The G-Code Solution to Skin Substitute Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) along with the Medicare Administrative Contractors (MACs) are actively working on updating skin substitute policies to address the infusion of new products and skyrocketing prices the space has seen in the past 5 years. This has resulted in payment policies and coverage decisions being considered that may jeopardize wound care as a specialty.
 
To address this area of policy in a holistic, long-term manner in which the practice can remain viable for the critical Medicare beneficiaries it serves, I am calling on CMS to adopt new G codes to replace Q code reimbursement and CPT 15000 codes for skin substitute application procedures and to establish skin substitute product code classes.

Shortcomings of Bundling Product Reimbursement with Application Service Reimbursement

In the CY 2023 Payment rules CMS acknowledged comments stating that providers are discouraged from treating wounds between 26 and 99 sq cm and over 100 sq cm in the outpatient hospital setting because of the financial losses the hospital experiences to provide such care.
 
CMS stated, “For example, it is possible that a provider could experience a financial loss when they perform a service where a patient receives 85 sq cm of a graft skin substitute product, but that same provider could see a financial gain when the next patient receives a skin graft where only 10 sq cm of product is used.”¹ 

Policy Solution: G Codes and Product Classes

CMS should establish temporary per square cm G codes to replace the current CPT skin substitute application codes. This would update the terminology, right-size the units with current utilization patterns, and categorize the codes by graft composition classes. CMS can swiftly implement these updates with G codes, whereas updating the old CPT 15271–15278 codes would take several years to be ushered through the American Medical Association’s (AMA) process. The Q codes for each individual product would remain and be billed, but at a zero-dollar amount. This allows for data tracking of individual product utilization. G code billing would be capped with a Medically Unnecessary Edit (MUE) of 200 square cm to prevent weekly skin substitute application to wounds too large to be healed by skin substitutes.
 
By creating these G codes, CMS would be able to address the terminology issues identified in previous rulemaking, while also being provided an opportunity to revisit the increments of each code (eg, providing for 1 sq cm increments) to best fit the codes for the wound sizes being treated in the hospital outpatient setting so as to ensure adequate reimbursement for services rendered and resources being utilized.
 
CMS should assign G-codes to the following classes of skin substitute types:

Human Living/Cryopreserved Tissue
Dehydrated Human/Amniotic Tissue
Animal Xenografts
Synthetics/Polymers

This would allow products to be compared to similar products and for them to be priced based on the cost of manufacturing. Manufacturers of a particular skin substitute product would have to provide graft composition type as well as evidence-based research/literature in order to be assigned to one of the following G code classifications:

Billing these new G codes would work in the following manner:
 
Physician office/home/nursing home. The new G codes would replace the CPT 15000 series application codes. One would bill both the new G code and the product code (ie, the A or Q code). The G code would reimburse at a capped per square cm rate corresponding to one of the four G code classifications. The product A or Q code would be submitted as a supply provided incident to a physician service and reimburse zero dollars. This allows for tracking of individual product utilization. The number of G code units allowed would be capped at 200 square cm. Since the CPT 15000 application codes are now replaced by the G codes, there is no second reimbursement for a single application. 
 
Hospital outpatient department (HOPD). The new G codes would replace the CPT 15000 series application codes. The hospital would bill both the new G code and the product code (ie, the A or Q code). The G code would reimburse at a capped per square cm rate corresponding to one of the four G code classifications. The product A or Q code would be submitted as a supply provided incident to a physician service and reimburse zero dollars. This allows for tracking of individual product utilization. The number of G code units allowed would be capped at 200 square cm. The physician would bill the G code and receive a flat physician rate (non-per square cm) in the same manner that the CPT 15000 currently does.
 
CMS administrators seemed very receptive to the G-code concept as it can be implemented quickly and seamlessly. It allows for an equal payment structure across all sites of service so that large wounds may also be treated in the HOPD setting. Lastly, with a reasonable reimbursement per square cm cap on each G code category, it would save CMS hundreds of millions of dollars per year and stop the cycle of skyrocketing skin substitute costs that have been threatening the viability of this important advanced modality.
 
I am asking for stakeholders to sign the attached petition to support a G-code solution and email it to:
gift.tee@cms.hhs.gov and zehra.hussain@cms.hhs.gov
 
Shaun Carpenter, MD, CWSP, is the Chief Medical Officer of MedCentris Wound Healing Institutes. Contact him at Dr.scarpenter@medcentris.com.

Reference

1. Centers for Medicare and Medicaid Services. Response to Comments: Skin Substitute Grafts/Cellular and/or Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers.

Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Today’s Wound Clinic or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.