How QHPs Can Tackle CTP Reimbursement Challenges

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My name is Kathleen Schaum and I'm the president of Kathleen D. Schaum and Associates Inc. And it is a consulting company that does reimbursement strategy and education for wound and ulcer management professionals and provider-based departments like wound care clinics and manufacturers and sales representatives.
 
What are the biggest challenges in the changing reimbursement climate for CTPs?
 
Well, reimbursement is composed of three things: coding, coverage, and payment, but the existence of a code doesn't guarantee coverage, and the existence of a code in an even a payment rate doesn't guarantee coverage. And more than 20 years ago the first CTPs were developed and released into the marketplace and in that time the Medicare administrative contractors would only pay for CTPs that had published evidence.
 
We are now seeing a switch back to that, where there's so many CTPs on the market, and the payers are starting to say, "Wait a minute, we only want to cover those that actually have published evidence, much like other drugs. We wouldn't use a drug that didn't have a trial and didn't have a study published." Well, the same is with the CTPs. So we are seeing a swing back to that.
 
Now why is that sort of a challenge is because there's quite a few manufacturers who haven't done published trials and haven't done the trials and then published them on CTPs. So that creates a bit of an issue because some of those products may not be covered now by the payers and the commercial payers haven't been covering them for a long time. The commercial payers only tend to cover the ones that do have published trials and published evidence and it seems as if Medicare is swinging back to that.
 
So the physicians who've been using just a huge variety of products may have to themselves shift back to saying, “Does this have published evidence? Why am I using this? Does this have the evidence so that it will be covered?”
 
The other thing that we find is that they often, in their documentation, aren't really justifying “What did I do with this wound and tried, and then the wound just didn't progress, and then why do I use a CTP? So what's the medical necessity for the CTP?” But then more importantly “Why did I pick this specific brand?” And that does need to be documented. And that has seemingly been a challenge for our physicians because when they get audited, we find that they haven't documented the why am I doing this and why am I using this brand?
 
And then the other challenge that they seem to have is they fail to realize that this is a surgical procedure. Even though you may not be doing it in an OR, it is still considered a surgical procedure. And so they need to document it as it is a surgical procedure and follow all the steps that need to be included in an operative report.
 
How can QHPs best tackle challenges with CTPs?
 
Well, they first have to follow the clinical practice guidelines that align with why would you use a CTP. They also have to pay attention to the payer’s coverage guidelines. That's really important.
 
And then before they do use a CTP, they really need to document everything they've been doing for the wound or ulcer all through the three, four weeks, however long they're doing conservative or standard care. And they need to do that better because if they document that clearly and then that brings them to the decision that they need to use a CTP, it should be very clear why they are doing that. And then they need to justify in that documentation—“Okay, we tried this, here's what's happening, the wound is stalled, it's not progressing”—and so then they need to document the medical necessity for what they are doing.
 
“Why am I doing this?” I cannot emphasize that enough. They seem to just say, "Applying a CTP." All right, when they really need to say, "Why am I doing it?" And then, "Okay, there's over 200 CTPs out there. Why am I picking this specific brand?" And it does need to be documented.
 
And then remembering that it is a surgical procedure, they need to document all the steps of the application of the CTP, including the fact that they fixated it, et cetera, into their documentation. They can't just say applied X CTP. They have to give all these steps, just like if they were in an OR, they need to do that.
 
The other thing they need to really remember is that Medicare only covers products that are in a sheet form, that come in a sheet form. So if they are using a product that is a sprinkle or a powder, or a cut-up, or whatever, they cannot use the application codes for that. They would have to report that as an evaluation and management service. They can't report it as an application.
 
And then finally, they need to pay attention to the code descriptions. Because the code descriptions for the application are in 25 square centimeter increments or 100 square centimeter increments. And they need to report the application code based on the size of the wound that they're taking care of, not on the size of the product that they purchased.