(Medicare Claims Processing Manual)

For claims with dates of service on or after April 13, 2021, PRP, for the treatment of chronic non-healing diabetic wounds must be billed reporting both an ICD-10 diagnosis code for diabetes mellitus and an ICD -10 diagnosis code for chronic ulcers.  - Two diagnosis codes are required - Diabetic Mellitus plus Chronic Ulcer   Diabetes Mellitus    E08.621  Diabetes mellitus due to underlying condition with foot ulcer  E08.622  Diabetes mellitus due to underlying condition with other skin ulcer  E09.621  Drug or chemical induced diabetes mellitus with foot ulcer  E09.622  Drug or chemical induced diabetes mellitus with other skin ulcer  E10.621  Type 1 diabetes mellitus with foot ulcer  E10.622  Type 1 diabetes mellitus with other skin ulcer  E11.621  Type 2 diabetes mellitus with foot ulcer  E11.622  Type 2 diabetes mellitus with other skin ulcer  E13.621  Other specified diabetes mellitus with foot ulcer  E13.622  Other specified diabetes mellitus with other skin ulcer    Chronic Ulcer      L97.111  Non-pressure chronic ulcer of right thigh limited to breakdown of skin  L97.112  Non-pressure chronic ulcer of right thigh with fat layer exposed  L97.113  Non-pressure chronic ulcer of right thigh with necrosis of muscle  L97.115  Non-pressure chronic ulcer of right thigh with muscle involvement without evidence of  necrosis  L97.116  Non-pressure chronic ulcer of right thigh with bone involvement without evidence of  necrosis  L97.118  Non-pressure chronic ulcer of right thigh with other specified severity  L97.114  Non-pressure chronic ulcer of right thigh with necrosis of bone  L97.121  Non-pressure chronic ulcer of left thigh limited to breakdown of skin  L97.122  Non-pressure chronic ulcer of left thigh with fat layer exposed  L97.123  Non-pressure chronic ulcer of left thigh with necrosis of muscle  L97.124  Non-pressure chronic ulcer of left thigh with necrosis of bone  L97.125  Non-pressure chronic ulcer of left thigh with muscle involvement without evidence of  necrosis  L97.126  Non-pressure chronic ulcer of left thigh with bone involvement without evidence of necros  L97.128  Non-pressure chronic ulcer of left thigh with other specified severity  L97.211  Non-pressure chronic ulcer of right calf limited to breakdown of skin  L97.212  Non-pressure chronic ulcer of right calf with fat layer exposed  L97.213  Non-pressure chronic ulcer of right calf with necrosis of muscle  L97.214  Non-pressure chronic ulcer of right calf with necrosis of bone  L97.215  Non-pressure chronic ulcer of right calf with muscle involvement without evidence of  necrosis  L97.216  Non-pressure chronic ulcer of right calf with bone involvement without evidence of necros  L97.218  Non-pressure chronic ulcer of right calf with other specified severity  L97.221  Non-pressure chronic ulcer of left calf limited to breakdown of skin  L97.222  Non-pressure chronic ulcer of left calf with fat layer exposed  L97.223  Non-pressure chronic ulcer of left calf with necrosis of muscle  L97.224  Non-pressure chronic ulcer of left calf with necrosis of bone  L97.225  Non-pressure chronic ulcer of left calf with muscle involvement without evidence of necros  L97.226  Non-pressure chronic ulcer of left calf with bone involvement without evidence of necrosis  L97.228  Non-pressure chronic ulcer of left calf with other specified severity  L97.315  Non-pressure chronic ulcer of right ankle with muscle involvement without evidence of  necrosis  L97.316  Non-pressure chronic ulcer of right ankle with bone involvement without evidence of  necrosis  L97.318  Non-pressure chronic ulcer of right ankle with other specified severity  L97.321  Non-pressure chronic ulcer of left ankle limited to breakdown of skin L97.322  Non-pressure chronic ulcer of left ankle with fat layer exposed  L97.323  Non-pressure chronic ulcer of left ankle with necrosis of muscle  L97.324  Non-pressure chronic ulcer of left ankle with necrosis of bone  L97.325  Non-pressure chronic ulcer of left ankle with muscle involvement without evidence of  necrosis  L97.326  Non-pressure chronic ulcer of left ankle with bone involvement without evidence of  necrosis  L97.328  Non-pressure chronic ulcer of left ankle with other specified severity  L97.411  Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin  L97.412  Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed  L97.413  Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle  L97.414  Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone  L97.415  Non-pressure chronic ulcer of right heel and midfoot with muscle involvement without  evidence of necrosis  L97.416  Non-pressure chronic ulcer of right heel and midfoot with bone involvement without  evidence of necrosis  L97.418  Non-pressure chronic ulcer of right heel and midfoot with other specified severity  L97.421  Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin  L97.422  Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed  L97.423  Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle  L97.424  Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone  L97.425  Non-pressure chronic ulcer of left heel and midfoot with muscle involvement  without evidence of necrosis  L97.426  Non-pressure chronic ulcer of left heel and midfoot with bone involvement  without evidence of necrosis  L97.428  Non-pressure chronic ulcer of left heel and midfoot with other specified severity  L98.411  Non-pressure chronic ulcer of buttock limited to breakdown of skin  L98.412  Non-pressure