Reimbursement Pathway for Fluorescence Imaging and Detection of Bacterial Burden

Reimbursement Pathway
for Fluorescence Imaging and
Detection of Bacterial Burden (>104 CFU/g)

There are CPT codes and an APC assignment specific to the procedure for “fluorescence wound imaging for bacterial presence, location, and load”1,2. The MolecuLight i:X® is the only fluorescence imaging device that can enable this procedure.

The reimbursement pathway for this procedure includes:

  • Physician work through two CPT® codes (Current Procedural Terminology – category III)
  • Facility payment through an APC assignment (Ambulatory Payment Classification) for HOPD and ASC settings

These codes were issued by the AMA and CMS after critical review of the large body of supporting clinical evidence. Each recognized the medical necessity of this procedure.

These CPT codes have been active as of July 1, 2020.

Table 1. Example Coding to Report the Use of the MolecuLight i:X for Imaging Bacterial Presence, Location and Load

Hospital or facility payment for 1500 claim submission may use place of service codes 19, 21, 22, 23, 24, 31, 32, 34.
* Payment range depends on several factors including payor discretion, geographic location, and the amount charged. National computed average on new codes may be available after 1 year of data collection (i.e. July 2021)
** HCPCS codes identify device costs related to the procedure important in cost analysis. Code E1399 durable medical equipment, miscellaneous. Code A4649 surgical supply: miscellaneous.
CPT is a registered trademark of the American Medical Association. CPT 0598T and CPT 0599T are new technology codes (category III), which are used to report work of the procedures, request payment from payers, and facilitate data collection on new services and procedures.
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Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements. The coding options listed here are commonly used codes and are not intended to be an all-inclusive list. Use of the codes provided herein allow payers to track new codes and their associated costs. The MolecuLight i:X detects wounds with elevated loads of bacteria when exposed to an excitation light. Fluorescence is only accurate under clinical darkness acheived using the DarkDrape or turning off the room lights. The MolecuLight i:X does not diagnose or treat skin wounds. The MolecuLight i:X is for prescription use only. This reimbursement guide pertains to the use of MolecuLight i:X in wound care as an imaging device.

DISCLAIMER: This reimbursement guide provides baseline reimbursement information as a convenience to MolecuLight i:X users. It is not a substitute for qualified reimbursement advice as to your specific situation. Coding, coverage and reimbursement decisions are subject to change without notice. Providers should always check with the appropriate payer before submitting claims. The use of appropriate codes, charges for service, and use of modifiers for services rendered is the responsibility of the healthcare provider. Providers are responsible for verifying coverage with payors, including the applicability of any non-coverage policies that may exist, and documentation required as justification/evidence for billed services. MolecuLight Inc. is not responsible for the timeliness, accuracy, completeness, or applicability of the information contained within this document. Since reimbursement laws, regulations, and payor policies change frequently, providers should consult their payers, coding specialists and/or legal counsel regarding coverage, coding and payment issues.

References
1Release of 2 New Category III Codes for Real-time Fluorescence Wound Imaging to the AMA website (Dec. 30, 2019) www.ama-assn.org/system/files/2019-12/cpt-category3-codes-long-descriptros.pdf
2CMS DHHS Pub 100-04 Medicare Claims Processing Transmittal 10166. July 2020 Update of the Hospital Outpatient Prospective Payment System. June, 2020
3AMA 2020 CPT Manual all rights reserved.
4CMS Physician relative value scale January 1, 2020.
5CMS OPPS Addendum B January 1, 2020.
6CMS Ambulatory Surgical Center (ASC) Addendum AA Final Rule corrected Covered Surgical Procedures for CY 2020.
7CMS ASC Addendum BB July 1, 2020 update.