The COVID-19 Public Health Emergency, Coding Changes, and Coverage Changes Continue

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.

After reading this column, take the Reimbursement Check-Up Quiz at the end.

A myriad of coding, coverage, and payment changes have kept this reimbursement author and consultant remarkably busy this year. As always, we will review the most significant changes throughout the year in Business Briefs, in Consultation Corner, at a Symposium on Advanced Wound Care (SAWC) main session, and at the SAWC reimbursement post-conference.

For this month, let us review the continuation of the COVID-19 public health emergency (PHE), and the continuation of the ever-changing codes and coverage.

Extension of the PHE, Waivers, and Expanded Telehealth Services

On January 14, 2022, Xavier Becerra, Secretary of the Department of Health and Human Services, renewed the PHE for 90 more days, effective January 16, 2022. This is the eighth renewal of the PHE since it was first declared on January 31, 2020. Therefore, all PHE waivers, which are scheduled to expire when the PHE ends, will remain in place until the middle of April 2022. In addition, all the Category 3 services that were added to the Medicare List of Telehealth Services during the PHE will remain payable under the Medicare Physician Fee Schedule through December 31, 2023. The waivers and the telehealth services have been invaluable to patients with chronic wounds/ulcers and to many professionals throughout the country.

If you have not been using the waivers and telehealth services to deliver care to your patients, you may want to reconsider—especially since the PHE has been extended once again!

Virtual Check-In Add-On Code Made Permanent

For many reasons, this author has been encouraging wound/ulcer management physicians/qualified health professionals (QHPs) to consider building virtual check-in services into their businesses. Because these patient-initiated audio-only services are not controlled by the telehealth regulations, they will not end when the PHE ends. Therefore, this is a wonderful time to educate your patients how to initiate virtual check-ins. Let us now review the important virtual check-in codes.

When the Centers for Medicare & Medicaid Services (CMS) created the first code for virtual check-ins, it was only for 5–10 minutes of medical discussion:

G2012    Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;     5-10 minutes of medical discussion

As increasingly more physicians/QHPs conducted virtual check-ins with their patients during the PHE, they reported to the CMS that they often need more than 5–10 minutes to discuss their patients’ issues. Therefore, in 2021 the CMS created an additional code for 11–20 minutes of medical discussion. This code was originally intended for temporary use during the PHE. It allowed audio-only interactions to be used for longer medical discussions to determine the necessity of an in-person visit. Throughout 2021, the CMS received positive feedback about the temporary add-on code. Therefore, in 2022, the CMS converted the temporary add-on code to a permanent code with Medicare payment.

G2252    Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;     11-20  minutes of medical discussion

Table 1 displays the 2022 Medicare payment status of the virtual check-in base code G2012 and the now permanent virtual check-in add-on code G2252.

Table 1

2022 Medicare Physician Fee Schedule National Average Allowable Rate

*The global concept does not apply to the code

Code Changes for Autologous Platelet-Rich Plasma (PRP) for Chronic Wounds/Ulcers

In the December Business Briefs column, we discussed the good news that the CMS now covers autologous PRP for the treatment of chronic non-healing diabetic wounds for a duration of 20 weeks, when the PRP is prepared by devices whose Food and Drug Administration (FDA)–cleared indications include the management of exuding cutaneous wounds, such as diabetic foot ulcers.¹ After the National Coverage Determination (NCD) was released, the CMS issued Transmittal 11119, which provided guidance to report HCPCS G0460 for this newly covered service.²

G0460    Autologous platelet-rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration, and dressings, per treatment.

Then in 2022 the CMS revised the description of G0460 and created a new code, G0465.

G0460    Autologous platelet-rich plasma for non-diabetic chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration, and dressings, per treatment.

