Health Information Management

Q&A: How do we report skin substitutes not on CMS’ high- or low-cost lists?

APCs Insider, September 12, 2014

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Q: On page 70 of Transmittal R2838CP, CMS indicates certain skin substitutes have been removed from the skin products list effective January 1, 2014. But on page 89 of the same transmittal, it states that some have been added to either the high-cost or low-cost skin substitute lists. We are receiving denials stating “HCPCS is invalid” when a product that is on neither list is on an account with a skin substitute application code.

If the codes, such as Q4113, Q4114, and Q4118, do not make either list, does that mean CMS does not consider the product a skin substitute and the application codes would be inappropriate to report with those products? Due to procedure-to-device edits, we are having trouble resolving these accounts. I have queried three different MACs asking for guidance but have yet to hear back from any of them.
A: Transmittal R2838CP lists the changes and updates made to the I/OCE for January 2014. HCPCS codes Q4113, Q4114, and Q4118 describe injectable formulas of GraftJacket®, Integra™, and MatriStem®, respectively. 
The 2014 CPT® guidelines provides the following definition: 
Skin substitute grafts include non-autologous human skin (dermal or epidermal, cellular and acellular) grafts (e.g., homograft, allograft), non-human skin substitute grafts (i.e., xenograft), and biological products that form a sheet scaffolding for skin growth. These codes are not to be reported for application of non-graft wound dressings (e.g., gel, ointment, foam, liquid) or injected skin substitutes. [emphasis added]
Based on these instructions, the injectable forms are not reported with the CPT® application codes 15271–15278. Therefore, CMS removed them from the high-/low-cost table and from the edit that pairs the skin substitute with the procedure. 
You didn’t note which MACs you contacted, but according to the information in the Medicare Coverage Database, these appear to be considered non-covered by the MACS. National Government Services has an article that accompanies LCD L26003 which states “the use of GraftJacket Xpress Flowable soft tissue scaffold is considered investigational and is not covered.”
Wisconsin Physician Services posted LCD L30135, which lists the items that are non-covered; all three of the codes Q4113, Q4114, and Q4118 are in the non-covered list.
CGS Administrators also has these codes listed on the non-covered list in LCD L33173 with a notation that states, Non-covered products: The following products are considered to be wound dressings and not separately payable as CTPs [cellular and/or tissue-based products].”   
Based on the information provided, the application codes are not appropriate for reporting the injectable substances, and these are also a non-covered service. You should check with your non-Medicare payers, as they may have coverage information related to these items as well. 
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.

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular