Presentation on theme: "Coding for Wound Care in 2011: Updates and Changes"— Presentation transcript:
1Coding for Wound Care in 2011: Updates and Changes
2New ICD-9 codes were introduced for 2009 Are YOU using them? For ICD-9 codes the word “Decubitus” has been replaced with the word “Pressure”New Codes:– Pressure ulcer, unspecified stage– Pressure ulcer, stage 1– Pressure ulcer, stage 2– Pressure ulcer, stage 3– Pressure ulcer, stage 4– Disorders of soft tissue, unspecified
3Ulcer & Wound Grading Wagner – 6 Grades UTSA – Lesion Depth with both Ischemia & Infection (Stage A-D, Grade 0-III)Pressure – 4 +2Doesn’t matter which system you use as long as you describe the ulcer adequately
4Pressure Ulcer Grading System Adopted in Feb by the National Pressure Ulcer Advisory Panel:Suspected Deep Tissue Injury - Purple or maroon area of discolored intact skin or blood-filled blister.
5Pressure Ulcer Grading System Stage 1 – Intact skin with non-blanchable redness or a localized area usually over a bony prominence.
6Pressure Ulcer Grading System Stage 2 – Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed.
7Pressure Ulcer Grading System Stage 3 – Full Thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle must not be exposed.
8Pressure Ulcer Grading System Stage 4 – Full Thickness tissue loss with exposed bone, tendon, or muscle. Slough and eschar may be present on some parts of the wound bed.
9Pressure Ulcer Grading System Unstageable – Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
10Ulcer ICD-9 Codes Lower limb 707.10 Ankle 707.13 Calf 707.12 Heel, MidfootFoot, ToesSpecified site NEC
11Codes For Skin Replacement Surgery The skin substitute application codes are being revised by CPT and “should be” available in CPT 2012Indications are that there will be codes based on size of skin substitute alone and not tissue type specificWound site preparation will be allowed to be used with application codesHope to have 0- or 10-day globals
12Codes For Skin Replacement Surgery There are codes for “Surgical Preparation,” formerly called Wound Bed Preparation.The codes are:15002150031500415005
13Codes For Skin Replacement Surgery CPT – Surgical Preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 cm2 or 1% of body area of infants and children.CPT – Each additional 100 cm2 or each additional 1% of body area of infants and children.
14Codes For Skin Replacement Surgery CPT Surgical Preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, neck ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 cm2 or 1% of body area of infants and children.CPT Each additional 100 cm2 or each additional 1% of body area of infants and children.
15Codes For Skin Replacement Surgery CPT 15002, 15003, & CAN be used with:15050 – 1525115330 – 1533615400 – 15421They CANNOT be used with:15340 – 1534115430 – 15431
16Codes For Skin Replacement Surgery CPT (per 25 cm2)APC – 013590-day globalTissue cultured epidermal autograftCultured autologous skin with only an epidermal layerHCPCS – Q4100 (NOS)e.g., CEA, Epicel, EpiDexCheck Medicare LCDs and other insurance policies for coverage of burns
17Codes For Skin Replacement Surgery CPT (per 100 cm2)APC – 013490-day globalAcellular dermal replacementA tissue-derived or manufactured device that provides immediate, temp. wound closure & that incorporates into the wound and promotes the generation of a neodermis that can support epidermal tissueIntegra Wound (510 K Clearance for wound care) - Q4108Check Medicare LCDs and other insurance policies for coverage
18Codes For Skin Replacement Surgery CPT (per 100 cm2)APC – 013590-day globalAllograft skinCadaveric human skin allograftHCPCS - Q4111Homograft-skin from skin banks; Gamma Graft (510- K clearance for wound care)Check Medicare LCDs and other insurance policies for coverage
19Codes For Skin Replacement Surgery CPT (per 100 cm2)APC – 013590-day globalAcellular dermal allograftDecellularized allogeneic dermis may require immediate concurrent coverage with autologous tissuee.g., Alloderm, Graft Jacket (510-K clearance for wound care)HCPCS code Q4107 (Q4113 for Xpress)Check Medicare LCDs and other insurancepolicies for coverage
20Wound Care Code Modifiers Check Medicare LCD for specific use for:KX modifier (Skin substitute products and their application procedures for which the skin substitute was handled, applied, and immobilized appropriately and according to manufacturers’ label instructions)JC (Report skin substitute products used as a skin graftJD (Report skin substitute products not used as a skin graft)JW (Product wasted - discarded)
21Codes For Skin Replacement Surgery CPT (per 25 cm2)G0440 / G0441 (Medicare codes)APC – 013410-day globalTissue cultured allogeneic skin substitute with both a dermal and epidermal layere.g., Apligraf (Q4101)
22CPT 15340 & 15341 G0440 / G0441 have 0-day global CPT & have a 10-day global periodG0440 / G0441 have 0-day globalPost-graft application visits are reimbursed after day 10The HCPCS Q4101 supply code for the product can be billed separately x 44 units& debridement code (11042) included in payment of all codes
24Codes For Skin Replacement Surgery CPT & have a 90-day global period (use -58 to bypass global)G0440 / G0441 have 0-day globalCPT (leg) & (foot/ankle) can be used for “surgical preparation of recipient site” with / 15366, not with “G” codesHCPCS code Q4106 for the product can be billed separately x 37.5 units
25Codes For Skin Replacement Surgery CPT (per 100 cm2)APC – 013590 day globalXenogeneic dermis - nonhuman dermis for temporary wound closuree.g., EZ Derm, Mediskin (510-K approval for wound care) Q4100 (not otherwise specified code)Check Medicare LCDs and other insurance policies for coverage
26Codes For Skin Replacement Surgery CPT per 100 cm2APC – 013590 day globalAcellular xenogeneic implant – de-cellularized nonhuman connective tissueOasis, Surgisis, PriMatrix, MatriStem (510 K approval for wound care)Check Medicare LCDs and other insurance policies for coverage
27CPT 15430 &15431 CPT 15430 & 15431 have a 90-day global period Post-graft application visits are included in the reimbursement (9 level II visits)DO NOT USE MODIFIER – 58HCPCS code for Oasis is Q4102HCPCS code for PriMatrix is Q4110HCPCS code for Surgisis & MatriStem is Q4100 (not otherwise specified code)CPT 1500x & Debridement codes (11042) included
28Codes For Skin Replacement Surgery “These codes are not intended to bereported for simple graft application aloneor application stabilized with dressings(e.g., by simple gauze wrap). ”“The Skin substitute/graft is anchored usingthe surgeon’s choice of fixation. Whenservices are performed in the office, thesupply of the skin substitute/graft shouldbe reported separately. Routine dressingsupplies are not reported separately.”