G0465     Autologous platelet-rich plasma for diabetic chronic wounds/ulcers, using an FDA-cleared device (includes administration, dressings, phlebotomy, centrifugation, and all other preparatory procedures, per treatment)

As you can see G0465 is now the appropriate HCPCS code to report when you apply the autologous PRP to a diabetic chronic wound/ulcer and meet the coverage criteria of the NCD. On January 12, 2022, the CMS rescinded Transmittal 11119 and replaced it with Transmittal 11171 which explained the revision of the description of G0460 and the creation of G0465.³ Then, on January 20, 2022, the CMS rescinded Transmittal 11171 and replaced it with Transmittal 11214, which 1) revised the implementation date to February 14, 2022 for the Medicare Administrative Contractors (MACs), 2) provided further claims processing direction, pertaining to G0460 and G0465,  to the MACs, and 3) included a list of acceptable diagnosis codes.⁴

Therefore, all hospital-owned outpatient wound/ulcer management provider-based departments (PBDs) and physician/QHP offices that perform this procedure should add the code G0465 to their charge sheets, to their coding and billing systems, and to their Charge Description Masters. Otherwise, claims may be denied because the NCD only covers the procedure for diabetic chronic wounds/ulcers. If G0465 is required after 20 weeks, the KX modifier should be added to G0465: this informs the MAC that the medical record includes documentation that justifies the medical necessity for additional treatments. Coverage of the treatment beyond 20 weeks is at the MAC’s discretion.

The MACs also have the discretion to cover and determine frequency for autologous PRP reported with G0460 for non-diabetic chronic wounds/ulcers, but that coverage must be determined case-by-case.

Following is the 2022 Medicare payment status for G0465:

•    Outpatient Prospective Payment System (OPPS):
   o    G0465 is assigned to Ambulatory Classification Group (APC) 054
   o    The Medicare national average allowable rate is $1,749.26
   o    The status indicator is “T” procedure or service, multiple procedure reduction applies
•    Medicare Physician Fee Schedule (MPFS):
   o    Each MAC will establish relative value units and payment amounts for G0465, generally on an individual case-by-case basis following review of documentation such as an operative/procedure report.

Coverage and Payment Holds for Some Cellular- and/or Tissue-Based Products (CTPs) for Skin Wounds

In December 2021 and January 2022, numerous wound/ulcer management physicians, QHPs, and PBDs began to report that their claims for CTPs were not paid by their Medicare Administrative Contractor (MAC). After further investigation, this author learned that two of the MACs, Noridian Healthcare Solutions and WPS Government Health Administrators, are currently holding claims for two separate scenarios:

1)    When amniotic and/or placental derived membrane products are used for non-wound indications

2)    When liquid CTPs with “Q” codes are used for any indication.

Neither Noridian nor WPS explained the reason they are holding the claims. They simply said that the claims will be held in the system until they receive further direction. Physicians, QHPs, and PBDs who submit their claims to Noridian and WPS should watch for further information from these MACs.

The good news is that the MACs are not holding claims for all CTPs!

New and Deleted ‘Q’ Codes for CTPs

Speaking of CTPs, four new products were assigned “Q” codes:
•    Q4199 CYGNUS Matrix, per sq cm
•    Q5251 VIM, per sq cm
•    Q4252 Vendaje, per sq cm
•    Q4253 Zenith Amniotic Membrane, per sq cm

In addition, the “Q” codes for two CTPs were deleted:
•    Q4228 BioNextPATCH, per sq cm
•    Q4236 CarePATCH, per sq cm

Physicians, QHPs, and PBDs who wish to use the new CTPs or who used the products with the deleted “Q” codes should take the time to update their charging systems, their billing systems, and their Charge Description Masters.

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.

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References
1. Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) 270.3 Blood-Derived Products for Chronic, Non-Healing Wounds. Last accessed January 21, 2022.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Transmittal 11119. Last accessed January 21, 2022.
3. Centers for Medicare and Medicaid Services. Medicare Claims Processing Transmittal 11171. Last accessed January 21, 2022.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Transmittal 11214. Last accessed February 3, 2022.