HOPD Coding and Medicare Payment for MolecuLight Real-Time Fluorescence Wound Imaging for Bacterial Presence, Location, and Load

Welcome. My name is Kathleen Schaum, and I am the President of Kathleen D. Schaum and Associates Inc, and for more than 40 years I've been providing reimbursement consultation and education to wound and ulcer management professionals and manufacturers. In my consulting business, Hospital Owned Outpatient wound and ulcer management Departments (HOPDs), and their coders and billers, frequently contact me regarding use of the Category III CPT codes that the American Medical Association (AMA) created and they are relevant to MolecuLight fluorescence wound imaging for bacterial presence, location, and load. Therefore, today I am going to share with you the seven most Frequently Asked reimbursement Questions about MolecuLight imaging and the correct answers to those questions.
 
Before we begin, let's discuss the reimbursement disclaimers. Information on reimbursement coding and Medicare payment is provided as a courtesy but does not constitute a guarantee or warranty that payment will be received, and the coding and Medicare outpatient perspective payment system information was current as of September 1st, 2023 and is subject to change. Also, Hospital Owned Outpatient Department professionals, coders, and billers should obtain from the correct payer the current coding payment system coverage policies and regulations that pertain to the specific work they perform. Finally, prior to performing fluorescence wound imaging, insurance benefit verification should be conducted to learn about medical necessity indications and limitations utilization guidelines and place of service requirements. Because we must respect trademarks, please remember that current procedural terminology and CPT^® are registered trademarks of the American Medical Association and that MolecuLight^® is a registered trademark MolecuLight Incorporated.
 
Now let's begin with the first Frequently Asked Question, and that is: What CPT codes should HOPDs report when they use MolecuLight fluorescence wound imaging for bacterial presence, location, and load?

Well, I'm excited to inform you that the American Medical Association created two Category III CPT codes which are relevant to the point of care fluorescence wound imaging using the MolecuLightDX and i:X devices. These codes became effective on July 1st, 2020. The base code is 0598T and its description is “non-contact real time fluorescence wound imaging for bacterial presence, location, and load per session” and it's for the first anatomic site. Now in case you are wondering, per session means per encounter. Now the add-on code is 0599T and the code description says that it is for “each additional anatomic site.” Now the CPT manual reminds us that add-on codes such as 0599T should be reported on claims separately in addition to the base code 0598T. For example, if images were taken of two ulcers on the same patient—one on the leg and the other on the foot, the HOPD should report one unit of 0598T for the first anatomic site and one unit of 0599T for the additional anatomic site.
 
The second Frequently Asked Question is: How should images of wounds on multiple anatomic sites performed on the same date of service be reported?

Per the code description, the fluorescence wound imaging procedure for the first anatomic site should be reported with CPT code 0598T, as we just discussed. Therefore, it makes sense that the October 1st, 2023 National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) only allow payment for this code per patient per date of service. If a patient requires imaging of additional anatomic sites during the same encounter, the MUEs allow payment for two units of CPT code 0599T on that date of service. For example, the patient pictured on this slide has three wounds on three different anatomic sites. All three wounds meet medical necessity requirements for imaging. Now the first anatomic site that was imaged was the wound on the heel, therefore one unit of 0598T should be reported for the heel wound image. The other two wounds are on two different anatomic sites, therefore two units of 0599T should be reported—one for each additional image of each additional anatomic site. Now if this patient were to need an image of a fourth wound on a different anatomic site such as the arm, the HOPD will not receive payment for that image because it exceeds the 0599T Medically Unlikely Edit limit of two units. Furthermore, if the patient has two wounds in the medial lumbar region instead of the one on the slide, only one unit of 0599T should be reported because both wounds are on the same anatomic site. Now, let's turn our attention to the NCCI procedure-to-procedure edits. HOPDs always want to know if there are any procedure-to-procedure edits when two different procedures are performed at the same encounter, such as performing a MolecuLight imaging and doing a surgical debridement. The good news is that there are no procedure-to-procedure edits for 0598T and 0599T that are on the NCCI edit files that were just released on October 1st, 2023.
 
The third Frequently Asked Question is: What are Category III CPT codes?

The American Medical Association created Category III CPT codes to provide quicker patient access to emerging technology that does not yet meet all the criteria for Category I CPT codes. Now the Category III codes allow reporting of new procedures to payers, data collection about the clinical efficacy and outcomes of the procedure, and provide the opportunity to demonstrate widespread adoption of the emerging technology. Now Category III CPT codes are temporary, and they're often converted to Category I CPT codes after five years. The information collected during the time of Category III CPT codes is essential to convert these codes into Category I CPT codes. The AMA must see evidence of strong uptake and utilization of the technology alongside strong published evidence as to its clinical efficacy and ability to improve patient outcomes. I am pleased to say that the MolecuLight codes are well on their way to being converted to Category I CPT codes. There is abundant published evidence as to its clinical efficacy and the uptake and utilization continue to increase. Now it's also important to note that the Category III codes may be renewed after 5 years, should more time be needed to meet the Category I CPT code requirements.
 
Now let's discuss the Frequently Asked Question number four: Our HOPD has never used Category III CPT codes. Are these codes appropriate for HOPDs to report to Medicare and other payers?

The answer to this question is “Yes!” Category III CPT codes, just like Category I CPT codes, are appropriate for HOPDs and other places of service to report. In fact, if medically indicated fluorescence wound imaging is performed by physicians or QHPs [qualified healthcare providers] in the HOPD setting, the facility is expected to report 0598T and, when appropriate, 0599T. Remember the basic coding rule: once a code exists, it must be used. Now these codes became effective on July 1st, 2020 and ever since then HOPDs across the country have been using the MolecuLight devices to perform fluorescence wound imaging for bacterial presence, location, and load and they have been reporting 0598T and 0599T.
 
