Coding & Reimbursement

Transcription

1 2013 Coding & Reimbursement

2 2013 Coding and Reimbursement MatriStem is a unique extracellular matrix derived from a porcine urinary bladder. It has been shown to be effective in the treatment of acute and recalcitrant ulcers in a variety of clinical settings. When used in the hospital, reimbursement varies by payer, contract terms and site of service. To help answer common coding and reimbursement questions from physicians, coders and hospital administrators, the following information is shared for educational and strategic planning purposes only. While ACell believes this information to be correct, coding information is subject to change without notice and providers are encouraged to speak regularly with their payers. For more information about ACell and MatriStem, please speak with your local sales professional or call the ACell Reimbursement Help Line at (800) x7. DISCLAIMER: The payments specified in this document are Centers for Medicare & Medicaid Services (CMS) national unadjusted averages. Actual payment rates will vary based on geographical adjustment to payments. As such, all codes provided herein are for illustrative purposes only and shall not be construed as a warranty, statement, promise or guarantee that these codes are accurate or that the product will be covered in all instances, and if covered, that reimbursement in the amounts specified will be received. Coding practice will vary by site of care, patient condition, range of services provided, local payer instructions and other factors. The decision as how to complete a reimbursement claim form, including codes and amounts to bill, is exclusively the responsibility of the provider. Coding requirements are subject to change at any time-check with your local payer regularly. Current Procedural Terminology (CPT) is registered trademark of the American Medical Association (AMA). 1

3 Indications MatriStem MicroMatrix (particles) is intended for the management of topical wounds including: partial and full- thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor sites/grafts, post-mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns and skin-tears), and draining wounds. The device is intended for one-time use. K MatriStem Wound Matrix (fenestrated sheets) is intended for the management of wounds including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/ undermined wounds, surgical wounds (donor sites/grafts, post-mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns and skin-tears), and draining wounds. The device is intended for one-time use. K MatriStem Multilayer Wound Matrix (meshed sheets) is intended for the management of wounds including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/ undermined wounds, surgical wounds (donor sites/grafts, post- Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns and skin-tears), and draining wounds. The device is intended for one-time use. K MatriStem Burn Matrix (meshed sheets) is intended for the management of wounds including: second-degree burns, partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor sites/grafts, post- Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, skin tears) and draining wounds. The device is intended for one-time use. K MatriStem Surgical Matrix RS, PSM, PSMX, & Thick (surgical mesh) are intended for implantation to reinforce soft tissue where weakness exists in urological, gynecological, and gastrointestinal anatomy including, but not limited to the following procedures: pubourethral support, tissue repair, body wall repair and esophageal repair. The device is intended for one-time use. K MatriStem Pelvic Floor Matrix (surgical mesh) is intended for implantation to reinforce soft tissue where weakness exists in gynecological anatomy including vaginal prolapse repair and reconstruction of pelvic floor. The device is intended for one-time use. K

4 Physician & Outpatient Facility Wound Care Coding Considerations Surgeons and professional coders are encouraged to review a current copy of AMA s CPT 2013 for the complete definition of Integumentary System surgery codes. For educational purposes only, common procedures include, but are not limited to, the following considerations: CPT Codes Debridement Codes Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Surgical Preparation Codes For Skin Replacement Surgery Used For Burns, Traumatic Wounds Or Necrotizing Infection 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 sq cm or 1% of body area of infants and children each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) 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, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) 3

5 CPT Codes Skin Substitutes Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area each; additional 25 sq. cm wound surface area, or part thereof. (List separately in addition to code for primary procedure) Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof. (List separately in addition to code for primary procedure) Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area each additional 25 sq. cm wound surface area, or part thereof. (List separately in addition to code for primary procedure) Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof. (List separately in addition to code for primary procedure) Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition to code primary procedure). Wound Management Codes Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Removal of devitalized tissue from wound(s); non-selective debridement, without anesthesia (eg, wet to-moist dressings, enzymatic, brasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters total wound(s) surface area greater than 50 square centimeters 4

6 Outpatient Facility Surgical Coding Considerations For educational purposes only, common Pelvic Floor, Hernia Repair, and Burns surgical procedures include, but are not limited to, the following considerations: CPT Codes Burns Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) medium (e.g., whole face or whole extremity, or 5% to 10% total body surface area) large (e.g., more than 1 extremity, or greater than 10% total body surface area) Escharotomy; initial incision each additional incision (List separately in addition to code for primary procedure) Hernia Repair Repair, paraesophageal hiatal hernia (including fundoplication); via laparotomy, except neonatal; without implantation of mesh or other prosthesis with implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication); via thoracotomy, except neonatal; without implantation of mesh or other prosthesis with implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication); via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis with implantation of mesh or other prosthesis Repair initial incisional or ventral hernia; reducible incarcerated or strangulated Repair recurrent incisional or ventral hernia; reducible incarcerated or strangulated Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection Repair umbilical hernia, age 5 yrs or older; reducible incarcerated or strangulated 5

