Coding Application Success Cases
Case examples of successful Coding Applications:
- Developed a successful coding strategy for the sheet and injectible versions of a tissue product. With KOL support, educated CMS regarding the regulatory and reimbursement requirements for the same. This was the first tissue product ever reviewed by CMS. Information was provided to a team of CMS physicians and policy staff of the unique FDA regulatory process for tissue products and provided input to modify FDA requirement for HCPCS codes. Successfully obtained a "J" code, a C code for pass through payment in the hospital outpatient department, and a "J" code for the injectible version of the product.
- Identified appropriate CPT codes and submitted coding verifications to several diagnostic tests, therapies for malignant melanoma, acute mylogenous leukemia, and hepatitis C, and organ transplant anti-rejection drugs.
- Provided input into the revision of vascular access codes, skin substitute codes and pathology laboratory tests sections of CPT Coding Book by working with the professional societies responsible for managing the revisions.
- Obtained a unique "J" code for a recombinant monoclonal antibody.
- Obtained a collagen wound filler coding category and successfully avoided the classification of the client product in the unclassified wound filler category by providing appropriate and compelling rationale.
Payer Alliance Success Cases
Case examples of Payer Alliance successes:
- Successfully obtained coverage and appropriate payment for totally subcutaneous vascular access device from Medicare, Medicaid, and some private payers although competitor product catheters were less costly than client device. This was accomplished over a period of 2-3 years by providing clinical and cost data to show better outcomes and cost savings to the payer.
- Positive Medicare coverage for a tissue product within six months of product launch. Convened a payer panel meeting to review a model health technology assessment tool, to develop model coverage policy, and to identify payer desired outcomes for clinical studies to support the private payer strategy of a tissue product.
- Reversal of several non coverage policies for a zenograft within one year based on payer alliance work. Development of private payer strategies for the same product including the analysis of payer coverage policies and the development of strategies to target the reasons for non - coverage.