Coding, Insurance & Reimbursement

Most private (insurance) and public (Medicare/Medicaid, DVA, etc) health benefits payors will reimburse the costs of maggot therapy and the cost of the maggots. However, AMA and CMS have not agreed on how to establish a maggot therapy-specific reimbursement code.

The last time the American Medical Association (AMA) and the Center for Medicare & Medicaid Services (CMS) issued official coding recommendations for maggot therapy was in 2008 (CPT® Assistant, V8 N9). Until AMA issues a new, MDT-specific procedure code, their basic advice still holds: code separately for the procedure (using an established debridement code) and for the maggots & supplies (using text descriptions, or HCPCS Level 2 codes, where they exist).

For the procedure code, consider using the debridement code: 97602 ("Non-excisional debridement"). For the supply code, they suggested using CPT® supply code 99070 ("Supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered"), followed by a written list of every specific product used.

If you use ABC codes, the maggots can be coded using ABC code for maggots (EAACT) or the HCPCS code for misc. devices (A9270).

Specifically, the AMA committee wrote, in part:

"The supply of the maggots should be reported in addition to the wound management code 97602 with CPT supply code 99070, Supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)."

CPT® Assistant, V8 N9, 2008

Additional recommendations can be found at these resources:

Remember: insurance claims are first reviewed by a screener whose job is to eliminate as many claims as possible. If they are unfamiliar with maggot therapy, their preliminary determination may be that maggot therapy is not a covered service. This is usually incorrect, and a thorough appeal will nearly always be accepted, if the treatment was consistent with official (FDA-sanctioned) indications. Monarch Labs and the BTER Foundation can help with appeals.

Remember, too, that reimbursement also depends on the location where care is delivered, and the personnel delivering that care. For example, many policies pay a flat rate for hospitalizations, nursing home stays, etc.

Disclaimer: Therapists and their institutions are ultimately responsible for selecting the appropriate billing codes, as dictated by the clinical indication, the procedure and supplies used, and the policies of third party payors.

For those patients who do not have medical insurance coverage, or whose coverage refuses to pay for the maggots, Monarch Labs has agreed to accept BTER Foundation Patient Assistance Grants in lieu of payment.

Information and applications for BTER Foundation Patient Assistance Grants can be found at: www.BTERFoundation.orb/indexfiles/pt_assist.htm

If your patients' third party payor refuses to compensate you for your maggot therapy services (procedure and/or supplies), be sure to inform us immediately.

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