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Maggot Therapy Coding & Reimbursement

May 24th, 2012 - Ronald Sherman
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 PURPOSE:

This article provides practical information for those interested in maggot therapy coding and reimbursement. It attempts to make available the most current and comprehensive information on the topic, continuing to evolve as maggot therapy coding itself grows and evolves.

 

BACKGROUND & HISTORY:

Maggot therapy is the intentional and therapeutic application of medicinal fly larvae to a wound for the purpose of debridement, disinfection and/or wound healing. In the U.S.,  at least one brand of medicinal maggots is cleared for marketing for the following indications:  "For debriding non-healing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcers, neuropathic foot ulcers and non-healing traumatic or post surgical wounds."

Maggot therapy may have been practiced in the U.S. for more than 80 years, and it may have, by now, an impressive body of literature to support its safety and efficacy, but coding and reimbursement remain archaic. Even worse, few people really know how best to work within the current system. Thus, there is a great need for a working and malleable reference such as this one.

Since 2004, the not-for-profit BioTherapuetics, Education & Research Foundation has been working actively towards creating simple coding and equitable reimbursement for maggot therapy. This is envisioned as a specific CPT® code, or a general CPT® code and a set of HCPCS supply codes that would adequately describe the treatment rendered. The Biotherapeutics, Education & Research (BTER) Foundation believes specific coding is appropriate because 1) the costs of materials (medical grade maggots and maggot dressings) far exceeds the typical level of reimbursement for the application procedure itself;  2) there is great variety of materials and methods in applying maggot therapy (most dressings are custom made by the therapist from a variety of materials), such that no single code can accurately or adequately represent the time, effort or materials used by the majority of therapists providing that treatment.

After numerous discussions with the American Medical Association (AMA) Committee for CPT® Coding and the Centers for Medicare and Medicaid (CMS), our understanding of their position is as follows:

1) Both AMA and CMS recognize the validity of the treatment and the right of therapists to be compensated

2)AMA believes the best route towards coding is the use of already existing procedure codes for debridement, combined with specific product codes (HCPCS codes to be issued by CMS) to denote the medical grade maggots and maggot dressings that would not be covered by the procedure code alone.

3) CMS believes that the best route towards coding is the development of procedures codes (to be issued by AMA) that denote  maggot debridement therapy (MDT) specifically, and include maggot-related products so that no new HCPCS codes would be necessary.

The BTER Foundation believes that a combination of CPT® and HCPCS codes would be ideal to most accurately describe the procedure of maggot debridement therapy and the rapidly growing number of products (of varying costs) specifically used in maggot therapy treatments.

 

CURRENT STATUS OF CODING AND REIMBURSEMENT:

A few sources for recommendations are listed below. It is acknowledged that they differ in some of their recommendations, due to changes over time and differing perspectives. The fact that there are not specific maggot therapy CPT® or HCPCS codes makes coding for MDT an issue of judgment and experience.

 

SPECIFIC CODING RECOMMENDATIONS:

My current coding recommendations are listed below. Of course, they are only guidelines, based on best opinions. They may change over time, as codes and precedents develop. Those seeking reimbursement must make their own determinations.

Within the CPT/HCPCS systems -


Within the ABC Coding System (alternative coding for non-physicians) -

 

ADDITIONAL COMMENTS & DISCUSSION:

The BTER Foundation has initiated a Reimbursement Appeal Assistance Program to assist therapists and patients in appealing denied claims for reimbursement of maggot therapy (and other biotherapies). Be sure to contact the BTER Foundation immediately if a claim was denied, in order to best assemble a successful appeal.

For those patients who do not have medical insurance coverage, or whose insurance provider still refuses to pay for the maggots, contact the BTER Foundation for information and applications for Patient Assistance Grants that cover medicinal maggots and other biotherapy supplies (www.BTERFoundation.orb/indexfiles/pt_assist.htm)

 

REFERENCES  REGARDING  MAGGOT  THERAPY  CODING:  

 

REFERENCES  FOR  MAGGOT  THERAPY  (will be helpful in appealing a denied claim): 

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