Q3 2012
Integra® Meshed Bilayer Wound Matrix – Reimbursement Manual
Q3 2012
Integra® Meshed Bilayer Wound Matrix – Reimbursement Manual
Table of Contents
Section I
Integra® Dermal Regeneration Template – Reimbursement Manual
Reimbursement Assistance Line…………………………………………………………3
Section II
Product Information for Integra® Meshed Bilayer Wound Matrix..……………………4
Section III
Insurance Summaries
Medicare…………………………………………………………………………………….5
Medicaid……………………………………………………………………………………. 6
Other Insurance Carriers………………………………….……………………………….6
Section IV
Inpatient Reimbursement
Inpatient Reimbursement Tool……………………………………………………………7
Section V
Same Day Surgery/Hospital
Outpatient Summary..……………………………………………………………………..9
Outpatient Reimbursement Tool…………………………………………………..……10
Section VI
Ambulatory Surgical Center
ASC Summary…………………………………………………………………………….13
Section VII
Physician Reimbursement
CPT Physician Reimbursement Tool…………………………………………………...14
RBRVS Information and Global Periods………………………………………………..17
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as providing
clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the Provider’s
responsibility to determine and submit appropriate codes, charges, and modifiers for services that are rendered.
Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of any non®
coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation assumes no
responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since reimbursement laws,
regulations, and payer policies change frequently, it is recommended that providers consult with their payers, coding
specialists, and/or legal counsel regarding coverage, coding, and payment issues
2
Integra Reimbursement Assistance Line
(877) 444-1122, Option 3
Integra LifeSciences Corporation has created this comprehensive Reimbursement Manual to
support customers in their efforts to obtain optimal reimbursement when utilizing Integra products.
Integra has used reasonable efforts to provide accurate information, but this information should not
be construed
as providing clinical advice, dictating reimbursement policy, or substituting for the
judgment of a practitioner. Integra LifeSciences Corporation assumes no responsibilities or
liabilities for the timeliness, accuracy, and completeness of the information contained herein. Since
reimbursement laws, regulations, and payer policies change frequently, it is recommended that
providers consult with their payers, coding specialists, and/or legal counsel regarding coverage,
coding, and payment issues.
Because Medicare rates are the only publicly posted rates and many other payers use the
Medicare payment levels to set their own rates, the figures below are provided as a frame of
reference for customers. The identification of payment rates is not a guarantee of coverage by
Medicare or other payers. Each provider is responsible for verifying coverage with the patient’s
insurance carrier, including the applicability of any non-coverage decision that may exist.
Moreover, the identification of codes in this document should not be construed as providing clinical
advice, dictating reimbursement policy, or substituting for the judgment of a practitioner. It is
always the Provider’s responsibility to determine and submit appropriate codes, charges
and modifiers for services that are rendered.
ICD-9 and CPT-4 coding assistance is available Monday through Friday from 8:30 a.m. to 5:30 p.m.
Eastern Standard Time by calling the Assistance Line number listed above.
Questions regarding product pricing or clinical issues should be directed to our Customer Service
department at 1-877-444-1122, option 1.
Reference: CPT® Code Book 2012, CPT Copyright 2012 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association. Fee Schedules, relative value units,
conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA
is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical
services. The ICD-9-CM codes and descriptors, and DRG payment groups are effective October 1, 2011.
.
3
Product Information
INTEGRA® MESHED BILAYER WOUND MATRIX
A bilayer advanced wound care device that is ideal for partial and full-thickness soft tissue trauma
and chronic wounds.
Available Sizes
Catalog Number
MWM2021
MWM202
MWM4051
MWM405
MWM4101
MWM410
MWM8101
MWM810
Size (cm2)
25cm2
25cm2
125cm2
125cm2
250cm2
250cm2
500cm2
500cm2
Size (inches)
2in x 2in
2in x 2in
4in x 5in
4in x 5in
4in x 10in
4in x 10in
8in x 10in
8in x 10in
Unit of Measure
1 sheet
5 sheets
1 sheet
5 sheets
1 sheet
5 sheets
1 sheet
5 sheets
Description
INTEGRA® Meshed Bilayer Wound Matrix is an advanced wound care device comprised of a
porous matrix of cross-linked bovine tendon collagen and glycosaminoglycan and a semipermeable polysiloxane (silicone) layer. The meshed bilayer matrix allows drainage of wound
exudates and provides a flexible adherent covering for the wound surface. The collagenglycosaminoglycan biodegradable matrix provides a scaffold for cellular invasion and capillary
growth.
