Coding and Reimbursement Issues for Platelet-Rich Plasma
Section snippets
Surgical Procedure Usage
If one is performing a PRP injection during a surgical procedure, all official sources (Center for Medicare and Medicaid Service [CMS], Current Procedural Terminology [CPT], American Academy of Orthopaedic Surgeons [AAOS], and so on) state that there would be no additional “professional” service CPT coding reported. The best reference is the April 2009 CPT Assistant where it states “The placement/injection of the cells into the operative site is an inclusive component of the operative procedure
“Stand-Alone” Usage
When performing PRP in a stand-alone situation, such as in the office, Ambulatory Surgical Center (ASC), or outpatient facility, and this is the only procedure performed, there is now a category III code that is used to report the “professional” service being rendered. The code that should be reported is 0232T: Injection(s), Platelet Rich Plasma, any tissue, including image guidance, harvesting, and preparation when performed. There are very significant bundling issues provided for this code;
Facility Reporting
Facilities that wish to submit a claim for this procedure should reference CMS Transmittal 1984, which provides information related to facility reporting and issues pertaining to their ability to report 0232T.
Carriers/Payer Issues
Most payers/carriers have internal policies of noncoverage for PRP-type services. A few examples are provided below, but providers should reference their specific contracts with the payer/carrier.
http://www.bcidaho.com/providers/medical_policies/med/mp_20116.asp: this policy addresses the use of blood-derived growth factors, including recombinant PDGFs and PRP, as a primary treatment of wounds or other musculoskeletal conditions, including but not limited to the treatment of diabetic ulcers,
Creative Coding
“Creative coding” of PRP in which finding a code that is “close” but does not really represent the service being rendered is not encouraged and can cause difficulties should a provider audit occur. The CPT guidelines are very clear in the CPT Manual; it states the following: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the
Words of Warning/Caution
Even though there may be a specific CPT code, it does not mean that payment will be provided by an insurance company or even Medicare. There are many procedures that are considered “noncovered,” experimental, or lacking medical necessity, which fall to the level of patient responsibility, and, thus, staff should be prepared to have the proper forms and paperwork available to alert patients before the service is rendered.
If there is no CPT code or Healthcare Common Procedure Coding System
References (0)
Cited by (3)
Incorporating Ortho-Biologics into Your Clinical Practice
2019, Clinics in Sports MedicineCitation Excerpt :As stated previously, ortho-biologics can be administered as an adjuvant in surgery or as a stand-alone procedure in the office setting. If performing an injection during a surgical procedure, no additional professional service Current Procedural Terminology (CPT) coding is reported.3,5 Coding is required if administered in the office as a stand-alone procedure, and many ortho-biologics have been recognized by CPT.
Intra-articular treatment options for knee osteoarthritis
2019, Nature Reviews RheumatologyThe Economics and Regulation of PRP in the Evolving Field of Orthopedic Biologics
2018, Current Reviews in Musculoskeletal Medicine
The information supplied here is based on CPT and CMS current guidelines and policies. Private payers/carriers can have their own policies and procedures that you will need to check with. As with all coding, guidelines can change and it is up to the coder/physician to ensure that they have all the current and accurate information. Authors do not assume any responsibility or liability for reimbursement decisions or claims denials made by payers because of the use of this coding information.