Podiatry Coding & Billing Alert

Question: My provider administers PRP injections. Is there a code for that? How do I ensure payment?

Texas Subscriber

Answer: The code for PRP injections is actually a category III code — 0232T, which came out in July 2010. Medicare only covers PRP injections for diabetic or non-healing wounds in clinical trials only. So, if your providers are not participating in a clinical trial and haven’t been registered with CMS for a clinical trial, you’re not going to get reimbursed for it.

“Everybody has policies about them and they’re not really budging … There hasn’t been any real change in the reimbursement since it (the code) was introduced six years ago,” says Lynn M. Anderanin, CPC, CPPM, CPC-I, COSC, senior director of Coding Education for Healthcare Information Services, in an audio-conference titled “Podiatry and Foot Care: Coding, Special Coverage & Reimbursement Guidelines for 2016,” presented on behalf of Audioeducator.com in February.

If you are administering PRP injections for pain management, then you would need to get your patient pay up front, suggests Anderanin. You could also get your patient to sign an advance beneficiary notice (ABN) before the injections. You must explain beforehand that it is the patient’s personal liability as it is not a covered service.

Coverage is only under certain circumstances: The Centers for Medicare & Medicaid Services (CMS) issued a Medicare National Coverage Determination on Aug. 2, 2012 which allows coverage of autologous PRP under coverage with Evidence Development (CED) with certain conditions. It covers autologous platelet-rich plasma (PRP) only for patients who have chronic non-healing diabetic, pressure, and/or venous wounds. The complete determination is available at: https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/Autologous-Platelet-rich-Plasma-PRP.html.

The CPT^® and HCPCS codes listed below are for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

• 0232T — Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed;
• P9020 — Platelet rich plasma, each unit;
• S0157 — Becaplermin gel 0.01%, 0.5 gm (recombinant platelet-derived growth factor);
• S9055 — Procuren or other growth factor preparation to promote wound healing.

Don’t do this: Do not report 0232T in conjunction with 20550, 20551, 20600-20610, 20926. The code specific guidelines advise you to not report 20550, 20551 in conjunction with 0232T. You also should not report 38220-38230 for bone marrow aspiration for platelet rich stem cell injection. For bone marrow aspiration for platelet rich stem cell injection, use 0232T.

Watch yourself: According to National Correct Coding Initiative (CCI) edits, as the code 0232T includes imaging guidance, you cannot report any imaging code such as:

• 76942 — Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation;
• 77002 — Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device);
• 77012 — Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation;
• 77021 — Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation.

Additionally, you cannot also report any platelet concentration service such as 86965 (Pooling of platelets or other blood products).

Note: P codes represent pathology and lab services, including blood products.

S codes represent drugs, services, and supplies that do not have a permanent national code. However, private sector and Medicaid payers require these codes to implement policies, programs, or claims processing and meet their particular needs. These codes are not payable by Medicare.