Acknowledgement:

Information on reimbursement in the United States is provided as a courtesy. Due to the rapidly changing nature of the law and Medicare payment policy, and our reliance on information provided by outside sources, the information provided herein does not constitute a guarantee or warranty by Smith and Nephew,Inc that reimbursement will be received.

This information is provided "AS IS" and without any other warranty or guarantee, expressed or implied, as to completeness or accuracy or otherwise. This information has been compiled based on data gathered from many primary and secondary sources, including the American Medical Association and certain Medicare contractors.

Physicians and other providers must confirm or clarify coding and coverage from their respective payers, as each payer may have differing formal or informal coding, coverage policies, or decisions. Physicians and providers are responsible for accurate documentation of patient conditions, and for reporting of procedures and products in accordance with particular payer requirements.

Reimbursement


CPT® Codes

Effective January 1, 2012, the American Medical Association (AMA) deleted the 24 former skin replacement and skin substitute CPT® codes1, including the two codes (15430, 15431) that were relevant to the application of the OASIS® Matrix products. To replace these codes, the AMA created 8 codes (15271-15278) to report the application of skin substitute grafts. These 8 new procedure codes are distinguished by the anatomic location and size of the wound rather than by product description. Most Medicare contractors have declared that these are appropriate billing codes for the application of OASIS® Matrix products.

Effective January 1, 2014, qualified healthcare professionals (QHPs) will continue to use the codes 15271-15278. NOTE: QHPs should report the “Q” code for the product in conjunction with 15271-15278.

Effective January 1, 2014, hospital-based outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) will continue to use the codes 15271-15278 ONLY to report:

  • The application of “high cost” cellular and/or tissue based products for wounds (CTPs) [old term “skin substitute grafts]
  • The application of all CTPs to non-Medicare payers, ONLY IF THE PAYER HAS DECIDED NOT TO USE THE NEW HCPCS CODES (C5271-C5278) for the application of “low cost” CTPs.

NOTE: HOPDs and ASCs should report the “Q” code for the product in conjunction with 15271-15278.

NOTE: The wound surface area applies to the size of the recipient site, not to the size or amount of product used.
NOTE: The wrists are considered part of the arm and the ankles are considered part of the leg.

Effective January 1, 2014, HOPDs and ASCs must use the new HCPCS codes (See HCPCS Codes for Application of Products) (C5271-C5278) to report.

    • The application of “low cost” CTPs to Medicare
    • The application of “low cost” CTPs to non-Medicare payers, ONLY IF THE PAYER HAS DECIDED NOT TO USE 15271-15278 for the application of “low cost” CTPs.

NOTE: Medicare has designated both OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix as “low cost” products

AMA Fixation Guidelines
Qualified healthcare professionals (QHPs) should document their clinically appropriate choice of fixation to anchor OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix because the introductory section of the Skin Replacement Surgery section of the CPT® 2014 Current Procedural Terminology codebook states:

 

"The graft is anchored using the individual's choice of fixation. When services are performed in the office, routine dressing supplies are not reported separately."

 

Download 2017 Coding Information specific to QHPs who apply the products and to HOPDs and ASCs when non-Medicare payers decided not to use the new HCPCS codes C5271-C5278.

Download 2017 Coding Information specific to HOPDs and ASCs when they report the application of “low cost” CTPs to Medicare or any other payer that also requires the new HCPCS codes C5271-C5278.

References:

1. CPT® 2014 Current Procedural Terminology, Professional Edition, American Medical Association, p. 78 - 82.

2. CPT® Changes 2012: An Insider's View, American Medical Association, pp. 27-29.

OASIS® is a registered trademark of Cook Biotech, Inc.
CPT® is a registered trademark of the American Medical Association.

 

 

 

 

 

 

 

 

 

 




©2015 Smith & Nephew, Inc. All rights reserved.
OASIS is a registered trademark of Cook Biotech, Inc.
All trademarks acknowledged. HS1187-0214

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