Indications
INTEGRA® Meshed Bilayer Wound Matrix is indicated for the management of wounds including:
partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular
ulcers, surgical wounds (donor sites/grafts, post-Moh’s surgery, post-laser surgery, podiatric,
wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns, and skin tears)
and draining wounds. INTEGRA® Meshed Bilayer Wound Matrix may be used in conjunction with
negative pressure wound therapy. The device is intended for one-time use.
4
Insurance Summaries
A Word about Insurance, Eligibility and Coverage
Medicare
Coverage for Integra® Meshed Bilayer Wound Matrix is dependent upon numerous factors, including
applicable policies that specific payers have established. For example, numerous Medicare contractors
and private carriers have non-coverage policies for Integra® Meshed Bilayer Wound Matrix when used in
lower extremity ulcers, and such policies may impact services furnished in the settings discussed below. In
the absence of a specific payer policy on an indication, an individualized coverage determination would be
made. As a result, it is important that providers using Integra® Meshed Bilayer Wound Matrix consider
pertinent payer policies and consult with the payer to confirm coverage of the product and related
procedures.
Inpatient: Medicare inpatient benefits are covered under Medicare Part A. Medicare reimburses for
services utilizing the Inpatient Prospective Payment System, using MS-DRG’s (Medical Severity Diagnosis
Related Groups). There are no separate payments for the product itself in the inpatient setting. The cost
of the product is factored into a lump sum payment, with the MS-DRG that is assigned to the case. In the
Inpatient section of this Guide, there are sample MS-DRG’s with their relative weights and Medicare
average payment rates for your reference. These are from the Federal Register, August 2011. Your
hospital’s Finance Department should be able to provide the hospital’s rate specific information for your
facility, and local medical policies should be considered to ensure the inpatient stay is covered.
Same Day Surgery /Outpatient Clinics (Hospital Based Outpatient): Medicare reimburses on APC’s
(Ambulatory Payment Classifications) for these settings. For your convenience, APC’s associated with the
use of Integra products are contained in the Same Day Surgery/Outpatient section of this Guide. Medicare
®
provides separate payments for drugs and biologics where covered by local medical policy. Integra
2
Meshed Bilayer Wound Matrix has been assigned HCPCS code C9363. The rate per cm will change
quarterly based on Average Sales Price Data submitted to CMS.
Ambulatory Surgical Centers (ASC): ASC’s are now reimbursed on an ASC methodology that consists
of a blended payment rate. For services added as covered services for 2008 and after, the payments are
based on a fully implemented rate with no transition. Separately payable drugs and biologics are not
subject to this transition. Current Procedural Terminology (CPT) codes for the application of Integra
15271-15278 are on the Medicare list of procedures allowed to be performed in an ASC environment.
Physician Office: The physician is reimbursed based on the RBRVS (Resource Based Relative Value
System). The temporary conversion factor for 2012 is $34.0376. The physician’s work Relative Value
Units (RVU’s) are provided in the Physician’s Office section of the Guide for your convenience. The
Integra product itself is billed using HCPCS code C9363, however this HCPCS code is not reimbursed in
the Physician Office Setting at this time.
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that
are rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the
®
applicability of any non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra
LifeSciences Corporation assumes no responsibility for the timeliness, accuracy, and completeness of the information
contained herein. Since reimbursement laws, regulations, and payer policies change frequently, it is recommended that
providers consult with their payers, coding specialists, and/or legal counsel regarding coverage, coding, and payment
issues. 5
Insurance
Summaries
Medicaid
Medicaid coverage and reimbursement varies from state to state for Inpatient stays, Same Day Surgery,
Clinics and Physician offices. Please verify your state’s Medicaid coverage and reimbursement policies.
Other Carriers
Other payers such as HMO’s and PPO’s will usually pay based on negotiated contract rates and per diem
payments. Hospitals may sometimes negotiate a separate payment for implanted devices or biologics.
Please contact the patient’s insurance carrier directly for coverage and eligibility requirements. Precertification based on medical necessity will assist in verification of coverage and payment in all settings.
