Clarifying Q-Codes with FlexHD® Acellular Hydrated
Dermis+ and XCM BIOLOGIC® Tissue Matrix
The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee by Ethicon concerning levels of reimbursement,
payment, or charge. Similarly, all CPT, ICD-10 and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by Ethicon that these
codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payor. CPT codes and descriptions are copyright 2015
American Medical Association. ICD-10 codes and descriptions are copyright 2015 World Health Organization; revise for use in the United States by the Centers for Medicare and Medicaid
Services (CMS) and the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS). Healthcare Common Procedure Coding System (HCPCS) Level
II codes and descriptions are copyright 2015 CMS. While we have made an effort to provide information that is current at the time of its issue, the information may not be as current
or comprehensive when you view it. We strongly recommend that you consult your counsel, reimbursement specialist or payor organization with regard to reimbursement policies.
Physicians should refer to their provider Carrier Manual for their geographic payment.
Executive Summary
HCPCS is the acronym for the Healthcare Common Procedure Coding System. These codes are frequently used to report supplies
and services that are not assigned a Level II CPT code. In some instances, private payor and/or Medicare may provide additional
reimbursement for some HCPCS codes. Facilities may use them to track device costs on the facility charge master or super bill.
• Q-codes are HCPCS codes used in the hospital outpatient setting; not in the hospital inpatient setting.
• Q-codes were reimbursed separately in the Medicare hospital outpatient until December 31, 2013.
Applicable skin substitute codes referenced:
• Effective January 1, 2014 most Q-codes are packaged within an Ambulatory Payment Classification (APC).
• Q4128 – Flex HD, Allopatch HD, or Matrix HD, per square cm (packaged as part of the primary procedure and not separately paid).
• Q4142 – XCM biologic tissue matrix, per square cm (packaged as part of the primary procedure and not separately paid).
Hospital Outpatient Facility
Center for Medicare and Medicaid Services (CMS) has changed the use of Q-codes in the hospital outpatient setting; CMS is
“packaging all drugs and biologicals that function as supplies when used in a surgical procedure”. This means that Q-codes must
be reported, but are not separately reimbursed.
CMS has assigned Q-codes to 2 categories:
1. High cost skin substitutes (more than $32 per sq. cm) and
2. Low cost skin substitutes (less than $32 per sq. cm).
CMS categorizes skin substitutes as high or low cost based on an analysis of average historical cost reported in claims data for
each Q-code published annually.1
Based on the new category requirements, hospitals will have to report the following:
High Cost Skin Substitutes (more than $32 per sq. cm)
• Skin Substitutes assigned to the high cost categories will be reported with Current Procedural Terminology (CPT) codes 15271 through 15278 and the appropriate Q-code.
• CPT codes 15271 through 15278 are for the application of skin substitutes by body area and size (100 sq. cm or larger).
Low Cost Skin Substitutes (less than $32 per sq. cm)
• Skin Substitutes assigned to the low cost categories will be reported with C-codes C5271 through C5278 and the appropriate HCPCS Q-code.
• Codes C5271 through C5278 are low cost application of skin substitutes by body area and size (100 sq. cm or larger).