7 CPT Codes Pelvic Floor Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy Combined anteroposterior colporrhaphy with enterocele repair Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach. (List separately in addition to code for primary procedure) Repair of enterocele, vaginal approach (separate procedure) Colpopexy, vaginal, extra peritoneal approach (sacrospinous, iliococygeus) Colpopexy, vaginal, intra peritoneal approach (uterosacral, levator myorrhaphy) Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach Paravaginal defect repair (including repair of cystocele, if performed); laparoscopic approach Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy Combined anteroposterior colporrhaphy with enterocele repair Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach. (List separately in addition to code for primary procedure) Repair of enterocele, vaginal approach (separate procedure) Colpopexy, vaginal, extra peritoneal approach (sacrospinous, iliococygeus) Colpopexy, vaginal, intra peritoneal approach (uterosacral, levator myorrhaphy) Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach Paravaginal defect repair (including repair of cystocele, if performed); laparoscopic approach 6

8 Inpatient Reimbursement: The site of service is dependent upon the patient s clinical presentation and determined at the discretion of the surgeon. Hospital inpatient facilities use Internal Classification of Disease, Ninth Revision, Clinical Modification (ICD- 9-CM) Procedure Codes (Volume 3) to describe procedures administered in the inpatient setting. ICD-9-CM Procedure Codes that appear relevant for wound care include, but are not limited to, the following considerations: ICD-9-CM Common Primary Procedures for Wounds and/or Burns Excisional debridement of wound, infection, or burn Nonexcisional debridement of wound, infection, or burn Heterograft to skin Other repair and reconstruction of skin and subcutaneous tissues Application of other wound dressing Common Primary Procedures for Pelvic Floor Repair of cystocele and rectocele Repair of cystocele with graft or prosthesis Vaginal suspension and fixation with graft or prosthesis Vaginal suspension and fixation Common Primary Procedures for Hernia Repair Repair initial incisional or ventral hernia; reducible incarcerated or strangulated Repair recurrent incisional or ventral hernia; reducible incarcerated or strangulated Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection Repair umbilical hernia, age 5 yrs or older; reducible Source: ICD-9-CM 2013, American Medical Association, Chicago, IL 7

9 Potential MS-DRG and Ambulatory Payment Classification (APC): The ICD-9-CM Diagnosis Code(s) (principal diagnosis and secondary diagnoses) and primary ICD-9-CM Procedure Code(s), along with other factors, determine the Diagnosis Related Group (DRG) that may apply to an inpatient discharge. If the procedure is performed in the outpatient setting (hospital outpatient department or ambulatory surgery center), the facility would select the appropriate CPT code. Relevant CPT codes, along with the corresponding Ambulatory Payment Classification (APC) and/or Ambulatory Surgical Center (ASC) payment rates, are also displayed below: MS-DRG - Wounds and Burns 463 Wound Debridement and Skin Graft except Hand, for Musculo-Connective Tissue Disorders with MCC 464 Wound Debridement and Skin Graft except Hand, for Musculo-Connective Tissue Disorders with CC 573 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis with MCC 574 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis with CC 575 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC 576 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis with MCC 577 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis with CC 578 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC 622 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC 623 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC Ambulatory Payment Classification (APC) - Wounds and Burns 133 Level I Skin Repair 134 Level II Skin Repair 135 Level III Skin Repair 136 Level V Skin Repair 8

10 MS-DRG - Pelvic Floor 662 Minor Bladder Procedures with MCC 663 Minor Bladder Procedures with CC 664 Minor Bladder Procedures without CC/MCC 748 Female Reproductive System Reconstructive Procedures Ambulatory Payment Classification (APC) - Pelvic Floor 195 Level VI Female Reproductive Procedures 202 Level VII Female Reproductive Procedures MS-DRG - Hernia Repair 353 Hernia Procedures Except Inguinal and Femoral with MCC 354 Hernia Procedures Except Inguinal and Femoral with CC 355 Hernia Procedures Except Inguinal and Femoral without CC/MCC 907 Other O.R. Procedures for Injuries with MCC 908 Other O.R. Procedures for Injuries with CC 909 Other O.R. Procedures for Injuries without CC/MCC Ambulatory Payment Classification (APC) - Hernia Repair 154 Hernia/Hydrocele Procedures MS-DRG - Burns 570 Skin Debridement with MCC 571 Skin Debridement with CC 572 Skin Debridement without CC/MCC 9

11 Ambulatory Payment Classification (APC) - Burns 013 Level II Debridement & Destruction 015 Level III Debridement & Destruction Medicare Addendum B - Final OPPS Payment by HCPCS Code for CY 2013 Code Description CMS Allowable Q4118 MatriStem MicroMatrix Please see website for current reimbursement rates. Q4119 Q4120 MatriStem Wound Matrix MatriStem Multilayer Wound Matrix MatriStem Burn Matrix Please see website for current reimbursement rates. C1763* Connective tissue, non-human (includes synthetic) C1781* Mesh (implantable) *Most commonly used with MatriStem Surgical Matrix RS, PSM, PSMX, & Thick Notes: Source: AMA HCPCS Level II For additional information and personal assistance, please call the ACell Reimbursement Help Line at (800) x7. 10

12 ACell, Inc Eli Whitney Drive Suite 200 Columbia, MD MK /2013