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


Private Payers and Medicare

Private payers and Medicaid normally use the same codes that Medicare uses. Qualified healthcare professionals (QHPs) should contact private payers and Medicaid to verify their HCPCS codes for OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix.

Because Medicare is packaging the payment of the OASIS® Matrix products into the new “low cost” HCPCS application codes (C5271-C5278), QHPs should ask the private payers and Medicaid the following questions:

  • Should the application of OASIS® Matrix products be reported with 15271-15278 OR C5271-C5278?
  • Are Q4102 and Q4124 separately payable?

Private payers and Medicaid vary in their coverage guidelines and payment rates.

For example, some private payers pay a flat fee per visit and others pay for procedures performed and products used. Some pay a percentage of charges and others pay a percentage of Medicare allowable rates.

Therefore, QHPs must verify private payer and Medicaid coverage and payment systems for the application of OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix and for the products themselves. In addition, QHPs should verify the patient’s insurance benefits and prior authorization requirements, if required, before applying OASIS® Matrix products.

  • Some private payers and/or Medicaid may require prior authorization and/or pre-determinations before approving the application of OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix
  • Prior to application, QHPs should verify private payer and Medicaid coding, coverage, and documentation requirements for each patient
  • If private payers deny coverage for OASIS® Wound Matrix and/or OASIS® Ultra Tri-Layer Matrix because they deem them to be "experimental" or "investigational," QHPs should supply the payer's medical director with the published information to support the medical necessity of OASIS® Wound Matrix and/or OASIS® Ultra Tri-Layer Matrix

    OASIS® is a registered trademark of Cook Biotech, Inc.




©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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If you have questions about OASIS® MATRIX products that are not answered by this Website, contact us.