Surgeon CPT, HCPCS, APC & ASC Codes
Surgeon Reimbursement
Surgeon
CPT Code2
Procedure
Medicare
Payment
National Average
Facility3
Medicare
Payment
National Average
Non-Facility3
High Cost Skin Substitute Graft Application
15271
Application of skin substitute graft to trunk, arms, legs, total wound surface area up
to 100 sq cm; first 25 sq cm or less wound surface area
$87
$143
15272
Application of skin substitute graft to trunk, arms, legs, total wound surface area up
to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List
separately in addition to code for primary procedure)
18
28
15273
Application of skin substitute graft to trunk, arms, legs, total wound surface area
greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of
body area of infants and children
2Ø9
3Ø3
15274
Application of skin substitute graft to trunk, arms, legs, total wound surface area
greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area,
or part thereof, or each additional 1% of body area of infants and children, or part
thereof (List separately in addition to code for primary procedure)
48
73
15275
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq
cm; first 25 sq cm or less wound surface area
99
152
15276
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq
cm; each additional 25 sq cm wound surface area, or part thereof (List separately in
addition to code for primary procedure)
26
35
15277
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area greater than
or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of
infants and children
233
330
15278
Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or
equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or
each additional 1% of body area of infants and children, or part thereof (List separately
in addition to code for primary procedure)
59
87
Hospital Outpatient Reimbursement
HCPCS Code3
Procedure
Status
APC
Medicare Payment4
T
5054
$1,411
N
N/A
Packaged, not
separately reimbursed
T
5055
2,137
N
N/A
Packaged, not
separately reimbursed
High Cost Skin Substitute Graft Application
15271
15272
15273
15274
Application of skin substitute graft to trunk, arms, legs, total
wound surface area up to 100 sq cm; first 25 sq cm or less wound
surface area
Application of skin substitute graft to trunk, arms, legs, total wound
surface area up to 100 sq cm; each additional 25 sq cm wound
surface area, or part thereof (List separately in addition to code for
primary procedure)
Application of skin substitute graft to trunk, arms, legs, total wound
surface area greater than or equal to 100 sq cm; first 100 sq cm
wound surface area, or 1% of body area of infants and children
Application of skin substitute graft to trunk, arms, legs, total wound
surface area greater than or equal to 100 sq cm; each additional 100
sq cm wound surface area, or part thereof, or each additional 1% of
body area of infants and children, or part thereof (List separately in
addition to code for primary procedure)
Surgeon CPT, HCPCS, APC & ASC Codes (continued)
HCPCS Code3
Procedure
Status
APC
Medicare Payment 4
15275
Application of skin substitute graft to face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound
surface area up to 100 sq cm; first 25 sq cm or less wound surface
area
T
5054
$1,411
15276
Application of skin substitute graft to face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound
surface area up to 100 sq cm; each additional 25 sq cm wound
surface area, or part thereof (List separately in addition to code for
primary procedure)
N
N/A
Packaged, not
separately reimbursed
15277
Application of skin substitute graft to face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound
surface area greater than or equal to 100 sq cm; first 100 sq cm
wound surface area, or 1% of body area of infants and children
T
5055
2,137
15278
Application of skin substitute graft to face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound
surface area greater than or equal to 100 sq cm; each additional 100
sq cm wound surface area, or part thereof, or each additional 1% of
body area of infants and children, or part thereof (List separately in
addition to code for primary procedure)
N
N/A
Packaged, not
separately reimbursed
