"Confusion" is the best word to describe many wound/ulcer management stakeholders' understanding of the coding and Medicare payment for cellular and/or tissue-based products (CTPs) for skin wounds. Because this author has been involved with education about and reimbursement strategies for CTPs since their inception in the late 1990s, she has seen coding, coverage, and payments change multiple times, resulting in providers' uncertainty.
In the early days of CTPs, the coding was quite simple: each brand of CTP was assigned a unique Healthcare Common Procedure Coding System (HCPCS) code, and the application codes were based on the anatomic location and size of the wound/ulcer. Therefore, preparing claims for the application of CTPs and understanding the Medicare allowable rates for the CTPs and their application was straightforward. The hardest part was obtaining coverage for each brand of CTP from the Medicare Administrative Contractors (MACs) and other payers.
If the brand of CTP was covered by the pertinent MAC, the Medicare payment to the physician or other qualified healthcare professional (QHP) for the CTP was based on its average sales price (ASP) plus 6%. Payment for the eight CTP application codes was based on the relative value units assigned to each code. Similarly, if the brand of CTP was covered by the pertinent MAC, the Medicare payment to the hospital-owned outpatient wound/ulcer management provider-based department (PBD), was ASP plus 6% for the product, and the ambulatory payment classification (APC) rate for the eight CTP application codes.
As the number of products on the market has exploded, the CMS has attempted to control the Medicare payment for the products and their application. However, these attempts have not always produced CMS's anticipated cost reduction, and have caused confusion to the physicians, QHPs, and PBDs. In this article, the author shares some CTP issues that still confuse wound/ulcer management stakeholders.
Confusing Issues for Physician/QHP Offices
* Even though CTP manufacturers report the ASPs of their CTPs every quarter, CMS has not published the ASPs for all brands of CTPs. For the products without published ASPs, the physician/QHP offices must report (on/with their claims) additional information regarding the invoice price of the product. The MACs continue to change both the information that is required and the method of submission. Therefore, physicians and QHPs should check their MAC's website for claim submission requirements when CMS has not published ASPs.
* When a physician/QHP finds it medically necessary to use one of the new CTPs that is assigned an A2XXX code, their coders and billers hesitate to report that code because they think that all HCPCS "A" codes are for supplies, which are not separately payable by Medicare. Physicians/QHPs should educate their coders and billers that the A2XXX codes are separately payable if the CTP is covered by their MAC.
* When physicians/QHPs apply low-cost CTPs in the PBD, they often tell their coders to report one of the application codes (C5271-C5278) for low-cost CTPs because they mistakenly believe they must distinguish between the application of high-cost and low-cost CTPs. However, physicians/QHPs should always use 15271-15278 to report their work applying CTPs no matter where they perform the procedure.
* When physicians/QHPs apply CTPs in their offices, they should report the number of sq cm of the product that was purchased for each patient. When their coders and billers see multiple units reported, such as 10, 30, 44, they frequently only report a unit of "1" on the claim. The physicians/QHPs then receive payment for only 1 sq cm, rather than the number of sq cm that were purchased for their patients' wounds/ulcers. When the coders and billers are queried about why they only reported a unit of "1," they typically say they know the physicians/QHPs only used one piece. The coders and billers should be reminded that the product code description is "per sq cm," not "per each."
* For many years, physician/QHP offices have been required to report the number of CTP sq cm applied on one claim line, and the number of CTP sq cm wasted on a second claim line. To identify that the units reported on the second claim line are for the amount wasted, the JW modifier (Drug/biological amount discard/not administered to any patient) is required to be attached to the HCPCS code on the second claim line. Because CMS is concerned about product wastage, they are tightening the coding requirements. Effective July 1, 2023, physician/QHP offices must append the modifier JZ (Zero drug amount discarded/not administered to any patient) to the HCPCS code when the entire sheet was applied and nothing was discarded. All CTP application claims without either JW or JZ will not be paid, and additional documentation will be requested. Effective October 1, 2023, claims without the appropriate JW and JZ modifiers will be returned as unprocessable.
Confusing Issues for PBDs
* Currently, CMS packages the payment for the CTP into the payment for the application. Because cost varies widely among the nearly 200 CTPs on the market, CMS divides the products into high-cost and low-cost payment groups. The high-cost products must be reported along with the application codes 15271-15278. The low-cost products must be reported along with the CMS-created application codes C5271-C5278. However, because CMS assigns HCPCS codes to new CTPs four times a year, PBD staff have a challenging time identifying which new CTPs are assigned to the high-cost and low-cost payment packages. Intuitively, they look at the Addendum A and B Updates to the Outpatient Prospective Payment System (OPPS) that are released quarterly, but those files only contain the CTP codes and the "N" status indicator, which shows that the payment for the CTP products is packaged into the payment for the application procedure. Very few PBDs are aware of the Integrated Outpatient Code Editor (I/OCE) Specifications,1,2 which are released at the beginning of every quarter. The January I/OCE update always includes a table of all the CTP high-cost/low-cost packaged payment assignments that exist on January 1 of that year. The April, July, and October I/OCE updates only include a table of the new CTPs and their high-cost/low-cost packaged payment assignments. If the PBD staff want to maintain a complete table of high-cost and low-cost packaged payment assignments, they must manually add the new products to the table that is released in the I/OCE every January.
* Many PBDs only load the application codes (15271-15278) for the high-cost products into their Charge Description Masters. This is problematic when physicians/QHPs wish to use newly released CTPs, which are usually assigned to the low-cost payment package until the manufacturers share the product's cost with CMS. Before adding the HCPCS code for a new CTP into their Charge Description Master, PBD staff should verify if it is assigned to the high-cost or low-cost payment package. If the PBD is using one or more CTPs that are assigned to the low-cost package, the application codes (C5271-C5278) should be added to the PBD Charge Description Master and reported when a low-cost CTP is applied. CAUTION: As stated above, physicians/QHPs should always use 15271-15278 to report the application of both high-cost and low-cost CTPs.
* Like the physician/QHP issue described above, PBD coders and billers hesitate to report the A2XXX codes that CMS assigns to some new CTPs and must be educated that the A2XXX codes, just like the "Q" codes, are required on the same claim with the application codes; if the product code is not on the claim, the procedure code will not be paid.
Confusing Issue for All Physicians, QHPs, and PBDs
Reimbursement is composed of three parts: coding, coverage, and payment. Often, CMS creates codes for products that may not be covered and paid for by Medicare, as is the case with CTPs that are not in sheet form. The CTP application codes are in the surgical section of the Current Procedural Terminology (CPT(R))1 book. The codes are described as skin substitute grafts, which means that sheet CTPs are grafted and anchored using the physician's/QHP's choice of fixation. The CPT book clearly states that the application codes should not be reported with other forms of CTPs such as gels, powders, ointments, foams, or liquids. In the 2023 OPPS Final Rule, CMS clarified that they follow the American Medical Association's guidelines and do not cover and pay for the application of CTPs that are not a sheet product (CTPs that are available in sheet form are easily identified because their HCPCS code description always includes the words, "per sq. cm.").
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