Health Information Management

Q&A: How does CMS decide skin substitute classifications?

APCs Insider, September 5, 2014

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Q: We have been using the skin substitute called BioDfence® Dry Flex in our wound clinic. This is classified as a low-cost item under the OPPS and we are paying a lot for this item. How do we get CMS to change the classification?
A: Under the 2014 OPPS methodology, CMS packaged all skin substitutes and assigned them to either the high-cost group or the low-cost group. The agency also created two sets of codes for the application procedures:
  • procedures that use high-cost skin substitutes are reported with HCPCS Level I codes (15271–15278)
  • procedures using low-cost skin substitutes are reported with HCPCS Level II codes (C5271–C5278)
Any new skin substitutes approved for payment during 2014 were assigned to the high-/low-cost group based on available pricing information. New products that don’t have pricing information are assigned to the low-cost category, with CMS expected to reevaluate the assignment once pricing information is available. 
Three of the new skin substitute products now have pricing information available and have been reassigned to the high-cost group. The items are:
  • Q4137, AmnioExCel® or BioDExCel™, per square centimeter
  • Q4138, BioDfence DryFlex, per square centimeter
  • Q4140, BioDfence, per square centimeter 
All three codes are assigned to status indicator N (items and services packaged into APC rates) to reflect the packaged status. Q4137’s assignment to the high-cost group is effective as of July 1, 2014, while Q4138 and Q4140 assignment is effective October 1, 2014. Be sure the staff responsible for assignment of the application procedure codes is aware of this change, so that the correct procedure code is reported based on the high-cost assignment. 
The transmittal for the OPPS update effective October 1, 2014 is located at CMS' website
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Florida, answered this question.

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