(Medicare Claims Processing Manual)

The applicable Healthcare Common Procedure Coding System (HCPCS) code for Electrical Stimulation and the covered effective date is as follows:   HCPCS  Definition  Effective Date  G0281 Electrical Stimulation, (unattended), to one or more areas for chronic Stage III and 04/01/2003 HCPCS  Definition  Effective Date  Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.   Medicare will not cover the device used for the electrical stimulation for the treatment of wounds.  However, Medicare will cover the service. Unsupervised home use of electrical stimulation will not be covered.   B.  FI Billing Instructions   The applicable types of bills acceptable when billing for electrical stimulation services are 12X, 13X, 22X, 23X, 71X, 73X, 74X, 75X, and 85X.  Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to FIs .  FIs pay for electrical stimulation services under the Medicare Physician Fee Schedule for a hospital, Comprehensive Outpatient Rehabilitation Facility (CORF), Outpatient Rehabilitation Facility (ORF), Outpatient Physical Therapy (OPT) and Skilled Nursing Facility (SNF).   Payment methodology for independent Rural Health Clinic (RHC), provider -based RHCs, free-standing Federally Qualified Health Center (FQHC) and provider based FQHCs is made under the all -inclusive rate for the visit furnished to the RHC/FQHC patient to obta in the therapy service.  Only one payment will be made for the visit furnished to the RHC/FQHC patient to obtain the therapy service.  As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for these therapy services.  Payment Methodology for a Critical Access Hospital (CAH) is on a reasonable cost basis unless the CAH has elected the Optional Method and then the FI pays115% of the MPFS amount for the professional component of the HCPCS code in addition to the technical component.  In addition, the following revenues code must be used in conjunction with the HCPCS code identified:  Revenue Code  Description  420 Physical Therapy  430 Occupational Therapy  520 Federal Qualified Health Center *  521 Rural Health Center *  977, 978 Critical Access Hospital - method II CAH professional services only  * NOTE:   As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for these therapy services.   C.  Carrier Claims   Carriers pay for Electrical Stimulation services billed with HCPCS codes G0281 based on the MPFS.  Claims for Electrical Stimulation services must be billed on Form CMS -1500 or the electronic equivalent following instructions in chapter 12 of this manual (http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf).  D.  Coinsurance and Deductible   The Medicare contractor shall apply coinsurance and deductible to payments for these therapy services except for services billed to the FI by FQHCs.  For FQHCs, only co- insurance applies.   11.2 - Electromagnetic Therapy  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD -10)  A. HCPCS Coding Applicable to A/B MACs (A and B)   Effective July 1, 2004, a National Coverage Decision was made to allow for Medicare coverage of electromagnetic therapy for the treatment of certain types of wounds.  The type of wounds covered are chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers.  All other uses of electromagnetic therapy for the treatment of wounds are not covered by Medicare.  Electromagnetic therapy will not be covered as an initial treatment modality.   The use of electromagnetic therapy will only be covered after appropriate standard wound care has been tried for at least 30 days and there are no measurable signs of healing.  If electromagnetic therapy is being used, wounds must be evaluated periodically by the treating physician but no less than every 30 days.  Continued treatment with electromagnetic therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.  Additionally, electromagnetic ther apy must be discontinued when the wound demonstrates a 100% epithelialzed wound bed.  Coverage policy can be found in Pub. 100- 03, Medicare National Coverage Determinations Manual, Chapter 1 section 270.1. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp)  The applicable Healthcare Common Procedure Coding System (HCPCS) code for Electrical Stimulation and the covered effective date is as follows:   HCPCS  Definition  Effective Date  G0329 ElectromagneticTherapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy  plan of care.  07/01/2004  Medicare will not cover the device used for the electromagnetic therapy for the treatment of wounds.  However, Medicare will cover the service.  Unsupervised home use of electromagnetic therapy will not be covered.   B. A/B MAC (A) Billing Instructions   The applicable types of bills acceptable when billing for electromagnetic therapy services are 12X, 13X, 22X, 23X, 71X, 73X, 74X, 75X, and 85X.  Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to A/B MACs (A).  A/B MACs (A) pay for electromagnetic therapy services under the Medicare Physician Fee Schedule for a hospital, CORF, ORF, and SNF.  Payment methodology for independent (RHC), provider- based RHCs, free -standing FQHC and provider based FQHCs is made under the all-inclusive rate for the visit furnished to the RHC/FQHC patient to obtain the therapy service.  Only one payment will be made f or the visit furnished to the RHC/FQHC patient to obtain the therapy service.  As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for the therapy service.   Payment Methodology for a CAH is payment on a reasonable cost basis unless the CAH has elected the Optional Method and then the A/B MAC (A) pays pay 115% of the MPFS amount for the professional component of the HCPCS code in addition to the technical component. In addition, the following revenues code must be used in conjunction with the HCPCS code identified:  Revenue Code  Description  420 Physical Therapy  430 Occupational Therapy  520 Federal Qualified Health Center *  521 Rural Health Center *  977, 978 Critical Access Hospital - method II CAH professional services only  * NOTE:  As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for the therapy service.  C. A/B MAC (B) Claims   A/B MACs (B) pay for Electromagnetic Therapy services billed with HCPCS codes G0329 based on the MPFS.  Claims for electromagnetic therapy services must be billed using the ASC X12 837 professional claim format or Form CMS-1500 following instructions in chapter 12 of this manual ( www.cms.hhs.gov/manuals/104_claims/clm104index.asp).  Payment information for HCPCS code G0329 will be added to the July 2004 update of the Medicare Physician Fee Schedule Database (MPFSD).   D.  Coinsurance and Deductible   The Medicare contractor shall apply coinsurance and deductible to payments for electromagnetic therapy services except for services billed to the A/B MAC (A) by FQHCs.  For FQHCs only co- insurance applies.   11.3  Autologous Platelet -Rich Plasma (PRP) for Chronic Non -Healing Wounds  (Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14- 22 MACs)   11.3.1  Policy  (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 April 13, 2021, contractors shall accept and pay for autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by devices whose Food and Drug Administration -cleared indications include the management of exuding cutaneous wounds, such as diabetic ulcers, in accordance with the coverage criteria outlined in Publication 100-03, chapter 1, section 270.3, of the National Coverage Determinations (NCD) Manual.   NOTE: Coverage of PRP services for the treatment of chronic non -healing diabetic wounds that are performed more than 20 weeks after the date of the first PRP service shall be determined by the local Medicare Administrative Contractor (MAC).    Coverage of autologous PRP for the treatment of all other chronic non-healing wounds (non-diabetic) will be determined by local MACs under section 1862(a)(1)(A) of the Social Security Act.   11.3.2  Healthcare Common Procedure Coding System (HCPCS) Codes and Diagnosis Coding (Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14- 22 MACs)   Healthcare Common Procedure Coding System (HCPCS) Code  Effective for claims with dates of service on or after April 13, 2021, Medicare providers shall report HCPCS code G0460 for PRP services for the treatment of chronic non-healing non-diabetic wounds.  Effective for claims with dates of service on or after April 13, 2021, Medicare providers shall report HCPCS code G0465 for PRP services for the treatment of chronic non- healing diabetic wounds under the conditions and criteria outlined in NCD Manual Section 270.3.  If ICD -10 Diagnosis coding is applicable  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