The Facts You Need to Know About CTP Reimbursement

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Today’s Wound Clinic or HMP Global, their employees, and affiliates.

Hello, wound and ulcer management stakeholders. I have just finished my presentation at the 2024 SAWC Spring in my home state of Florida. The title of my presentation was “CTPs/Skin Substitutes: Reimbursement Facts, and Nothing but the Facts!”

The topic was very timely for two major reasons. Number one, wound and ulcer management professionals throughout the country are being audited when their usage of cellular and /or tissue-based products for skin wounds is high. Second, all the Medicare Administrative Contractors in the United States recently released the same proposed Local Coverage Determinations and Local Coverage Articles pertaining to the application of CTPs for diabetic foot ulcers and venous leg ulcers. I shared 10 major CTP reimbursement facts with today's attendees.
 
First, I reminded everyone that they are in the wound and ulcer management business, not the CTP application business. Therefore, they must document the wound and ulcer assessment at every encounter and that every encounter is unique and different.
 
Second, before applying a CTP, physicians and qualified healthcare professionals must use and document conservative wound and ulcer management for a minimum of 4 weeks. Therefore, I provided and reviewed a wound and ulcer management documentation checklist.
 
Third, if conservative management helps, this plan of care must be modified and the physicians or other qualified health care professionals must justify why a CTP is medically reasonable and necessary, and why the specific grant of CTP was selected.
 
Fourth, the physician or qualified health care professional must thoroughly describe the surgical application procedure in an operative or procedure note. If additional applications are necessary, evidence of improvement and measurable changes must be documented.
 
Fifth, I shared the fact that inadequate and incomplete documentation cause the most claimed denials and repayments, and that this loss of revenue is absolutely preventable.
 
Sixth, we then discuss the fact that product codes and the number of square centimeters applied and wasted must be accurately reported in the medical record and on claims submitted to the payers.
 
Seventh, we discussed the fact that some CPTs, such as gels, powders, ointments, foams, liquids, or injected products do not qualify to be reported with the CTP application codes.
 
Eighth, we then discussed the fact that physicians and QHPs should always report the application codes 15271–15278 when they apply "covered" CTPs, and that hospital-owned outpatient wound ulcer management provider-based departments should only report those application codes when CPTs assigned to the high-cost package are applied. Now when covered CTPs are assigned to the low-cost package, the hospital-owned provider -based departments should report the application codes C5271 through C5278.
 
Ninth, we then discussed the fact that the existence of a code and a Medicare payment rate do not guarantee coverage and that physicians and qualified healthcare professionals must comply with the coverage requirements of each patient's payer.
 
And finally, we concluded with the fact that the physicians and qualified healthcare professionals should select products and procedures based on the patient's clinical needs, not on the payment rate that the physicians and qualified healthcare professionals like.
 
We also discussed the fact that physicians and qualified healthcare professionals who purchase CTPs are paid separately for the product and the procedure, and that hospital-owned provider-based departments receive a package payment for the procedure which includes the payment for the product.
 
I hope that the attendees and you will remember these reimbursement facts when you use CTPs for your patients. Thank you for listening. Feel free to contact me at 561-670-7176 if you need further assistance. Now, I am off to participate in a live interview about the proposed LCDs and LCAs pertaining to the CTPs. Thank you.