of interest to you.⁴ The PTP files are quite simple to filter so you can determine, in a few seconds, if one procedure is a component of another procedure. Once you learn how to filter the PTP files, you should never have to ask anyone about NCCI edits again. Simply bookmark the NCCI website and you should be good to go.

The answer to question number 2 is a bit more complex. The MLN Global Surgery Booklet describes what is included and what is not included in the global surgery period.⁵ One of the items identified as not included in the global surgery period is: “Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery.” Because negative pressure wound therapy is not part of normal recovery from surgery, it appears it is not included in the global surgery period.

In addition, the MLN Global Surgery Booklet also says the global surgical payment rules do not apply to codes that are assigned the global surgery indicator XXX. When you visit the Medicare Physician Fee Schedule (MPFS) look-up tool and click on the “display all columns” to see the global surgery indicator column, you will see that 97605–97608 are assigned the global surgery indicator of XXX—the global concept does not apply to the code.⁶ Therefore, it appears physicians should be able to code and receive payment for 97605–97608 applied in their offices during the 90-day global surgery period. In addition, remember that effective January 1, 2020 the codes 97607 and 97608 for the application of new dNPWT devices now have published allowable rates on the MPFS. See Table 3 for the 2020 national average allowable rates for the application of both NPWT DME and dNPWT.

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@bellsouth.net.

1. National Coverage Determination List of Covered Diagnosis Codes for Hyperbaric Oxygen Therapy: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR11134.zip. Last accessed September 9, 2020.
2. International Classification of Diseases, 10th Revision (ICD10) and Other Coding Revisions to National Coverage Determination (NCDs): MLN Matters Number 11134: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11134.pdf. Last accessed September 9, 2020.
3. National Correct Coding Initiative (NCCI) Edits webpage: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index. Last accessed September 8, 2020.
4. How to Use the Medicare National Correct Coding Initiative (NCCI) Tools: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/how-to-use-ncci-tools.pdf. Last accessed September 8, 2020.
5. MLN Global Surgery Booklet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf. Last accessed September 9, 2020.
6. Medicare Physician Fee Schedule Look-Up Tool: https://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Last accessed September 9, 2020.