January 2014 Jean C. Russell, MS, RHIT Richard Cooley, BA, CCS Matthew H. Lawney MSPT, MBA, CHC,

2 Agenda Proposed Changes High and Low Cost Tissues Reporting Procedures New OCE Edit

3 Packaging Changes

4 Increased Packaging Packaging Proposal number 2 CMS proposed to expand to include all drugs, biologicals and radiopharmaceuticals that are part of any surgical procedure (including skin substitutes)

5 2. Drugs/Biologicals/Radiopharm Dx Surgical Procedures In 2013 implantable biologicals are packaged as integral to surgical implant procedures This included alloderm during hernia or breast implant procedures When billed as revenue code 278 these tissues were packaged unconditionally But were paid when billed as a biological (revenue code 636) with a tissue application code, such as 15271, 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

6 2. Drugs/Biologicals/Radiopharm Dx Surgical Procedures Commenters stated that the cost of the skin tissue ranges from $7 to $200 per square cm In response, CMS identified each of the skin substitutes as either high or low cost (see Table 13) The threshold is $32 per square centimeter

7 2. Drugs/Biologicals/Radiopharm Dx Surgical Procedures All others are considered low cost High Cost Pass- Through

8 2. Drugs/Biologicals/Radiopharm Dx Surgical Procedures High cost and pass-through skin substitute application should be reported with the standard CPT application codes: – Low cost skin substitutes will be reported with the new HCPCS codes: C5271 – C5278 (see Table 14) Pass-through skin substitutes will have an off-set applied

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10 Setting this Up Easier to implement when the surgical procedure is hard-coded on the CDM Suggest setting up a set of surgical procedures for low-cost and high-cost tissue applications Same surgical code will be default code ( ) Map to the C code for low cost tissues applications for Medicare (C5271-C5278) Make the Pick List / CDM Description specific to “high” or “low” cost tissue Mark the tissue charges in a similar manner

11 New OCE Edit OCE edit 87 Implemented January 2014 Skin substitute application procedure without appropriate skin substitute product code

12 New OCE Edit “Effective 1/1/2014 (v15.0), the submission of certain skin substitute application procedures require the reporting of a skin substitute product for the same day. Certain skin substitute application procedures and skin substitute products will be divided into two lists based on high or low cost. Claims containing a high cost skin substitute application procedure without any of the high cost skin substitute product codes, and conversely any low cost skin substitute application procedure without a low cost skin substitute product code for the same day, will be returned to the provider (edit 87).“

13 Questions and Discussion

14 Contact Us Richard Cooley Phone: Matthew Lawney Phone: Jean Russell Phone:

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16 CPT ® Current Procedural Terminology (CPT®) Copyright 2013 American Medical Association All Rights Reserved Registered trademark of the AMA

17 Disclaimer Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.