Frequently Asked Question number five is: What is the Medicare national average allowable OPPS facility rate for fluorescence wound imaging?

As you probably know the Outpatient Prospective Payment System, better known as OPPS, assigns codes that require similar resources to groups called Ambulatory Payment Classification (APC) groups. Then each APC group has a published national average allowable OPPS payment rate. And for 2023, 0598T is assigned to APC group 5722; it has an OPPS status indicator of T, and it has a published national average allowable OPPS rate of $280.06. Now that allowable rate will vary from hospital to hospital, therefore all listeners should verify their HOPDs unique OPPS rate for APC group 5722.
 
Now, let's talk about the add-on code 0599T. Just like nearly all other add-on codes, 0599T is not assigned to an APC group. It has an OPPS status indicator of N and it's packaged into the payment for the base code 0598T. That is why you do not see an OPPS allowable rate for 0599T.
 
That brings us to frequently asked question number six: What are OPPS status indicators?
 
Well, OPPS status indicators are unique to HOPDs and they inform these facilities of two things: first, whether a code is payable, not payable, or packaged by Medicare and second, if the code is or is not subject to multiple procedure discounting by Medicare. CPT code 0598T has a T status indicator as was shown on the last slide. This means that if 0598T is the only procedure performed at that encounter, the Medicare payment will be based upon 100% of the HOPDs unique allowable rate. Now if two procedures are performed at the same encounter and both of their codes are assigned a T status indicator, Medicare payment for the code with the highest allowable rate will be based upon 100% the HOPDs unique allowable payment rate, and Medicare payment for the code with the lowest allowable rate will be based upon 50% of the HOPDs unique allowable rate. Therefore, if 0598T is billed at the same encounter with another code that is assigned a T status indicator and that other code has a higher allowable rate than 0598T, the Medicare payment for 0598T will be 50% the HOPDs unique allowable rate.
 
By now you probably want to know some examples of OPPS status indicators assigned to common procedures performed in HOPDs. Well, at the top of the slide are a few examples of the many procedures that are assigned T status indicators. Of course, the first one we've talked about is the fluorescence wound imaging, 0598T. The second is surgical debridement of subcutaneous tissue, 11042 and the application of cellular and/or tissue-based products for skin wounds and those are the base codes for the application of both the high-cost and the low-cost CTPs.
 
Now at the bottom of the slide are a few examples of the many procedures and products that are assigned N status indicators. Remember, if a code is assigned an N status indicator the payment for that code is packaged into the payment for another code. Therefore, the packaged code is not separately paid in the HOPD. And some examples of this, of course we just spoke about the fluorescence wound imaging add-on code 0599T, and then the add-on code for the surgical debridement of subcutaneous tissue, which is 1145, and then all the add-on codes for the application of both high-cost and low-cost CTPs. And then the actual CTPs themselves, the products, all have an N status indicator no matter whether the product has a “Q” or “A” code and they are all packaged.
 
That brings us to Frequently Asked Question number seven, which is the last question for today: Does Medicare publish allowable rates for Physicians who perform a MolecuLight procedure in HOPDs?  

In contrast to Category I CPT Codes, all Category III CPT codes are contractor-priced on the Medicare Physician Fee Schedule. That means that each Medicare Administrative Contractor (MAC) determines if the procedure will be covered and determines the allowable rate in its jurisdiction. Now at the time of this recording, CPT codes 0598T and 0599T have published allowable rates on nearly all of the MACs Physician Fee Schedules. The payment amounts differ per MAC, and in some cases per state, but the national averages are $72.47 for 0598T and $43.93 for 0599T. This information is current as of September 1st, 2023 and is subject to change. Physicians and QHPs should use your MACs Physician Fee Schedule lookup tool to verify the published rates for 0598T and 0599T. Now I'm pleased to tell you that MolecuLight continues to engage with Medicare and other payers to negotiate payment amounts that are proportional to the work involved in the procedure.
 
Now that we have addressed the seven most Frequently Asked Questions about the HOPD coding and payment for MolecuLight, let's review the important takeaways:

• The AMA created Category III CPT codes 0598T and 0599T for fluorescence wound imaging for bacterial presence, location, and load based on published evidence for this procedure using the MolecuLight device. Now the assignment of Category III codes to emerging technology like MolecuLight is a completely normal AMA process that enables patient access to the technology while the data and utilization needed for a Category I CPT code is collected.
• Now, let's talk about the reporting of these codes. HOPDs should report 0598T and 0599T when MolecuLight is medically indicated and used. Now CPT code 0598T is assigned to APC group 5722 and has a 2023 Medicare national average allowable rate of $280.06. And as we discussed, payment for CPT code 0599T is packaged into the payment of CPT code 0598T and does not have a separate OPPS payment. Now, Physicians and QHPs also report 0598T and 0599T when they use MolecuLight in the HOPD.
• Because of the strong published evidence for use of the MolecuLight device, nearly all of the MACs have published rates on their Physician Fee Schedules for both 0598T and 0599T. The average of the MACs published rates is $72.47 for 0598T and $43.93 for 0599T -- however, the rates vary depending on the MAC and the geography where performed.

Before closing this presentation, I would like to thank MolecuLight for sponsoring this reimbursement education program. And in addition, I would like to thank you for allowing me to share how HOPDs should code and how both HOPDs and physicians may be paid by the Medicare Administrative Contractors for the use of MolecuLight fluorescence wound imaging.
 
Thank you very much.