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Important Terms to Know: CTP Reimbursement

Practice Accelerator
November 30, 2023

Cellular and/or tissue-based products: Engineered wound dressing products created to promote biological repair or regeneration of wound tissue by providing signaling, structural, or cellular elements with or without systems that contain living tissue or cells These products actively promote healing by stimulating the patient’s own cells to regenerate healthy tissue. There are multiple options for these products.

Clinical setting of use/provider type: Acute care hospital, long-term care or rehabilitation hospital, skilled nursing facility, home health agency, physician’s office, outpatient clinic, hospice, assisted living residence, nursing home, or patient’s home. Each of these settings may carry its own unique Place of Service code that providers should include on their service claim submissions.

Current Procedural Terminology (CPT) Codes: These characterize the procedure performed by a provider, and oftentimes in wound care will also indicate anatomic location and size of the wound in question. Codes such as this may be employed, for example, for debridement.

Diagnosis-Related Group (DRG): For long-term acute care hospital and acute care stays, the DRG system dictates the total payable cost for a given diagnosis (ie, a lump sum payment based on what Medicare determines the cost should be for treating a patient with a given diagnosis). Like HOPD billing, the DRG system drives facilities to remain vigilant of cost for the duration of the patient's acute stay.

Healthcare Common Procedure Coding System (HCPCS): a standardized language used to describe services and medical equipment/ products provided during the delivery of care. For reporting equipment and products, generic terminology identifies durable medical equipment, supplied used in conjunction with equipment and products, such as wound dressings. Drug and biologics codes are described by brand name.

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International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM): These are the corresponding diagnosis codes that align with the procedure performed by the provider and any product used.

Local Coverage Determination (LCD): Medicare Administrative Contractors (MACs) make these decisions regarding coverage of a product or service that will then apply to their specific region of jurisdiction.

Medicare Administrative Contractor (MAC): This is a regionally based Medicare insurer that processes certain claims for Medicare fee-for-service beneficiaries. MACs often have a multi-state jurisdiction, and administer many aspects of the Medicare program including claim processing, provider enrollment, audit, reimbursement, establishing LCDs, and reviewing medical recording. For Medicare Parts A and B, examples of MACs are Noridian Healthcare Solutions, CGS Administrators, Novitas Solutions, and Palmetto GBA.

Payor medical necessity requirements: Specific diagnoses (International Classification of Diseases-tenth revision [ICD-10]) or other clinical conditions that must be present, including documentation of prior treatments tried and failed for the treatment, equipment, or product to be covered and reimbursed. Providers should consult their Local Coverage Determination (LCD) documents to learn specific medical necessity requirements established for individual codes, like those for cellular and tissue-based products.

Utilization parameters: Limits on frequency of treatment, number of supplies allowed per a period of time, or restrictions on a specific treatment modality.

Information regarding coding, coverage, and payment is provided as a service to our audience. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.