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


Medicare Payment for Hospital-Owned Outpatient Departments (HOPDs)

Please click the plus (+) signs to the left of the topics to learn more.

 

The APC system is the Outpatient Prospective Payment System for HOPD clinic visits, procedures, and separately payable products. It applies to all HOPDs, except for those in Maryland, VA hospitals, and Critical Access hospitals.

Clinic visits and procedures are assigned to APC groups based on the resources necessary to provide care. Each APC group has a national payment allowable, which is adjusted according to geographic region and to the particular facility.

When covered by the Medicare contractor, the 2017 HCPCS® codes relevant to the application of OASIS® Matrix products are assigned to the APC groups 5053 ("Level II Skin repair"), and 5054 ("Level III Skin Repair").

The application HCPCS codes that are assigned to APC group 5053 are:

  • C5271
  • C5275
  • C5277

NOTE: The add-on codes C5272, C5276, and C5278 are packaged by Medicare. Therefore, they have not been assigned to an APC group. The application HCPCS code that is assigned to APC group 5054 is

  • C5273

NOTE: The add-on code C5274 is packaged by Medicare. Therefore, it has not been assigned to an APC group.

NOTE: At each HOPD encounter where OASIS® Matrix products are applied and fully documented (including the method of fixation), the HOPD should still report the HCPCS codes for the procedure, the HCPCS codes for the add-on codes, and the HCPCS codes for the OASIS® Matrix product applied.

Dressings and medical supplies are bundled into the APC payment.

 
 

Effective January 1, 2014, Medicare packaged the payment for the “add-on” procedure code and for the OASIS® Matrix product into the APC payment rate for the application procedure.

Below is an overview of the Medicare national average Hospital Outpatient Prospective Payment System (HOPPS) “Packaged” Payment Rates* for the application codes (C5271-C5278) when the product is covered by Medicare.

* Payments are nationally unadjusted average amounts, and do not account for differences in payment due to geographic variation.

** These rates do not account for the impact of the sequester.

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

 
 

The patient is responsible for paying the 20% coinsurance of the Medicare APC allowable rates and the Medicare Physician Fee Schedule allowable rate.

The patient's Medicare coinsurance owed to the HOPD and to the qualified healthcare professional for the application of OASIS® Matrix products will vary, depending on the anatomic location of the wound surface area.

To obtain this quarter's HOPD Medicare Payment Information Sheet for OASIS® Matrix products, please download the HOPD Medicare Quarterly Payment Information Sheet.

 
 

Application of OASIS® Wound Matrix in an HOPD

  • The QHP prepares a 2 cm x 6 cm diabetic foot ulcer for application of OASIS® Wound Matrix
  • The HOPD acquires a 3 cm x 7 cm piece (21 sq cm) of OASIS® Wound Matrix
  • The QHP applies a total of 16 sq cm to the prepared wound surface and to the wound margins and discards 5 sq cm
  • The QHP anchors OASIS® Wound Matrix with his/her choice of clinically appropriate fixation
  • The QHP secures OASIS® Wound Matrix with a non-adherent dressing and any additional dressings necessary to either absorb exudate or donate moisture and secures the primary dressing(s) with an appropriate secondary dressing

 

NOTE: When required and/or appropriate, the HOPD reports the name of the product (OASIS® Wound Matrix or OASIS® Ultra Tri-Layer Matrix), its size, and its product number in the appropriate field of a paper claim or in the narrative field of an electronic claim.

 

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

Medicare Payment for ASCs

 

 




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OASIS is a registered trademark of Cook Biotech, Inc.
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