2016 Update: Cellular and/or Tissue Based Products for Wounds.
Many readers have been asking questions about the 2016 Medicare outpatient prospective payment system (OPPS) coding, payment, and coverage of cellular and/or tissue based products for wounds (CTPs; outdated term 'skin substitute' I have gathered all the readers' questions on this topic andwill provide the answers. As a reminder, please continue to send questions that you would like to see answered in this column. Q: Did any new CTPs receive Healthcare Common Procedure Coding System (HCPCS) codes for 2016? A: Yes, several new CTPs were assigned HCPCS codes effective January 1, 2016. Q4161 BIO CONNEKTWoundMatrix, per square centimeter Q4162AMNIOPROFlow, BIOSKINFlow, BIORENEWFlow, WOUNDEX Flow, AMNIOGEN A, AMNIOGEN C, 0.5 mL Q4163 AMNIOPRO, BIOSKIN, BIORENEW, WOUNDEX, AMNIOGEN 45, AMNIOGEN 200, per square centimeter Q4164 HELICOLL, per square centimeter Q4165 KERAMATRIX, per square centimeter Q: I am confused by the 2016 descriptions for HCPCS codes C9349 and Q4153. Did their descriptions change from 2015? A: Yes, their descriptions did change. See Table 1. If you use those products, be sure to update your charge sheets and/or your Charge Description Masters (CDMs) Q: Are the CTPs still packaged into the OPPS payment for the associated CTP application procedure? A: Yes, the CTPs that do not qualify for OPPS pass through status are packaged into the OPPS payment for the associated CTP application procedure. For OPPS packaging purposes, the CTPs are divided into 2 groups: (1) 'high cost' CTPs and (2) 'low cost' CTPs. Table 2 lists theCTPproducts assigned to the high cost group in 2015 versus 2016, and Table 3 lists the CTP products assigned to the low cost group in 2015 versus 2016. For Medicare billing, high cost CTPs should be reported in combination with the performance of one of the CTP application procedures described by CPT* codes 15271Y15278. For Medicare billing, low cost CTPs should be reported in combination with the performance of one of the CTP application procedures described by HCPCS codes C5271YC5278. Q: What are the packaged 2016 OPPS payment rates for the application of high cost and low cost CTPs? A: Table 4 displays the changes, from 2015 to 2016, of OPPS payment rates for high cost CTPs. Table 5 displays the changes, from 2015 to 2016, of OPPS payment rates for lowcost CTPs. Many readers know that I keep reminding the hospital based outpatient wound care departments (HOPDs) to check their CDM charges for the application of CTPs to wounds equal to or greater than 100 sq cm. Here's the reason why: The OPPS charges submitted to Medicare in 2013 set the OPPS national average allowable rates for 2015, and the 2014 OPPS charges submitted to Medicare in 2014 set the OPPS national average allowable rates for 2016. Please note that in 2013 HOPDs chargedmore for high cost CTPs applied towounds equal to or greater than 100 sq cm on the trunk, arms, and legs (15273) than they did for the same size wounds on smaller anatomic locations such as the feet (15277) This made no sense to me because the HOPDs had to purchase the same amount of product for wounds equal to or greater than 100 sq cmVnomatter what anatomic location was receiving the CTP application. This hugeCDMerror caused the 2015OPPS rates for 15273 and 15277 to be widely different. SomeHOPDs corrected thatCDMerror in 2014,which caused the 2016 rates to be identical for 15273 and 15277. However, HOPDs should carefully examine their 2016 CDM charges for application of high cost CTPs to large wounds. Ask yourself, 'How much will the HOPD have to pay for the high cost CTP that the HOPD uses for wounds equal to or greater than 100 sq cm? Youmay find that your HOPD needs to increase your CDM charges for 15273 and 15277. Remember, your 2016 charges are setting your 2018 OPPS allowable rates. A similar situation occurred for low cost CTPs applied to wounds equal to or greater than 100 sq cm. In 2013, HOPDs chargedmore for low cost CTPs applied towounds equal to or
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