Reimbursement

Medicare

PICO Service and PICO System

Effective January 1, 2015, two new Category I CPT® codes, 97607 and 97608, were established to report negative pressure wound therapy (NPWT) using disposable, non-durable medical equipment. This includes:

  • provision of exudate management collection system;
  • topical application(s);
  • wound assessment; and
  • instructions for ongoing care

These codes will replace the Medicare created G-codes, G0456 and G0457, that were implemented January 1, 2013 to provide a mechanism for payment of NPWT using a disposable device. Here are the new codes with their descriptions:

97607: Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management  collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

97608: Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management  collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters

While HCPCS A9272 (Suction, Disposable, Includes Dressing, All Accessories and Components, Any Type, Each) has been issued, products reported with this code are not covered by Medicare.     

Physician services

Provided that the NPWT service is medically necessary, any physician claims submitted for PICO reporting CPT codes 97607 and 97608 will be priced in CY 2016 under the Medicare Physician Fee Schedule on an individual claim basis by each Medicare contractor.

Effective January 1, 2015, Medicare has deleted temporary codes G0456 and G0457. Physicians will no longer be able to report these temporary codes for the PICO System.

CPT Code12016 Medicare National Average Payment2
 97607  Carrier priced
 97608  Carrier priced
Global Period

In the final CY 2016 Medicare Physician Fee Schedule rule, Addendum B, CMS has assigned CPT codes 97607 and 97608 a global period indicator of “XXX” (Global concept does not apply). Other CPT codes may be assigned a global period of 0, 10 or 90 days, or “YYY” which is established by the contractor.

Hospital Inpatient

Medicare does not separately reimburse hospitals for the PICO System when performed in the inpatient setting. If covered, payment for the PICO System is included in the MS-DRG for the primary procedure in which it is used. Physician services are separately billable and are reported with the new CPT codes 97607 and 97608.

Ambulatory Surgical Center

CPT codes 97607 and 97608 are not recognized as a covered service by Medicare when performed in an Ambulatory Surgical Center.

Hospital Outpatient Department

For CY 2016 Medicare has assigned CPT codes 97607 and 97608 (Single Use non-DME Powered Negative Pressure Wound Therapy) to Ambulatory Payment Classification (APC) 5052 Level II Debridement and Destruction with a status indicator of “T” (procedure or service subject to multiple procedure reduction),  provided that the NPWT service is medically necessary. The national average payment for CY 2016 is $225.55.

CPT CodeAPCStatus indicator*2016 Medicare National Average Payment3
 97607 5052 T $225.55
97608 5052  T $225.55

*Status Indicator “T” paid separately; subject to multiple procedure reduction. 

Commercial insurers

PICO Device

Commercial Health Plans may instruct providers to report HCPCS code A9272 Wound Suction, Disposable, Includes Dressing, All Accessories and Components, Any Type, Each, for use in claims reporting of the PICO System. Final determination of coverage for wound suctioning systems will be at individual carrier discretion. Please contact individual carriers for specific claim submission preferences. 

Billing PICO when used in the home

Because PICO may be used in the home, some health plans may cover the PICO System under their DME benefit or other benefit category.  In that case, they may request that HCPCS code A9272 be reported. Final determination of coverage and payment will be at the carrier’s discretion.

HCPCS  Code4Description2016 National
Average Commercial DME Payment
 A9272 Wound Suction, Disposable, Includes Dressing, All Accessories and Components, Any Type, Each Carrier discretion

Modifiers: In the case where a health plan may cover the PICO device as DME, providers may also be required to submit specific DME modifiers.

DME Modifier4Description
-NU  New equipment purchase

PICO topical application and wound assessment

Individual Health Plans may instruct providers to report the PICO service with CPT codes 97607 and 97608. This service includes:

  • provision of exudate management collection system
  • topical application(s)
  • wound assessment
  • instructions for ongoing care

97607: Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management  collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

97608: Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management  collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters

Please contact the individual health plans for coding guidance on reporting the PICO service.

Other sites of services

For coverage and coding guidance of the PICO System when provided in other sites of services, e.g. Ambulatory Surgical Centers, Home Health Care and Long Term Care Hospitals, please contact the individual health plans.

For more information or help with these reimbursement materials, please contact:

The information contained in this document is not intended to guarantee coverage or reimbursement, and Smith & Nephew makes no other representations as to selecting codes for procedures or compliance with any other billing protocols or prerequisites. As with all claims, individual physicians are responsible for exercising their independent clinical judgment in selecting the codes that most accurately reflect the patient’s condition and procedures performed. Providers should refer to current, complete, and authoritative publications or insurer policies for selecting codes based on the care rendered to an individual patient, and may wish to contact individual carriers, fiscal intermediaries, or other third-party payers as needed for specific information on coverage policies and claims reporting preferences.

References
  1. CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
  2. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, & Other Revisions to Part B for CY 2016; Final Rule Federal Register (80 Fed Reg. No. 220) November 16, 2015, 42 CFR Parts 405, 410, 411 et al. Addendum B.
  3. Medicare Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Short Inpatient Hospital Stays; Transition for Certain Medicare- Dependent, Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System; Provider Administrative and Judicial Review; Final Rule, Federal Register Vol. 80, No 219, November 13, 2015, 42 CFR Parts 405, 410, 412 et al. Addendum B.
  4. HCPCS Level II 2015 Professional Edition, MA ,Elsevier, St. Louis , Missouri 2015.
  5. Hospital ICD-9-CM 2014, Volumes 1, 2, 3. American Medical Association, Chicago, Il 2012.