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 Qualified Healthcare Professionals (QHPs)

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

 

The Medicare Physician Fee Schedule (MPFS) is the payment system for QHP evaluation and management services and procedures. Effective January 1, 2012, CMS assigned zero (0) global surgical days to the new codes on the MPFS for the application of skin substitute grafts (15271-15278). If covered by the Medicare contractor, QHPs may now code and bill for each medically necessary application that is fully documented (including the method of fixation) in the procedure/operative report.

 
 

Below is an overview of the 2017 Medicare national average QHP payment rates for CPT® codes 15271-15278, when performed in the office and in facilities, and when covered by Medicare.

*Payments are nationally unadjusted average amounts and do not account for differences in payment due to geographic variation. QHP fees are those applicable to participating QHPs. The allowed rate for non-participating QHPs is set at 95% of the allowable for participating QHPs. Non-participating QHPs are subject to the limiting charge rules. Drugs and biologicals are paid on a mandatory assignment-related basis. The coinsurance is limited to 20% of the allowable fee.

http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2016ASPFiles.html

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.

NOTE: Dressings and medical supplies are usually bundled into the MPFS payment.

 
 

The patient is responsible for paying the 20% coinsurance of the Medicare MPFS allowable rate.

The patient's Medicare coinsurance for the application of OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix will vary depending on the anatomic location and the size of the wound surface area.

 
 

OASIS® Wound Matrix:

When covered by the Medicare contractor, the HCPCS code Q4102, assigned to OASIS® Wound Matrix, is separately payable in a QHP office based on the Average Sales Price (ASP) as reported by the manufacturer on a quarterly basis.

The ASP payment may change on a quarterly basis. QHPs should review the ASP file at the beginning of each calendar quarter: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2016ASPFiles.html.

OASIS® Ultra Tri-Layer Matrix:

When covered by the Medicare contractor, the HCPCS code Q4124, assigned to OASIS® Ultra Tri-Layer Matrix, is separately payable in a QHP office.

HCPCS code Q4124 is not yet listed in the ASP Medicare Part B Drug Pricing File. The payment allowance limits for drugs and biologicals that are not included in the ASP Medicare Part B Drug Pricing File or Not Otherwise Classified (NOC) Pricing File, other than new drugs that are produced or distributed under a new drug application (or other application) approved by the FDA, are based on the published Wholesale Acquisition Cost (WAC) or invoice pricing. In determining the payment limit based on WAC, the contractors follow the methodology specified in Publication 100-04, Chapter 17, Drugs and Biologicals, for calculating the AWP, but substitute WAC for AWP. The payment limit is the lesser of 106% of the lowest-priced brand or median generic WAC.

Therefore, when reporting Q4124 OASIS® Ultra Tri-Layer Matrix that was applied in the qualified healthcare professional's office, include the following information in field 19 of a paper claim or in the narrative field of an electronic claim:

  • Product name
  • Product size
  • Product number
  • Invoice price per piece (not per box)
  • Shipping cost
 
 

Below is an overview of the Third Quarter 2017 average sales price (ASP)-based allowable payment rates for HCPCS codes Q4102 and Q4124 and the 2017 Medicare national average physician payment rates for CPT® codes 15271-15278, when performed in the office and in facilities, and when covered by Medicare.

The ASP-based allowable payment rates are updated on a quarterly basis. The ASP-based allowable payment rates for the OASIS® products' HCPCS Q-codes in this table reflect rates that are effective July 1, 2017 through September 30, 2017. The Medicare payment rates for the CPT® codes are effective January 1, 2017 through December 31, 2017.

*Payments are nationally unadjusted average amounts, and do not account for differences in payment due to geographic variation. Physician fees are those applicable to participating physicians. The allowed rate for non-participating physicians is set at 95% of the allowable for participating physicians. Non-participating physicians are subject to the limiting charge rules. Drugs and biologicals are paid on a mandatory assignment-related basis. The coinsurance is limited to 20% of the allowable fee.

http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2016ASPFiles.html

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 procedure with status indicator of "2," the procedure with the highest fee schedule amount is paid 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.

NOTE: The payment allowance limits for drugs and biologicals that are not included in the ASP Medicare Part B Drug Pricing File or Not Otherwise Classified (NOC) Pricing File, other than new drugs that are produced or distributed under a new drug application (or other application) approved by the FDA, are based on the published Wholesale Acquisition Cost (WAC) or invoice pricing, except under OPPS, where the payment allowance limit is 95% of the published Average Wholesale Price (AWP). In determining the payment limit based on WAC, the contractors follow the methodology specified in Publication, 100-04, Chapter 17, Drugs and Biologicals, for calculating the AWP, but substitute WAC for AWP. The payment limit is 106% of the lesser of the lowest-priced brand or median generic WAC.

NOTE: When reporting Q4124 OASIS Ultra Tri-Layer Matrix that was applied in the qualified healthcare professional's office, include the following information in field 19 of a paper claim or in the narrative field of an electronic claim: product name, size, product number, invoice price per piece, and shipping cost.

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

 
 

Application of OASIS® Wound Matrix in a QHPs Office

  • The QHP prepares a 2 cm x 6 cm diabetic foot ulcer for application of OASIS® Wound Matrix
  • The QHP acquires a 3 cm x 7 cm piece (21 sq cm) of OASIS® Wound Matrix and 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

*QHPs should review each Medicare contractor's coding guidance regarding the use of modifiers.

NOTE: When required and/or appropriate, the QHP 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. When the QHP purchases and applies OASIS® Ultra Tri-Layer Matrix, the QHP should also report his/her invoice price per piece and shipping cost in field 19 of a paper claim or in the narrative field of an electronic claim.

Medicare Payment for HOPDs

 

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

 

 

 




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OASIS is a registered trademark of Cook Biotech, Inc.
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