HCPCS update reminder: Billing for amniotic membrane

October 18th, 2019 / By Camille Ruiz, RHIA

It’s that time of year, coders, when many of us are attending webinars on 2020 Coding updates. For outpatient hospital coders and CDM staff, this will include ICD-10-CM/PCS as well as CPT and HCPCS. I was reviewing new HCPCS codes when I came across a new FDA-approved Human amniotic membrane (HAM) product. Since the FDA approval is recent, this is not an existing HCPCS. The vendor for the product is referenced as HCPCS V2790 Amniotic membrane. This is not a new HCPCS, but it reminded me to always look up the HCPCS long description and double check the recommendation. The long description for V2790 is Amniotic membrane for surgical reconstruction, per procedure. I double checked the CMS Outpatient Code Editor (OCE). The OCE cross-references V2790 with the following ocular procedure CPT codes:

If I had applied V2790 other amniotic supplies based on the HCPCS descriptions, I would have potentially created coding edits and delays in reimbursement. V2790 is for the supply. I also found a CMS Local Coverage Article for Billing and Coding: Amniotic Membrane Billing Guidelines for HCPCS Code V2790 (A53441) revised on  October 3, 2019. My next check was reimbursement. V2790 is packaged as a comprehensive APC rate for the procedure CPT code under the Outpatient Prospective Payment System (OPPS). For an added twist, there are specific HCPCS Q codes available for some existing amniotic biologics. These HCPCS Q codes include biologicals that might be cross-referenced with device-dependent skin-substitute to graft procedure edits which are not applicable here. Some providers may apply amniotic off-label to aid in healing. The V2790 long description does not specify amniotic applied to an ocular surface, but CMS establishes that link with the OCE cross-reference. Now for the bad news: Commercial insurance might deem these products and procedures as investigational and therefore not a covered benefit. To summarize, check and double check before assigning new HCPCS codes. 

Camille Ruiz is an outpatient CDI consultant at 3M Health Information Systems.