Have You Correctly Added Imaging Study Codes to Your Charging System?

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Wound/ulcer management professionals and their coders/billers do not seem to be aligned about the correct codes to report for the various imaging study technologies that have been launched over the last 2 years. In fact, numerous hospital-owned outpatient wound/ulcer management provider-based departments (PBDs) have reported that they purchased one or more of the imaging technologies for their physicians and qualified healthcare professionals (QHPs) to use, but that they cannot charge for the studies.

When this author asked the obvious “why” question, the answer was always the same: “We are not allowed to add the codes to our Charge Description Master because our coders/billers say the codes cannot be reported by PBDs and are not payable by Medicare.”

Because coding and Medicare payment misperceptions regarding imaging studies appear to be widespread throughout the country, let us review the misperceptions, the correct codes, and the 2022 Medicare payment for the imaging study technologies that have proven to be extremely useful to patients, professionals, and payers.

Coding and 2022 Medicare Payment Misperceptions

This author interviewed many codes and billers throughout the country. Some clearly understood correct coding for the new imaging studies, as well as the 2022 Medicare payment for PBDs and physicians/QHPs. Unfortunately, many did not know the correct coding and Medicare payment information. Following are the most common misperceptions that this author heard:

• The code assigned to the spatial frequency domain imaging (SFDI) of skin is a clinical laboratory code and cannot be reported by, and paid to PBDs, physicians, and QHPs.
• The CPT^®1 Category III codes (created for non-contact real-time fluorescence wound imaging, hyperspectral imaging, and non-contact near-infrared spectroscopy) cannot be reported by and paid to PBDs.
• Medicare payment rates are not published for any of the CPT Category III codes in any site of care.

Correct Coding and 2022 Medicare Payment Information

The coders and billers are correct that the SFDI code 0061U (currently assigned to Clarifi Imaging System [Modulim]) is a clinical laboratory code:

          0061U 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

The code is paid under the Medicare Clinical Laboratory Fee Schedule. However, the coders and billers did not know that 0061U is excluded from the Clinical Laboratory Improvement Amendments (CLIA) edits. Therefore, 0061U can and should be reported by physician/QHP offices and PBDs when they perform SFDI imaging. The 2022 national average Medicare allowable rate for 0061U is identical in the physician/QHP office and in the PBD: $25.20/test.² 

• CPT Category III codes can and should be reported by physicians, QHPs, and PBDs when they perform the next three imaging studies

1.    The CPT Category III codes currently assigned to MolecuLight i:X Wound Imaging Device (MolecuLight) are:

          0598T Noncontact real-time fluorescence wound imaging, for bacterial presence, location, and load, per session; first anatomic site (e.g., lower extremity)

          +0599T each additional anatomic site (e.g., upper extremity)

Like all CPT Category III codes, 0598T and 0599T do not have relative value unit assignments on the Medicare Physician Fee Schedule (MPFS). Each Medicare Administrative Contractor (MAC) will determine the physician/QHP payment rates and coverage. Therefore, physicians/QHPs should educate the medical director of their MAC about the value that each of the emerging technologies provides to the patients, to the professional’s medical decision making, and to the payers. That education should assist the MACs to establish accurate allowable rates and positive coverage.

Unlike the MPFS, the Medicare Outpatient Prospective Payment System (OPPS) for PBDs usually assigns CPT Category III codes to Ambulatory Payment Classification (APC) Groups and assigns OPPS status indicators to the codes. CPT Category III code 0598T is assigned to APC Group 5722 that has a 2022 national average Medicare allowable rate of $270.29 per anatomic site per session.³

The code is assigned OPPS status indicator of “T.” This means that if 2 procedures with the “T” status indicator are performed during the same encounter, Medicare will reduce the payment for one of the procedures. The CPT Category III add-on code 0599T is assigned status indicator “N,” which means the payment for 0599T is packaged into the Medicare OPPS payment for 0598T. Therefore, like all other add-on codes in OPPS, CPT Category III code 0599T is not assigned to an APC Group.

