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Q/A: Reporting platelet rich plasma injection on Medicare claims

APCs Insider, January 28, 2011

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Q: The 2011 CPT® Manual includes code 0232T for injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed. May hospitals report this on Medicare outpatient claims?

A: First, let’s review Level III CPT codes published by the AMA. In very simple terms, Level III codes represent services that are considered emerging new technology within the healthcare industry. Very often these procedures, tests, and services are considered investigational or experimental, and many payers will have specific coverage requirements, including noncoverage indications.
Reporting these services begins with a Level III code, which is a temporary assignment of a CPT code with “T” as the last character listed. Most of these codes eventually will be relocated to the front of the CPT Manual along with assignment of a Level I CPT code.

The specific CPT code listed previously is a good example because CMS issued a National Coverage Determination (NCD) related to this service. This determination is one of noncoverage, specifically for chronic, nonhealing cutaneous wounds and acute surgical wounds when autologous platelet rich plasma (PRP) is applied directly to a closed incision or used for dehiscent wounds.

Effective March 19, 2008, upon reconsideration, the evidence is not adequate to conclude that autologous PRP is reasonable and necessary and remains non-covered for the treatment of chronic non-healing, cutaneous wounds. Additionally, upon reconsideration, the evidence is not adequate to conclude that autologous PRP is reasonable and necessary for the treatment of acute surgical wounds when the autologous PRP is applied directly to the closed incision, or for dehiscent wounds.

Note that in CY 2011 Addendum B, code 0232T is assigned to APC 0340 with a national unadjusted payment of $46.23. However, don’t confuse an assigned payment rate in Addendum B with Medicare coverage. Status indicator and payment rate assignments don’t guarantee that a service is covered or medically necessary in a particular circumstance. All hospitals must exercise their own due diligence with internal use of NCDs and Local Coverage Determinations (LCD) as provided by their Medicare Administrative Contractor (MAC).

Share this information with surgical and HIM coding staff members because they may encounter the documentation for this service, specifically in conjunction with arthroscopic procedures, such as shoulder procedures.

Editor’s note: Denise Williams, RN, CPC-H, Director of Revenue Integrity Services at Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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