Neurosurgery Coding Alert

Question: Is there a CPT code for autologous platelet rich plasma grafts that our surgeons sometimes use for postoperative non-healing wounds?

South Dakota Subscriber

Answer: CPT does not contain a category I code that describes autologous platelet rich plasma grafts appropriately. Some billers have been reporting 20926 (Tissue grafts, other [e.g. paratenon, fat, dermis]) with success. But unless you-ve been specifically instructed by your payer, this code is inappropriate and could very likely result in trouble at audit time, as well as payer refund requests. A review of policy statements from several payers specifically warn against reporting 20926 for any blood-derived products for wound care.

HCPCS does contain a category III code, S9055 (Procuren or other growth factor preparation to promote wound healing), that a number of payers recommend for reporting such autologous grafts.

Medicare does not recognize S codes for payment and has recently released a national noncoverage determination for platelet-derived wound-healing formulas intended to treat patients with chronic, nonhealing wounds. To justify the noncoverage, CMS argues, "The clinical evidence does not support a benefit in the application of autologous PRP for the treatment of chronic, non-healing, cutaneous wounds. Therefore, CMS determines it is not reasonable and necessary and is nationally non-covered."

However, at least one payer, Blue Cross/Blue Shield of North Carolina, has allowed payment for these grafts (when reported with S9055) in limited cases, so it may be worth your while to contact the payer directly and ask for direction if you are unsure.

Keep in mind: Code S9055 is for the graft material only. As such, your surgeon cannot bill the code unless he supplies the material. There is no separate reimbursement for applying the material (which is considered to be like a dressing).

Resource: You can view the BCBSNC policy at www.bcbsnc.com/services/medical-policy/pdf/growth_factors_in_wound_healing.pdf.