Health Information Management

Q/A: Payment for skin substitutes

APCs Insider, April 13, 2012

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Q: We do not always receive payment for skin substitutes that we report. They appear in Addendum B as separately payable, but the line item indicates zero reimbursement. Do you have any information about this?

A: The October 2008 update to OPPS (Transmittal1599) instructed facility providers not to report the HCPCS code when a skin substitute was used as a surgical implant or inserted into the body.

Remember that under APCs, supply items are packaged into surgical procedures and are not separately payable. CMS considers inserted or implanted skin substitutes surgical supplies.. The HCPCS code was correctly reported only when an item was used as a skin substitute. Providers found this difficult to operationalize.

Effective April 1, CMS instructed facility providers to report HCPCS codes for skin substitutes regardless of how they are used. New edits in the Integrated Outpatient Code Editor (I/OCE) will process the line item for payment only when providers report the HCPCS code with a CPT® code that describes the application of a skin substitute (CPT codes 15271–15278).

In all other situations, the I/OCE will change the status indicator to N and package the item into the surgical procedure. CMS reminds providers to report the units based on the HCPCS description.

Documentation should support the amount of product used to support the units billed.

Providers should carefully review their remittance advices to ensure receipt of appropriate payment when skin substitutes are reported with CPT codes 15271–15278.

The April 2012 update appears in Transmittal 2418, published March 2. Details of the I/OCE edit appear in Transmittal 2423, published March 9.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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