Questions About Coding and Payment for Application of CTPs Are on the Rise!

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.

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Although wound/ulcer management professionals have been applying cellular- and/or tissue-based products (CTPs) for skin wounds for many years, questions about the coding and payment for the products and the work to apply them have increased significantly throughout 2021.

To better understand why these questions are on the rise, this author always asks what is the “question behind the question”? Following are some of the frequent responses from the wound/ulcer management professionals and their coders and billers.

•    “Our hospital owned outpatient wound/ulcer management provider-based department (PBD) is using CTPs for the first time and no one knows how to correctly add them to our Charge Description Master.”

•    “The physicians, qualified healthcare professionals (QHPs) and coders in our office-based practice do not agree how to code the procedure for applying the product.”

•    “Representatives from the various companies sometimes provide conflicting directions regarding coding, payment, and coverage.”

•    “Our physician/QHP office receives adequate payment for the application procedure but the payment for the CTP itself is ridiculously small in comparison to the cost of the product.

•    “We thought we knew how to code for the CTPs, but after a recent audit, our physician/QHP office incurred a large repayment.”

In case you are experiencing one or more of these situations, let us review the frequently asked questions about coding and payment for application of CTPs.

Q:      

Exactly what codes and units for the application of CTPs should we include on our PBD’s Charge Description Master?

A:     

The PBD should follow 4 steps to add CTP information to the Charge Description Master. These steps should account for the application procedure and the exact brand name of CTPs that are on the PBD formulary.

1.    The PBD should make a list of all the CTPs that are on their formulary, verify the correct HCPCS codes for each CTP, and verify whether each CTP is assigned to the high-cost or low-cost Medicare payment package.

2.    The PBD should add the HCPCS code, the brand name, the unit of “1,” and the correctly marked-up charge for 1 square centimeter of each CTP. NOTE: When the PBD enters their charges into their charging system, they should report the total number of square centimeters purchased and applied. If a portion of the product was wasted, some Medicare Administrative Contractors (MACs) require the PBD to separately report the number of square centimeters applied with the JC modifier and the number of square centimeters wasted with the JW modifier.

3.    If the formulary includes high-cost CTPs, add the application codes 15271–15278, the unit of “1,” and the correctly marked-up charges. NOTE: The marked-up charges for 15271, 15272, 15275, and 15276 should be for the application of 25 square centimeters. When the PBD enters their charges into their charging system, they should report the unit of “1” for the base codes 15271 and 15275. They should report the unit of “1,” “2,” or “3” for 15272 and 15275 depending on the additional increments of 25 square centimeters applied.  The marked-up charges for 15273, 15274, 15277, and 15278 should be for the application of 100 square centimeters. When the PBD enters their charges into their charging system, they should report the unit of “1” for the base codes 15273 and 15277. They should report the unit of “1,” “2,” or “3” for 15274 and 15278 depending on the additional increments of 100 square centimeters applied.

4.    If the formulary includes low-cost CTPs, add the application codes C5271–C5278, the unit of “1,” and the correctly marked-up charges. NOTE: The marked-up charges for C5271, C5272, C5275, and C5276 should be for the application of 25 square centimeters. When the PBD enters their charges into their charging system, they should report the unit of “1” for the base codes C5271 and C5275. They should report the unit of “1,” “2,” or “3” for C5272 and C5275 depending on the additional increments of 25 square centimeters applied. The marked-up charges for C5273, C5274, C5277, and C5278 should be for the application of 100 square centimeters. When the PBD enters their charges into their charging system, they should report the unit of “1” for the base codes C5273 and C5277. They should report the unit of “1,” “2,” or “3” for C5274 and C5278 depending on the additional increments of 100 square centimeters applied.

Q:     

Although CTPs are available in a variety of sizes, the administrator for our PBD will not allow us to purchase CTPs greater than 15 square centimeters. What should we do if the wound surface area is greater than 15 square centimeters?

A:    

To bill compliantly for the application of a CTP, the physician/QHP must apply the CTP to the entire wound surface and fixate the CTP with his/her choice of fixation. Therefore, the PBD must purchase enough product to cover the entire wound surface. If you are only permitted to purchase small sizes of CTPs, you should purchase enough pieces for the physician/QHP to cover the entire wound surface with the CTP.