2.    The CPT Category III code currently assigned to HyperView Imaging System (HyperMed) is:

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

Under OPPS, CPT Category III code 0631T is assigned to APC Group 5731, which has a 2022 national average Medicare allowable rate of $25.23 per extremity. The code is assigned OPPS status indicator ”Q1.” This means that if this imaging study is performed during the same encounter with another service/procedure assigned to either status indicator “S,” “T,” “V,” or “X,” the OPPS payment for 0631T will be packaged into the payment for the other service/procedure.
Like other CPT Category III codes, the physicians/QHPS should educate their MAC medical director about the value of this emerging technology.   

3.    The last, but not least, imaging study to review is the Snapshot_NIR Imaging Device (Kent Imaging), which has 3 different CPT Category III codes.

          0640T Non-contact near-infrared spectroscopy studies of flap or wound (for example, the measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation (StO₂)); image acquisition, interpretation and report, each flap or wound

          0641T Non-contact near-infrared spectroscopy studies of flap or wound (for example, the measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation (StO₂)); image acquisition only, each flap or wound

          0642T Non-contact near-infrared spectroscopy studies of flap or wound (for example, the measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation (StO₂)); interpretation and report only, each flap or wound

Like the other CPT Category III codes, Medicare payment and coverage for physicians/QHPs is at the discretion of each MAC medical director. Physicians and QHPs should take the opportunity to educate their MAC medical director in order to gain adequate payment and coverage for 1) CPT Category III code 0640T when they provide the equipment, take the image, interpret the results, and write the report; and for 2) CPT Category III code 0642T when they only interpret the results and write the report.

Under OPPS, CPT Category III code 0641T is assigned to APC Group 5723 that has a 2022 national average Medicare allowable rate of $34.57 per flap or wound. The code is assigned OPPS status indicator “T,” which means that if two procedures with the “T” status indicator are performed during the same encounter, Medicare will reduce the payment for one of the procedures.

Summary

If you wish to incorporate one or more of these imaging studies into your medical decision-making process, you should add the correct codes into your electronic health record and into your charging system. In addition, feel free to share this article with any coders/billers who have misperceptions about these emerging technologies.

Keep in mind that CPT Category III codes are temporary five-year codes. If wound/ulcer management professionals want these emerging technologies to be awarded CPT Category I codes at the end of the five years, they must show widespread usage. This can be achieved by reporting, on Medicare claims, all of the imaging studies performed.

CAUTION: A CPT Category III code may or may not be assigned a CPT Category I code: your utilization and submission of the correct codes on your Medicare claims play a large part in the coding decision at the end of the five-year period. Wound/ulcer management professionals have been requesting new diagnostic technology from the manufacturers. Now that these emerging technologies are available, wound/ulcer management professionals should use the technology and report the correct codes on their Medicare claims.

This author’s experience is that the MAC medical directors resist paying for emerging technologies with CPT Category III codes until they hear from physicians/QHPs in their jurisdictions. Therefore, as already stated several times, physicians/QHPs should request a peer-to-peer teleconsultation with your MAC medical director. During that time, educate the medical director how these imaging studies improve your medical decision making and provide better outcomes for the Medicare beneficiaries. Your thorough, enthusiastic education should assist the medical director to cover the technology and to set accurate payment rates. In addition, you can prove to your coders and billers that Medicare will cover and pay physicians/QHPs for emerging technology assigned to CPT Category III codes.

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. CPT^® is a registered trademark of the American Medical Association. Current Procedural Terminology (CPT^®) is copyright 2021 American Medical Association. All Rights Reserved Applicable FARS/DFARS apply.

2. Centers for Medicare and Medicaid Services. 2022 Medicare Clinical Laboratory Fee Schedule Files. Last accessed February 25, 2022.

3. Centers for Medicare and Medicaid Services. 2022 OPPS Fee Schedule Addendum B. Last accessed February 25, 2022.