29Reimbursement for Advanced Wound Care Modalities How payers determine coverageProduct classificationClinical evidenceFDA approval (PMA vs. 510 K)Existing policiesCAC opinionLiteraturePublic comment
30Common Products used for Advanced Wound Care ApprovalCPT CodesGlobalLCD CoverageApligrafPMA (VLU and DFU)15340, 15341(per 25 cm2)G0440/G044110-day0 MedicareVLU and DFUDermagraftPMA (DFU)15365, 15366(per 100 cm2)90-dayDFU; use of -58 modifier variesOasis510K15430, 15431Use of -58 modifier limited or NOIntegra15175, 15176Limited or NO coverageGraftjacket15330,15331Limited coverage
31CMS & Advanced Wound Care Modalities Some MACs are in a “state of flux”The number of Medicare contractors is being condensedLCDs are being changed and re-mixedEvidence-based products are being reimbursedCACs role is changingNot a good time to be a newly listed modalityPrivate insurance may consider many as experimental & investigational
32Change in Wording + New Code 11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 cm2 or less Add-on: each additional 20 cm2, or part thereof
33Change in Wording + New Code 11043 Debridement, muscle, and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 cm2 or less Add-on: each additional 20 cm2, or part thereof
34Change in Wording + New Code Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 cm2 or lessAdd-on:each additional 20 cm2, or part thereof
35CMS & DebridementMany CMS medical directors have expressed in their LCDs that there should be a limited frequency of use for CPT &Place of Service has also come into question by these CMS medical directors.Read your LCD.
36Provider is required to have direct (one-on-one) patient contact.Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area; first 20 cm2.each additional 20 cm2.
41Full Thickness, Subcutaneous Tissue, Muscle, & Bone
42Other Codes for Wound Care 11000 – Debridement of extensive eczematous or infected skin; up to 10% of body surfaceThis code will be deleted in 2011Typically a code used primarily for dermatological purposesShould be used sparingly in diabetic, venous stasis, and pressure ulcers0-day globalNot typically a “podiatric” code
43Other Codes for Wound Care 20000 – has been deleted in 201120005 – Incision and drainage of soft tissue abscess, subfascial, (ie, involves the soft tissue below the deep fascia) (verbiage changed)These codes may be used in conjunction with a diagnosis of osteomyelitis10-day global
44Other Codes for Wound Care 27603 – Incision & drainage, leg or ankle; deep abscess or hematoma27607 – Incision (e.g., osteomyelitis or bone abscess), leg or ankle27640 – Partial excision (craterization, saucerization, or diaphysectomy) bone (osteomyelitis or exostosis); tibia27641 – fibulaThese codes have a 90-day global
45Other Codes for Wound Care 28120 – Partial excision (craterization, saucerization, or diaphysectomy) bone (osteomyelitis or bossing); talus or calcaneus28122 – tarsal or metatarsal bone, except talus or calcaneus28124 – phalanx of toeThese codes have a 90-day global
46Other Codes for Wound Care 28002 – Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space10-day global28003 – multiple areas90-day global28005 – Incision, bone cortex (e.g., osteomyelitis or bone abscess), foot
47Negative Pressure Wound Therapy Codes 97605 – NPWT (vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction for ongoing care, per session; total wound(s) surface area less than or equal to 50 cm297606 – total wound surface greater than 50 cm2Selective debridement and dressings are INCLUDED in these codesFDA warning about bleeding complications – Document that you have explained this to your patient
48Unna Boot Code 29580 – Unna Boot This is “officially” listed in the “casting and strapping” section of CPT and, therefore, it is not considered a bandage and is separately billable
49Multi-Layer Compression System – NEW CPT CODE for 2010 For multi-layer compression dressing, also known as a “high compression bandage system” (Profore, DynaFlex), the NEW CPT code is
50Reimbursement for Advanced Wound Care Modalities Always check your LCD for coverage and payment variationsThere are many inconsistencies for products and procedures from payer to payerProducts and procedures with consistent coverage are typically safe, effective, and provide multiple patient and physician benefits
51Platelet Rich Plasma Category III (tracking) code - 0232T Effective as of 1/01/20100232T – Injection(s), platelet rich plasma, any tissue, including guidance, harvesting and preparation when performedA high-quality study just published in JAMA showed that platelet rich plasma was not effective in treating Achilles tendinitis