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


Frequently Asked Questions

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No. A thorough, complex clinical evaluation by a physician, podiatrist, or non-physician practitioner leads to the decision to perform the surgical procedure 15271-15278 (application of skin substitute graft). The application procedure requires the knowledge and skill of the physician, podiatrist, or non-physician practitioner and is critical to the success of OASIS® Matrix products. The application procedure consists of appropriate wound bed preparation, meticulous application of the OASIS® Matrix product to the wound surface, appropriate fixation with the physician's method of choice, hydration of the product, appropriate dressing to protect the wound and the product, and appropriate off-loading (if required).

 
 

The 2017 CPT® codebook makes it clear that the surgical preparation codes 15002-15005 may only be billed on the same encounter when treating a burn, a traumatic wound, or a necrotizing infection.

Likewise, the 2017 CPT® codebook makes it clear that 15002-15005 should not be reported when removing nonviable tissue or debris in a chronic wound such as a venous or diabetic wound. For those chronic venous or diabetic wounds, providers should use either the surgical debridement codes (11042-11047) or the medical debridement codes (97597-97598).

The 2017 CPT® codebook also states that surgical or medical debridement of chronic wounds is considered separate only when:

  • Gross contamination requires prolonged cleansing
  • Appreciable amounts of devitalized or contaminated tissue are removed
  • Debridement is carried out separately without primary closure

The 2017 CPT® codebook also reminds providers that removal of the current skin substitute graft and/or simple cleansing of the wound is included in the application of the skin substitute graft code when it is performed.

Most Medicare contractors' Local Coverage Determinations include guidelines that further clarify and/or restrict the use of the debridement codes and the application of skin substitute graft codes during the same patient encounter. Providers should read and follow the pertinent Local Coverage Determination(s) regarding this topic.

Providers should also review the National Correct Coding Initiative (NCCI) edits at the beginning of each calendar quarter. As of January 1, 2017, the NCCI edits list numerous procedures that cannot be billed together with the application of a skin substitute graft during the same encounter. Several debridement codes in column II are coupled with the new skin substitute graft codes in the NCCI edits in column I on both the physician and hospital outpatient edit lists.

 
 

The physician's office should refer to the National Correct Coding Initiative (NCCI) Edits to ensure that the 2 procedures are not included in a bundled charge. These edits apply to physicians and non-physician practitioners and are updated on a quarterly basis. Your biller and/or coder should check the latest NCCI edits here.

Example: Approximately 200 other CPT® codes, including 29580 (application of Unna boot), are bundled into 15271-15278. Therefore, the application of an Unna boot can be billed only if it is used to manage another problem, such as a venous ulcer on the opposite leg.

NOTE: When CPT® codes 15271, 15273, 15275, or 15277 are reported on the same day as one or more additional procedures with a multiple surgery indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (e.g., for a procedure with a status indicator of "2," the procedure with the highest fee schedule amount is paid at 100%, the next 3 procedures ranked by fee schedule amount are paid at 50% each, and any additional procedures are paid "by report"). Payment will be based on the lower of (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.

 
 

The HCPCS code descriptions of Q4102 and Q4124 define the unit of measure as "per sq. cm." Providers should bill the actual number of square centimeters acquired for the patient for that application.

 
 

When wound surface areas are smaller than 100 sq cm, select either:

  • 15271 or 15275, based upon the anatomical location of the wound
    • 15271 should be selected when the skin substitute graft is applied to the wound surface area of the trunk, arms, or legs that is 25 sq cm or less
    • 15275 should be selected when the skin substitute graft is applied to the wound surface area of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits that is 25 sq cm or less

Use the appropriate new add-on codes 15272 and 15276 for each additional 25 sq cm of wound surface area, or part thereof.

NOTE: If the wound surface area of anatomic sites that are grouped together into the same code descriptor is 100 sq cm or more, do not use these 4 codes.

When the wound surface area is greater than or equal to 100 sq cm, select either:

  • 15273 or 15277, based upon the anatomical location of the wound
    • 15273 should be selected when the skin substitute graft is applied to the wound surface area of the trunk, arms, or legs that is greater than or equal to 100 sq cm, or 1% of body area of infants and children under the age of 10
    • 15277 should be selected when the skin substitute graft is applied to the wound surface area of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits that is greater than or equal to 100 sq cm, or 1% of body area of infants and children under the age of 10

Use the appropriate new add-on codes 15274 and 15278 for each additional 100 sq cm of wound surface area, or part thereof; or each additional 1% of body area of infants and children, or part thereof.

NOTE: If the wound surface area of anatomic sites that are grouped together into the same code descriptor is less than 100 sq cm, do not use these 4 codes.

 
 

Effective January 1, 2009, CMS announced two new HCPCS code modifiers:
JC - skin substitute used as a graft
JD - skin substitute not used as a graft

CMS did not release directives regarding the JC and JD modifiers. Therefore, Medicare contractors may issue their own directions for use of JC and JD. To prevent inappropriately denied claims, all providers should contact the Medicare contractor that processes their Medicare claims and ascertain 1) if the JC and JD modifier should be attached to the Q4102 and Q4124 codes, and 2) the proper usage of each modifier.

 
 

Medicare contractors require all physician and QHP offices to report discarded amounts of OASIS® products on a separate claim line item by attaching the JW modifier to Q4102 and Q4124 (resulting in 2 claim lines: Q4102 plus Q4102JW; or Q4124 plus Q4124JW). 

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




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