Health Information Management

Q&A: Should we be reimbursed for skin substitutes?

APCs Insider, September 20, 2013

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Q: We are using Mediskin® and E-Z Derm® xenograft skin substitutes for wound care, but the business officetold us that Medicare is not reimbursing for these products. We are using them according to the manufacturer instructions. Should we be reimbursed?

A: Mediskin and EZ Derm products are indicated for use on partial-thickness skin loss, skin ulcerations, and abrasions. CMS assigned the following HCPCS codes to these products effective January 1, 2013:

  • Q4135 – Mediskin, per square centimeter
  • Q4136 – EZ Derm, per square centimeter

However, the codes were assigned a status indicator of E (not paid by Medicare when submitted on outpatient claims).

CMS is changing the status indicator to K (paid under OPPS; separate APC payment) for dates of service furnished on or after October 1, 2013, and the codes will be separately paid. The prices for these items will be updated quarterly based on CMS’ usual methodology.

Be sure that the documentation for these items includes the size of the biological and that the number of units reported reflects the size, based on square centimeters. Across the nation, many providers continue to report a unit of one for the sheet of product; if this is the case in your facility, there could be an underreporting of these biologicals and a lack of appropriate reimbursement received. In addition, the cost is being inaccurately reflected on the claims data reported to CMS, which in turn affects the data for future rate setting.

CMS announced this update in Transmittal 2775.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question. 

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