Integra is pleased to provide information to support efforts to pre-certify the procedure with the patient’s
insurance carrier.** Integra sales representatives have pre-certification/appeal packets available for your use,
which include:
•
•
•
•
•
•
Information on how to appeal a Medicare Claim Determination
Sample Letter of Medical Necessity
Sample Statement of Medical Necessity that should include physician’s clinical notes and photos
from the patient’s medical record
Package Insert
FDA Approval Letter
Bibliography of clinical articles relative to the Integra® Matrix Family of Products
Appeal Packets can also be found on Integra’s Reimbursement Website at
www.integralife.com/reimbursement under each specific Integra® Matrix Product.
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of
®
any non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation
assumes no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since
reimbursement laws, regulations, and payer policies change frequently, it is recommended that providers consult with their
payers, coding specialists, and/or legal counsel regarding coverage, coding, and payment issues. 6
Inpatient Reimbursement
Billing
All inpatient claims should be submitted using UB-92 claim form, bill type 11X.
Common ICD-9-CM Procedure Codes
Used in Integra cases utilizing Integra® Meshed Bilayer Wound Matrix:
Code
Description
86.67
Dermal Regenerative Graft
Common ICD-9-CM Diagnosis Codes
Used in Integra cases utilizing Integra® Meshed Bilayer Wound Matrix:
Wounds
Code
Description
707.0X
Pressure Ulcer
707.1X
Ulcer of Lower Limbs, Except Pressure Ulcer
707.8, 707.9
Chronic Ulcers of Specified and Unspecified Sites
440.23
Atherosclerosis of the Extremities with Ulceration
250.8X, 707.1X
Diabetic Ulcer
459.31,
Chronic Venous Hypertension with Ulcer
459.33
Chronic Venous Hypertension with Ulcer and
Inflammation
Disruption of External Operation (Surgical) Wound
998.32
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of any
®
non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation assumes
no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since reimbursement
laws, regulations, and payer policies change frequently, it is recommended that providers consult with their payers, coding
specialists, and/or legal counsel regarding coverage, coding, and payment issues. 7
Inpatient Reimbursement
Inpatient Reimbursement Reference Tool for Integra® Meshed Bilayer Wound Matrix
ICD-9 Code
Code Description
2012 Potential MS-DRG’s
86.67
Dermal Regenerative Graft
463-465, 573-578, 622-624, 904-906
Potential MS-DRG Assignments Associated with code 86.67 for
Integra® Meshed Bilayer Wound Matrix
MSDRG
Description
Relative
Weight
(RW)
463
5.0438
2.9658
$16,701
1.7406
$9,802
573
Wound Debridement and Skin Graft Except Hand, for Musculo-Connective
Disorders with MCC
Wound Debridement and Skin Graft Except Hand, for Musculo-Connective
Disorders with CC
Wound Debridement and Skin Graft Except Hand, for Musculo-Connective
Disorders without CC/MCC
Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with MCC
Medicare
Average
Payment
Rate
$28,402
3.4249
$19,286
574
Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC
2.6984
$15,195
575
Skin Graft and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC
1.2271
$6,910
576
Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with MCC
3.4936
$19,673
577
Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis with CC
1.8118
$10,203
464
465
578
Skin Graft and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC
1.0684
$6,016
622
3.8339
$21,589
1.8542
$10,441
0.9965
$5,611
904
Skin Grafts and Wound Debridement for Endocrine, Nutritional, and Metabolic
Disorders with MCC
Skin Grafts and Wound Debridement for Endocrine, Nutritional, and Metabolic
Disorders with CC
Skin Grafts and Wound Debridement for Endocrine, Nutritional, and Metabolic
Disorders without CC/MCC
Skin Grafts for Injuries with CC/MCC
3.1057
$17,489
905
Skin Grafts for Injuries without CC/MCC
1.1702
$6,590
906
Hand Procedures for Injuries
1.0566
$5,950
623
624
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of any
®
non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation assumes
no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since reimbursement
laws, regulations, and payer policies change frequently, it is recommended that providers consult with their payers, coding
specialists, and/or legal counsel regarding coverage, coding, and payment issues. 8
Same Day Surgery/Hospital Outpatient
Hospital Outpatient Department
Note: Use UB-92 claim form, bill type13X
Reference: CPT® Code Book 2012, Skin Replacement Surgery and Skin Substitutes Section, CPT Copyright 2012 American Medical
Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Skin Replacement Surgery
Skin replacement surgery consists of surgical preparation and topical placement of an autograft (including tissue cultured autograft) or
substitute graft (ie, homograft, allograft, xenograft). The graft is anchored using the provider’s choice of fixation. When services are
performed in the office, routine dressing supplies are not reported separately.
