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)

Finalized Confidentiality of Alcohol and Drug Abuse Patient Records Regulations
August 31st, 2018 - Wyn Staheli, Director of Research
In January, the U.S. Department of Health and Human Services (HHS) issued updates to the privacy regulations regarding the confidentiality of patient information of substance use disorder patients (42 CFR Part 2).  This notice included references to better alignment with HIPAA regulations, but did state that Part 2 is more protective ...
Pricing for ASC’s and APC’s
August 27th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...
PSAVE Pilot Program - What Does it Mean to You?
August 20th, 2018 - Wyn Staheli, Director of Research
Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?
Importance of Depression Screenings
August 16th, 2018 - Wyn Staheli, Director of Research
Why would a chiropractor be concerned about depression screenings when you aren’t trained to be a mental health provider? The answer lies in patient outcomes. Many quality care organizations recommend depression screenings for patients with a chronic condition. According to The National Institute of Mental Health, “People with other chronic ...
Using Modifiers 96 and 97
August 16th, 2018 - Wyn Staheli, Director of Research
The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. ...
Medicare Timed Codes Guidelines
August 16th, 2018 - Wyn Staheli, Director of Research
Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time. It should be noted that while ...
QPro’s First Annual QPro Con
August 15th, 2018 - Chris Woolstenhulme QCC, CMCS, CPC, CMRS
Date: October 9-10 Time: 9-3 MST QPro Con is featuring a virtual event with keynote speakers and experts with years of hands-on experience in the healthcare industry. Stay ahead of the changes and keep informed of important information that affects the healthcare community. Attendees receive 12 FREE CEUs with the purchase ...



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