High Cost Skin Substitute Graft Application (continued)
Low Cost Skin Substitute Graft Application
C5271
Application of low cost skin substitute graft to trunk, arms, legs, total
wound surface area up to 100 sq cm; first 25 sq cm or less wound
surface area
T
5053
429
C5272
Application of low cost skin substitute graft to trunk, arms, legs, total
wound surface area up to 100 sq cm; each additional 25 sq cm
wound surface area, or part thereof (list separately in addition to code
for primary procedure)
N
N/A
Packaged, not
separately reimbursed
C5273
Application of low cost skin substitute graft to trunk, arms, legs, total
wound surface area greater than or equal to 100 sq cm; first 100 sq
cm wound surface area, or 1% of body area of infants and children
T
5055
2,137
C5274
Application of low cost skin substitute graft to trunk, arms, legs,
total wound surface area greater than or equal to 100 sq cm; each
additional 100 sq cm wound surface area, or part thereof, or each
additional 1% of body area of infants and children, or part thereof (list
separately in addition to code for primary procedure)
N
N/A
Packaged, not
separately reimbursed
C5275
Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits,
total wound surface area up to 100 sq cm; first 25 sq cm or less
wound surface area
T
5053
429
C5276
Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits,
total wound surface area up to 100 sq cm; each additional 25 sq cm
wound surface area, or part thereof (list separately in addition to code
for primary procedure)
N
N/A
Packaged, not separately
reimbursed
C5277
Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits,
total wound surface area greater than or equal to 100 sq cm; first 100
sq cm wound surface area, or 1% of body area of infants and children
T
5054
1,411
Surgeon CPT, HCPCS, APC & ASC Codes (continued)
HCPCS Code3
Procedure
Status
APC
Medicare Payment 4
N
N/A
Packaged, not
separately reimbursed
Low Cost Skin Substitute Graft Application (continued)
C5278
Application of low cost skin substitute graft to face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits,
total wound surface area greater than or equal to 100 sq cm; each
additional 100 sq cm wound surface area, or part thereof, or each
additional 1% of body area of infants and children, or part thereof (list
separately in addition to code for primary procedure)
Skin Substitute Supply Codes
C9349
FortaDerm, FortaDerm antimicrobial
G
1657
$109
Q4121
Theraskin
G
1479
$36
NOTE: Status code N – Items and Services Packaged into APC rates (packaged); Status code T – Procedure or Service, Multiple Procedure Reduction Applies (separate APC payment); Status code G –
Nonpass-Through Drugs and Nonimplantable Biologicals, Including Therapeutic Radiopharmaceuticals (separate APC payment)
Free-Standing Ambulatory Surgery Center
HCPCS Code4
Status
Medicare Payment 4
15271, 15275
G2
$789
15273, 15277
G2
1,195
15272, 15274, 15276, 15278
N1
Packaged, not separately
reimbursed
C5271, C5275
G2
240
C5273
G2
1,195
C5277
G2
789
C5272, C5274, C5276, C5278
N1
Packaged, not separately
reimbursed
C9349
K2
109
Q4121
K2
36
High Cost Skin Substitute Graft Application
Low Cost Skin Substitute Graft Application
Skin Substitute Supply Codes
NOTE: Status code N1 – Items and Services Packaged into APC rates (packaged); Status code G2 – payment based on OPPS relative payment weight; K2 - Drugs and biologicals paid separately when
provided integral to a surgical procedure on ASC list, payment based on OPPS rate.
HCPCS Code4
HCPCS Description (per sq. cm.)
Status
Skin Substitute Assignments to
High Cost and Low Cost Groups5
Skin Substitute Assignments to High Cost and Low Cost Groups
C9349
FortaDerm, FortaDerm antimicrobial
G
High
C9358
SurgiMend, fetal
N
Not Listed
C936Ø
SurgiMend, neonatal
N
Not Listed
C9363
Integra Meshed Bil Wound Matrix
N
High
Q41ØØ
Skin substitute, NOS
N
Low
Q41Ø1
Apligraf
N
High
Q41Ø2
Oasis Wound Matrix
N
Low
Q41Ø3
Oasis Burn Matrix
N
High
Q41Ø4
Integra Bilayer Matrix Wound Dressing (BMWD)
N
High
Q41Ø5
Integra Dermal Regeneration Template (DRT)
N
High
Q41Ø6
Dermagraft
N
High
Q41Ø7
Graftjacket
N
High
Q41Ø8
Integra Matrix
N
High
Surgeon CPT, HCPCS, APC & ASC Codes (continued)
HCPCS
Code4
HCPCS Description (per sq. cm.)