The following definition should be applied to those codes that reference “100 sq cm or 1% of body area of infants and children” when
determining the involvement of body size: The measurement of 100 sq cm is applicable to adults and children age 10 or older; percentages of
body surface area apply to infants and children younger than 10 years of age. The measurements apply to the size of the recipient site.
Procedures involving wrist and/or ankle are reported with codes that include arm or leg in the descriptor.
Surgical Preparation
Surgical preparation odes 15002-15005 for skin replacement surgery describe the initial services related to preparing a clean and viable wound
surface for placement of an autograft, flap, skin substitute graft or for negative pressure wound therapy. In some cases, closure may be
possible using adjacent tissue transfer (14000-14061) or complex repair (13100-13153). In all cases, appreciable nonviable tissue is removed
to treat a burn, traumatic wound or a necrotizing infection. The clean wound bed may also be created by incisional release of a scar
contracture resulting in a surface defect from separation of tissues. The intent is to heal the wound by primary intention, or by the use of
negative pressure wound therapy. Patient conditions may require the closure or application of graft, flap, or skin substitute to be delayed, but in
all cases the intent is to include these treatments or negative pressure therapy to heal the wound. Do not report 15002-15005 for removal of
nonviable tissue/debris in a chronic wound (eg, venous or diabetic) when the wound is left to heal by secondary intention. See active wound
management codes (97597-97598, 97602) and debridement codes (11042-11047) for this service. For necrotizing soft tissue infections in
specific anatomic locations, see 11004-11008.
Select the appropriate code from 15002-15005 based upon location and size of the resultant defect. Use 15002 or 15004, as appropriate, for
excisions and incisional releases resulting in wounds up to and including 100 sq cm of surface area. Use 15003 or 15005 for each additional
100 sq cm or part thereof. Report complex repairs, adjacent tissue transfer, flaps and grafts separately. Report the application of the skin
substitute codes 15271-15278 separately.
Application of Skin Substitute Grafts
Skin substitute grafts include non-autologous human skin (dermal or epidermal, cellular and acellular) grafts (eg, homograft, allograft), nonhuman skin substitute grafts (ie, 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 (eg, gel, ointment, foam, liquid) or injected skin substitutes. Removal of current graft
and/or simple cleansing of the wound is included, when performed. Do not report 97602. Debridement is considered a separate procedure
only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissues are removed,
or when debridement is carried out separately without immediate primary closure.
Select the appropriate code from 15271-15278 based upon location and size of the defect. For multiple wounds, sum the surface area of all
wounds from all anatomic sites that are grouped together into the same code descriptor.
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of any
®
non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation assumes
no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since reimbursement
laws, regulations, and payer policies change frequently, it is recommended that providers consult with their payers, coding
specialists, and/or legal counsel regarding coverage, coding, and payment issues. 9
Same Day Surgery/Hospital Outpatient
Surgical Preparation Codes* for Skin Replacement Surgery –
Used for burns, traumatic wounds or necrotizing infection
CPT
Code
15002
+15003
15004
+15005
Description (Based on Size of Wound)
Surgical preparation or creation of recipient site by excision of open wounds, burn
eschar or scar (including subcutaneous tissues), or incisional release of scar
contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and
children
Each additional 100 sq cm, or part thereof, or each additional 1% of body area of
infants and children (List separately in addition to code for primary procedure)
Surgical preparation or creation of recipient site by excision of open wounds, burn
eschar, or scar (including subcutaneous tissues), or incisional release of scar
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet
and/or multiple digits; first 100 sq cm or 1% of body area of infants and children
Each additional 100 sq cm, or part thereof, or each additional 1% of body area of
infants and children (List separately in addition to code for primary procedure)
2012 Medicare
Base Payment
Rate in Facility
$347.63
$347.63
$227.80
$347.63
*Codes 15002-15005 are typically used for the initial excision of a wound bed for a graft. Use debridement codes
11042-11047, or 97597-97602 for removal of non-viable tissue/debris in a chronic wound when the wound is left to
heal by secondary intention when appropriate.
