Codapedia is now a division of Find-A-Code

Maggot Therapy Coding & Reimbursement

May 24th, 2012 - Ronald Sherman
0 Votes - Sign in to vote or comment.

 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): 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Small Practices are Affected by MIPS Increased Thresholds
June 25th, 2018 - Wyn Staheli, Director of Research
We recently heard about a small practice that had been faithfully submitting all the required “G” codes for the Quality Payment Program (QPP) only to discover that for 2018 they are excluded from MIPS because the low volume threshold increased from $30,000 in Part B allowed charges or 100 Part ...
How Does the Physician Compare Website Affect You?
June 25th, 2018 - Wyn Staheli, Director of Research
The physician compare website may not be working quite the way you think it is. Not all providers will have rankings showing up for them. Physician compare lists basic information, but quality measure information was not added until this year (2018) and not all quality measures are included in the ...
VA Expands Telehealth
June 14th, 2018 - Wyn Staheli, Director of Research
On May 11, 2018, the Department of Veterans Affairs (VA) released its final rule on the "Authority of VA Health Care Providers to Practice Telehealth." Effective June 11, 2018, VA providers will be able to provide telehealth services across state lines. This move will make it easier for veterans to obtain ...
Will Medicare's Proposed Reformations Affect Your Practice?
June 12th, 2018 - Wyn Staheli, Director of Research
Recently, Medicare's Innovation Center released an informal Request for Information (RFI) seeking input on several different system reformation proposals. As the market moves towards more value based payment systems, innovation and new models are being sought to both reduce costs and increase quality. This article outlines the ideas presented in the ...
Inappropriate Use of Units Costs Practice Over $800,000
June 11th, 2018 - Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
Coding for Strains in ICD 10
May 30th, 2018 - BC Advantage
According to the National Institutes of Health, a review was carried out on 20 patients who had a pectoralis major muscle repair between 2003 and 2011, and the results were as follows....
AMA vs Medicare rules and the use of the PT modifier
May 22nd, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Be sure to review the specific payer policy you are submitting claims to. Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary. The use of the PT modifier is ...



About Codapedia & Find-A-Code Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™/Find-A-Code™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2018 Find A Code, LLC - CPT® copyright American Medical Association