chronic ulcer of buttock with fat layer exposed  L98.413  Non-pressure chronic ulcer of buttock with necrosis of muscle  L98.414  Non-pressure chronic ulcer of buttock with necrosis of bone  L98.415  Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necros  L98.416  Non-pressure chronic ulcer of buttock with bone involvement without evidence of necrosis  L98.418  Non-pressure chronic ulcer of buttock with other specified severity  L98.421  Non-pressure chronic ulcer of back limited to breakdown of skin  L98.422  Non-pressure chronic ulcer of back with fat layer exposed  L98.423  Non-pressure chronic ulcer of back with necrosis of muscle  L98.424  Non-pressure chronic ulcer of back with necrosis of bone  L98.425  Non-pressure chronic ulcer of back with muscle involvement without evidence of necrosis  L98.426  Non-pressure chronic ulcer of back with bone involvement without evidence of necrosis  L98.428  Non-pressure chronic ulcer of back with other specified severity  L98.491  Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin  L98.492  Non-pressure chronic ulcer of skin of other sites with fat layer exposed  L98.493  Non-pressure chronic ulcer of skin of other sites with necrosis of muscle  L98.494  Non-pressure chronic ulcer of skin of other sites with necrosis of bone         Frequency Requirements:   Effective for claims with dates of service on and after April 13, 2021, contractors shall cover PRP services for chronic non- healing diabetic wounds, G0465, for a maximum of 20 weeks beginning with the first week of treatment.   Effective for claims with dates of services on or after April 13, 2021, the local MACs shall have discretion to pay PRP services for chronic non- healing diabetic wounds, G0465, that are performed more than 20 weeks after the date of the first PRP service w hen the -KX modifier is reported on the claim.  Effective for claims with dates of service on and after April 13, 2021, contractors shall have discretion to cover, and determine frequency for, PRP services for chronic non- healing non-diabetic wounds, G0460.   11.3.3  Types of Bill (TOB)  (Rev. 11214, Issued: 01- 20-22, Effective:04 -13-21, Implementation: 01- 03-22 Shared Systems Contractors, 02- 14-22 MACs)    11.3.4  Payment Method  (Rev. 11214, Issued: 01- 20-22, Effective:04 -13-21, Implementation: 01- 03-22 Shared Systems Contractors, 02- 14-22 MACs)   Payment for PRP services is as follows:    Hospital outpatient departments TOBs 12X and 13X  based on the Outpatient Prospective Payment System   Skilled Nursing Facility TOBs 22X and 23X  based on the Medicare Physician Fee Schedule (MPFS)   TOB  71X  based on the all -inclusive rate   TOB 75X  based on the MPFS   TOB 77X  based on the all -inclusive rate   TOB 85X  based on reasonable cost   Critical Access Hospitals TOB 85X and revenue codes 096X, 097X, or 098X  based on the MPFS   Local MACs shall pay for PRP services for hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission on an outpatient basis, TOB 13X, in accordance with the terms of the Maryland waiver.   11.3.5 - Place of Service (POS) for Professional Claims  (Rev. 11214, Issued: 01- 20-22, Effective:04 -13-21, Implementation: 01- 03-22 Shared Systems Contractors, 02- 14-22 MACs)   Effective for claims with dates of service on or after August 2, 2012, place of service (POS) codes 11, 22, and 49 shall be used for PRP services.  Effective for claims with dates of service on or after April 13, 2021, POS codes 11, 19, 22, and 49 shall be used for PRP services.   11.3.6  Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason Codes (CARCs) and Group Codes (Rev. 11214, Issued: 01- 20-22, Effective:04 -13-21, Implementation: 01- 03-22 Shared Systems Contractors, 02- 14-22 MACs)   Contractors shall deny claims for PRP services when provided on other than TOBs 12X, 13X, 22X, 23X, 71X, 75X, 77X, and 85X using:   MSN 21.25 -  This service was denied because Medicare only covers this service in certain settings.   Spanish Version -  El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.   CARC 58 -  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.   RARC N428 -  Service/procedure not covered when performed in this place of service.   Group Code -  CO (Contractual Obligation)    Contractors shall reject claims for PRP services for the treatment of chronic non -healing diabetic wounds, G0465, that are performed more than 20 weeks after the date of the first PRP service when the --KX modifier is NOT included on the claim using the following messages:   CARC 119  Benefit Maximum for this time period or occurrence has been reached.   RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  Medicare Summary Notice (MSN) 20.5  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version: Estos servicios no pueden ser pagados porque sus beneficios se han agotado.  Group Code  CO (Contractual Obligation)  Contractors shall deny/reject claims for PRP services for the treatment of chronic non-healing diabetic wounds, G0465, that dont contain the appropriate diagnosis codes as noted above and use the following messages:  Claim Adjustment Reason Code (CARC) 50 - These are non -covered services because this is not deemed a 'medical necessity' by the payer. Remittance Advice Remark Code (RARC) N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at: www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD. Medicare Summary Notice (MSN) 15.19 - We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy of the LCD at www.cms.gov/medicare- coverage- database