Topical Placement of Skin Substitute
CPT
Code
15271
+15272
15273
+15274
15275
+15276
15277
+15278
Description (Based on Size of Wound)
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)
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
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)
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
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)
.
10
2012 Medicare
Base Payment
Rate in Facility
$227.80
$83.55
$347.63
$227.80
$227.80
$83.55
$347.63
$227.80
Same Day Surgery/Hospital Outpatient
Epidermal Autograft Procedure***
CPT
Code
15110
+15111
15115
+15116
Description (Based on Size of Wound)
2012 Medicare
Base Payment
Rate in Facility
Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of
infants and children
Each additional 100 sq cm, or each additional 1% of body area of infants and children,
or part thereof (List separately in addition to code for primary procedure)
Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands,
feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and
children
Each additional 100 sq cm, or each additional 1% of body area of infants and children,
or part thereof (List separately in addition to code for primary procedure)
$347.63
$347.63
$347.63
$347.63
***Modifier -59 should be used if the epidermal autograft or another skin substitute product is applied as part
of a staged procedure during a different surgical encounter after the initial placement of a skin substitute.
C Code for Hospital Outpatient Department (effective Q3 2012)
C9363 – Integra® Meshed Bilayer Wound Matrix, per sq cm
$19.03/cm2 (APC)
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of
®
any non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation
assumes no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since
reimbursement laws, regulations, and payer policies change frequently, it is recommended that providers consult with their
payers, coding specialists, and/or legal counsel regarding coverage, coding, and payment issues. 11
Same Day Surgery/Hospital Outpatient
APC’s associated with CPT codes:
First Procedure APC
Second Procedure APC
135 (excision)
134/135 (application)
135 (epidermal autograft)
HCPCS Code for Product Reimbursement:
®
C9363 – Integra Meshed Bilayer Wound Matrix (BWM), per sq cm
HCPCS Modifiers:
JC
JD
JW
Skin substitute used as graft
Skin substitute not used as graft
Drug amount discarded/not administered to any patient
Note: The updated rates can be obtained through different parts of the Centers for Medicare and Medicaid Services website. The current
quarterly rates can be found for OPPS at http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage (Addendum B), for ASCs at
http://www.cms.gov/ASCPayment/11_Addenda_Updates.asp#TopOfPage (Addendum BB), and the ASP for Medicare Part B drugs at
http://www.cms.gov/McrPartBDrugAvgSalesPrice/01a17_2012ASPFiles.asp#TopOfPage
Product Size
2in x 2in
4in x 5in
4in x 10in
8in x10in
2
cm Units
25
125
250
500
Potential Modifiers:
-58
-51
-78
-22
-76
Staged procedure
Multiple procedures
Return to OR for a related procedure during postoperative period
Unusual procedural services (burns)
Repeat procedure by the same physician
Revenue Code:
C9363 is reported in Revenue Code 636
Common ICD-9 Codes:
Wounds:
707.0X
707.1X
707.8, 707.9
440.24
250.8X, 707.1X
459.31, 459.33
998.33
Decubitus ulcers
Ulcer of lower limbs
Chronic ulcers of specified and unspecified sites
Atherosclerosis of the extremities with ulceration
Diabetic ulcer
Chronic venous ulcers
Disruption of external operation wound
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of
®
any non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation
assumes no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since
reimbursement laws, regulations, and payer policies change frequently, it is recommended that providers consult with their
payers, coding specialists, and/or legal counsel regarding coverage, coding, and payment issues. 12
Ambulatory Surgical Centers
Summary of CMS Regulation CMS-1525-FC: This final rule with comment period revises the Medicare
hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and
changes arising from our continuing experience with this system. In this final rule with comment period, we
describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital
outpatient services paid under the OPPS. These changes are applicable to services furnished on or after
January 1, 2012
In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center
(ASC) payment system to implement applicable statutory requirements and changes arising from our
continuing experience with this system. In this final rule with comment period, we set forth the relative
payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these
changes apply, and other ratesetting information for the CY 2012 ASC payment system. These changes are
applicable to services furnished on or after January 1, 2012.