Status
Skin Substitute Assignments to
High Cost and Low Cost Groups6
Skin Substitute Assignments to High Cost and Low Cost Groups
Q411Ø
Primatrix
N
High
Q4111
GammaGraft
N
Low
Q4112
Cymetra, injectable
N
Not Listed
Q4113
GraftJacket Xpress
N
Not Listed
Q4114
Integra Flowable Wound Matrix
N
Not Listed
Q4115
AlloSkin
N
Low
Q4116
AlloDerm
N
High
Q4117
Hyalomatrix
N
Low
Q4118
Matristem Micromatrix
N
Not Listed
Q4119
MatriStem Wound Matrix
N
Low
Q412Ø
MatriStem Burn Matrix
N
High
Q4121
Theraskin
G
High
Q4122
DermACELL
N
High
Q4123
AlloSkin RT
N
High
Q4124
OASIS Ultra Tri-Iayer Wound Matrix
N
Low
Q4125
ArthroFlex
N
Not Listed
Q4126
MemoDerm, DermaSpan, TranZgraft, or InteguPly
N
High
Q4127
Talymed
N
High
Q4128
FlexHD, AllopatchHD, or Matrix HD
N
Low
Q4129
Unite Biomatrix
N
Not Listed
Q413Ø
Strattice™
N
Not Listed
Q4131
Epifix
N
High
Q4132
Grafix Core
N
High
Q4133
Grafix Prime
N
High
Q4134
hMatrix
N
High
Q4135
Mediskin
N
Low
Q4136
E-Z Derm
N
Low
Q4137
AMNIOEXCEL or BIODEXCEL
N
High
Q4138
Biodfence DryFlex
N
High
Q4139
Amnio or BioDMatrix, injectable
N
Not Listed
Q414Ø
BioDFence
N
High
Q4141
AlloSkin AC
N
High
Q4142
XCM Biologic Tissue Matrix
N
Not Listed
Q4143
Repriza
N
Low
Q4145
Epifix, injectable
N
N/A
Q4146
Tensix
N
Low
Q4147
Architect, Architect PX, Architect FX
N
High
Q4148
NEOX 1K
N
High
Q4149
Excellagen
N
Not Listed
Q415Ø
AlloWrap DS or Dry
N
High
Q4151
AmnioBand, Guardian
N
Low
Surgeon CPT, HCPCS, APC & ASC Codes (continued)
HCPCS
Code4
HCPCS Description (per sq. cm.)
Status
Skin Substitute Assignments to
High Cost and Low Cost Groups6
Q4152
DermaPure
N
Low
Q4153
Dermavest
N
High
Q4154
BIOVANCE
N
Low
Q4155
NEOXFLO or CLARIXFLO
N
Not Listed
Q4156
NEOX 100
N
Low
Q4157
Revitalon
N
Low
Q4158
MariGen
N
Low
Q4159
Affinity
N
High
Q416Ø
NuShield
N
High
Q4161
Bio-connekt
N
Low
Q4162
Amnio bio and woundex flow
N
Low
Q4163
Amnio bio and woundex
N
Low
Q4164
Helicoll
N
Low
Q4165
Keramatrix
N
Low
NOTE: Status code N – Items and Services Packaged into APC rates (packaged); Status code G – Nonpass-Through Drugs and Nonimplantable Biologicals, Including Therapeutic Radiopharmaceuticals
(separate APC payment)
NOTE: Several of these codes were not assigned to a Low/High Cost skin substitute bucket; however, they have status code N – packaged.
1. Federal Register, Vol. 79, No. 217, Monday, November 10, 2014/Rules and Regulations; Final Hospital Outpatient Payment. 2. All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions,
numeric modifiers, instructions, guidelines and other material are copyright 2015 American Medical Association. 3. Federal Register, Vol. 80, No. 221, Monday, November 16, 2015/Rules and Regulations.
2016 Physician Conversion Factor (CF) = $35,8279. 4. All Healthcare Common Procedure Coding System (HCPCS) Level II alpha-numeric codes, descriptions, instructions, guidelines and other material are
copyright 2015 Centers for Medicare & Medicaid Services (CMS). All Rights Reserved. 5. Federal Register, Vol. 80, No. 220, Friday, November 13, 2015/Rules and Regulations; Final Ambulatory Surgery Center
Payment. 6. Federal Register, Vol. 79, No. 217, FY 2016 Final HOPPS Rule; Table 50- Skin Substitute Assignments to High Cost and Low Cost Groups
Ethicon Reimbursement Support Program – (888) 750-1242 – [email protected]
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