Health Information Management

Note changes for skin substitutes, mental health codes

JustCoding News: Outpatient, May 30, 2012

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Facilities can't bill for skin substitutes unless they also bill for a skin substitute application procedure on the same date, according to the April update to the Integrated Outpatient Code Editor (I/OCE). If facilities don't comply with this practice, they won't receive payment for the skin substitute. The April update includes a list of eight procedure codes (CPT® codes 15271-15278) and 27 specific skin graft materials.

"You can't just bill the material by itself and expect to get paid for it," says Dave Fee, MBA, product marketing manager of outpatient products at 3M Health Information Systems in Murray, Utah. "You have to be very clear about what you did."

Three of the skin substitute codes have status indicator G, meaning CMS will reimburse facilities at average sales price (ASP) plus 6% when these codes are reported. Two of the skin substitute codes are packaged with status indicator N, and the remaining 22 codes have a status indicator K, meaning facilities receive ASP plus 4% reimbursement.

"This is the biggest issue [in the update] for any facility that does a lot of grafting, such as those that treat a lot of burn patients," Fee says. Facility coders may also see these skin substitutes applied to cancer patients who had skin removed or patients with certain infections that damage the skin. Every time coders report one of the 27 skin substitute codes, they need to make sure they also report an accepted procedure code.

Some of the skin substitutes are very costly, so facilities could lose significant revenue if coders don't report the skin substitute and the application procedure together, Fee says. For example, Q4114 (Integra flowable wound matrix, injectable, 1cc) reimburses approximately $1,090 per unit. When reported alone—and without the procedure—this error can have a large financial impact, he explains.

Coders and chargemaster coordinators must note two caveats to the April update regarding skin substitutes. The first involves TRICARE, which is an insurance provider for military personnel and their families. TRICARE is following CMS' lead by requiring facilities to report skin substitutes and application procedures on the same date as a prerequisite for payment. However, TRICARE modified the list of skin substitute codes by adding two codes and removing five.

"They have 24 codes for the graft material instead of 27, and two of them are different," Fee says. "I thought that was interesting."

The second caveat involves ambulatory surgery centers (ASC). At this time, it's unclear whether ASCs will follow the same rules when billing skin substitutes and their application, Fee says. "I know there are two codes, Q4100 and Q4130, that are not on the list of skin substitutes for ASCs."

Coders must pay attention to the setting in which the procedure took place, what procedure the provider performed, and the third-party payer that will be processing the claim. These factors will affect how coders report the services.

Mental health diagnosis codes
CMS added the following six long-standing ICD-9-CM mental health codes to the list of codes that qualify patients for partial hospitalization programs:

  • 291.89: Other alcohol-induced mental disorders
  • 293.84: Anxiety disorder in conditions classified elsewhere
  • 327.02: Insomnia due to mental disorder
  • 327.15: Hypersomnia due to mental disorder
  • 327.42: REM sleep behavior disorder
  • 327.43: Recurrent isolated sleep paralysis

Bilateral CPT codes
CMS removed CPT code 36000 (introduction of needle or intracatheter, vein) from the conditionally bilateral list. In addition, CMS removed the following two codes from the inherently bilateral list and added them to the conditionally bilateral list:

  • 64613: Chemodenervation of muscle(s); muscle(s) innervated by facial nerve
  • 64614: Chemodenervation of muscle(s); cervical spinal muscle(s)

When a provider performs a conditionally bilateral service bilaterally, coders must append modifier -50 (bilateral procedure) to the code.

New pass-through drugs and biologics
CMS granted pass-through status for these four HCPCS codes:

  • C9288: Injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial
  • C9289: Injection, asparaginase Erwinia chrysanthemi, 1,000 international units (IU)
  • C9290: Injection, bupivicaine liposome, 1 mg
  • C9291: Injection, aflibercept, 2 mg vial

CMS published specific instructions regarding code C9291:

Eylea (aflibercept) is packaged in a sterile, 3 mL single use vial containing a 0.278 mL fill of 40 mg/mL Eylea (NDC 61755-0005-02). As approved by the Food and Drug Administration (FDA), the recommended dose for Eylea is 2 mg every 4 weeks, followed by 2 mg every 8 weeks. Payment for HCPCS code C9291 is for the entire contents of the single-use vial, which is labeled as providing a 2 mg dose of aflibercept. As indicated in 42 CFR § 414.904, CMS calculates an ASP payment limit based on the amount of product included in a vial or other container as reflected on the FDA-approved label, and any additional product contained in the vial or other container does not represent a cost to providers and is not incorporated into the ASP payment limit. In addition, no payment is made for amounts of product in excess of that reflected on the FDA-approved label.

CMS deactivated these two modifiers:

  • V8: Dialysis access-related infection is present ¬(documented and treated) during the billing month
  • V9: No dialysis access-related infection, as defined for modifier V8, is present during the billing month

The complete April 2012 update to the I/OCE can be downloaded from the CMS website.

Editor’s note: This article was originally published in the June issue of Briefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at


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