Q:     

Our physician works in both a PBD and in her private office. She believes she should report the codes 15271–15278 for the CTPs designated as high-cost and that she should report C5271–C5278 for the CTPs designated as low-cost. The coders and billers disagree and believe that the physician should always use the codes 15271–15278 for her work of applying CTPs. Can you help us solve this disagreement?

A:     

Yes, the answer is quite simple. The Medicare payment system for the PBD and for the physician are totally different. The designation of high-cost and low-cost CTPs is only applicable to the Medicare payment system for the PBD. Therefore, the physician should always report her work of applying CTPs with the codes 15271–15278—no matter whether she applies the CTPs in the PBD or in her office.

Q:     

Where can we find the correct information pertinent to the coding, Medicare payment, and Medicare coverage of the application of the various CTPs?

A:     

This information is not found in one sole resource. The codes and coding guidance for the application of CTP procedures are found in the current year’s CPT^®1 manual, which can be purchased in paper or digital format. The codes for each CTP are listed in the alpha-numeric HCPCS file, which is updated quarterly.² The Medicare payment rules are updated every year. This year’s Medicare payment rules for the PBD are found in the Hospital Outpatient Prospective Payment System Final Rule³, and for the physicians/QHPs are found in the Medicare Physician Fee Schedule Final Rule.⁴ If a MAC has a published Local Coverage Determination (LCD) and Local Coding Article (LCA) pertaining to CTPs, you will find those documents in both your MAC’s website and the Medicare Coverage Database⁵, which contain all draft and final LCDs and LCAs. If you have a need to review retired LCDs and LCAs you can find them in the Medicare Coverage Database Archive.⁶

Q:     

Will you please consult with our physician/QHP office to review our submitted CTP claims and the remittance advices for those same claims? We feel sure that we are submitting the correct codes. We are paid correctly for the application procedure but are paid a ridiculously small amount for the CTP. We have no idea why this is occurring.

A:     

After reviewing the physician/QHP office claims and remittance advices, this consultant found that the submitted codes and units for the application procedure were reported correctly. In addition, the codes for the CTP products were also correctly reported. However, the units attached to the products’ HCPCS codes were incorrect: every claim reported a unit of “1,” which told their MAC to only pay them for 1 square centimeter. The physician/QHP office is supposed to report the total number of square centimeters applied and wasted. Let’s consider a few examples: a) if the office purchased and applied 10 square centimeters of a CTP, the units reported on the claim should be 10; b) if the office purchased 20 square centimeters of a CTP, but only applied 14 square centimeters and wasted 6 square centimeters, the office should have reported the HCPCS code with the JC modifier and 14 units on one claim line and the same HCPCS code with the JW modifier and 6 units on a second claim line. Once the physician/QHP office began correctly reporting the units for the CTPs, they received adequate Medicare payment.

Q:     

Our physician/QHP office just received the results of an audit of our claims for the application of CTPs. We used the correct codes for the procedure and for the product, but we incurred a large repayment after the audit. Can you please educate us how to improve our coding, so this does not happen to the office in the future?

A:    

After reviewing the documentation and the submitted codes, this consultant found a very consistent coding error. The error is easiest explained with an example:

The wound surface area of a diabetic foot ulcer was 15 square centimeters, and a 44 square centimeter CTP was purchased. The office correctly reported the amount of product applied (15 square centimeters) on one claim line with modifier JC and the amount of product wasted (29 square centimeters) on another claim line. The office incorrectly reported the application codes. They reported 1 unit of 15275 and 1 unit of 15276, which meant the wound surface area was between 26 and 49 square centimeters, when it was only 15 square centimeters.

When this consultant questioned the office coders about this, they said “We based the application codes on the amount of product purchased.” The coders should have only reported 15275 and 1 unit because the diabetic foot ulcer was less than 25 square centimeters. Therefore, the auditors were correct to take repayments for all the claims that reported the work to apply the CTPs based on the size of the CTPs purchased rather than on the size of the wound surface areas to which the CTPs were applied.

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.

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References

1. CPT is a registered trademark of the American Medical Association. All Rights Reserved.
2. Alpha-numeric HCPCS file. Last accessed June 19, 2021.
3. 2021 Hospital Outpatient Prospective Payment System Final Rule. Last accessed June 19, 2021.
4. 2020 Medicare Physician Fee Schedule Final Rule: Last accessed June 19, 2021.
5. Medicare Coverage Database. Last accessed June 20, 2021.
6. Medicare Coverage Database Archive. Last accessed June 20, 2021.