Health Information Management

Q/A: Coding for wound care with no-cost skin substitute

APCs Insider, October 19, 2012

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Q: Our wound care department receives skin substitutes, such as Apligraf, from our vendor free of charge. Since we aren’t purchasing the skin substitute, we can’t report the skin substitute HCPCS code and we are receiving an edit for reporting the procedure without a corresponding skin substitute. Can we report a debridement code instead since the provided debrided the wound bed before using the product?

A: First and foremost, it is inappropriate to approximate a lesser CPT® code for a procedure that has a dedicated CPT code. Therefore, do not report a debridement code for the skin substitute application because the preparation of the wound bed is integral to the overall skin substitute procedure.
Next, reviewing the edit files on the CMS website. CMS has not instituted a device-to-procedure or procedure-to-device edit to require the skin substitute HCPCs code and application HCPCs code be reported together. 
With that said, the April 2012 update to OPPS (Transmittal 2418) states:
Hospitals are reminded that HCPCS codes describing products that can be used as skin substitutes, as listed in Table 5 below, will be separately paid only when used with one of the CPT codes describing the application of a skin substitute (15271-15278). Effective April 1, 2012, CMS is implementing logic changes to the I/OCE to ensure that separate payment is made for skin substitutes only when they are billed with a skin substitute application procedure.
The description of this edit indicates that it is a reimbursement rule that prevents separate payment for the skin substitute unless it is reported with the appropriate application code. Beginning April 1, 2012, the I/OCE should reimburse the code for the skin substitute only when reported with one of the specific application codes (CPT 15271-15278).
The documentation in Integrated OCE, version 13.1, supports this also:
22) Certain skin substitute products will be separately paid, based on their standard SI/APC assignment, only when billed with specified skin substitute application procedure codes. If one of the specified application procedure codes is not present on the same date of service as the skin substitute, the skin substitute product will be packaged (will have its status indicator changed to N).
Now let’s wrap up all the information. Initially you need to determine where the edit is occurring. It could be in your facility’s claim scrubber, which means it was programmed by an outside vendor. This may require a discussion with the vendor and determination of whether this is a “warning” to help with review to insure all services/items have been reported and can be bypassed, or if this is a “hard stop” edit and must be resolved.
Next contact your FI/MAC to determine if its claims processing system contains an edit that requires the code for the skin substitute be reported with the procedure code. Explain the situation regarding receiving some skin substitutes at no cost and discuss the possibility of reporting a line item with the HCPCS code for the skin substitute and a token charge. CMS has defined a token charge as less than $1 and this is used with other items when a device/procedure edit is in place and the device is obtained at no cost.
Obtaining this information should provide a resolution for how to report the service provided to the beneficiary on a clean and compliant claim.
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.

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