CPT
Code
Short
Descriptor
15002
+15003
15004
+15005
15271
+15272
15273
+15274
15275
+15276
15277
+15278
15110
+15111
15115
+15116
Wound prep, trk/arm/leg
Wound prep, addl 100cm
Wound prep, f/n/hf/g
Wound prep, f/n/hf/g, addl cm
Skin sub graft trnk/arm/leg
Skin sub graft t/a/l add-on
Skin sub grft t/arm/lg child
Skn sub grft t/a/l child add
Skin sub graft face/nk/hf/g
Skin sub graft f/n/hf/g addl
Skn sub grft f/n/hf/g child
Skn sub grft f/n/hf/g ch add
Epidrm autogrft trnk/arm/leg
Epidrm autogrft t/a/l add-on
Epidrm a-grft face/nck/hf/g
Epidrm a-grft f/n/hf/g addl
Subject to
Multiple
Procedure
Discounting
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
CY2012
Base
Payment
$200.57
$200.57
$131.43
$200.57
$131.43
$48.21
$200.57
$131.43
$131.43
$48.21
$200.57
$131.43
$200.57
$200.57
$200.57
$131.43
C Code for Ambulatory Surgical Center (effective Q3 2012)
C9363 – Integra® Meshed Bilayer Wound Matrix, per sq cm
$19.03/cm2 (ASC)
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of
®
any non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation
assumes no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since
reimbursement laws, regulations, and payer policies change frequently, it is recommended that providers consult with their
payers, coding specialists, and/or legal counsel regarding coverage, coding, and payment issues. 13
Physician’s Reimbursement
Note: Use CMS 1500 claim form for billing
®
Reference: CPT Code Book 2012, Skin Replacement Surgery and Skin Substitutes Section, CPT Copyright 2012
American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical
Association.
Skin Replacement Surgery
Skin replacement surgery consists of surgical preparation and topical placement of an autograft (including tissue cultured
autograft) or substitute graft (ie, homograft, allograft, xenograft). The graft is anchored using the provider’s choice of
fixation. When services are performed in the office, routine dressing supplies are not reported separately.
The following definition should be applied to those codes that reference “100 sq cm or 1% of body area of infants and
children” when determining the involvement of body size: The measurement of 100 sq cm is applicable to adults and
children age 10 or older; percentages of body surface area apply to infants and children younger than 10 years of age. The
measurements apply to the size of the recipient site.
Procedures involving wrist and/or ankle are reported with codes that include arm or leg in the descriptor.
Surgical Preparation
Surgical preparation odes 15002-15005 for skin replacement surgery describe the initial services related to preparing a
clean and viable wound surface for placement of an autograft, flap, skin substitute graft or for negative pressure wound
therapy. In some cases, closure may be possible using adjacent tissue transfer (14000-14061) or complex repair (1310013153). In all cases, appreciable nonviable tissue is removed to treat a burn, traumatic wound or a necrotizing infection.
The clean wound bed may also be created by incisional release of a scar contracture resulting in a surface defect from
separation of tissues. The intent is to heal the wound by primary intention, or by the use of negative pressure wound
therapy. Patient conditions may require the closure or application of graft, flap, or skin substitute to be delayed, but in all
cases the intent is to include these treatments or negative pressure therapy to heal the wound. Do not report 15002-15005
for removal of nonviable tissue/debris in a chronic wound (eg, venous or diabetic) when the wound is left to heal by
secondary intention. See active wound management codes (97597-97598, 97602) and debridement codes (11042-11047)
for this service. For necrotizing soft tissue infections in specific anatomic locations, see 11004-11008.
Select the appropriate code from 15002-15005 based upon location and size of the resultant defect. Use 15002 or 15004,
as appropriate, for excisions and incisional releases resulting in wounds up to and including 100 sq cm of surface area. Use
15003 or 15005 for each additional 100 sq cm or part thereof. Report complex repairs, adjacent tissue transfer, flaps and
grafts separately. Report the application of the skin substitute codes 15271-15278 separately.
Application of Skin Substitute Grafts
Skin substitute grafts include non-autologous human skin (dermal or epidermal, cellular and acellular) grafts (eg, homograft,
allograft), non-human skin substitute grafts (ie, 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 (eg, gel, ointment, foam, liquid) or
injected skin substitutes. Removal of current graft and/or simple cleansing of the wound is included, when performed. Do
not report 97602. Debridement is considered a separate procedure only when gross contamination requires prolonged
cleansing, when appreciable amounts of devitalized or contaminated tissues are removed, or when debridement is carried
out separately without immediate primary closure.
Select the appropriate code from 15271-15278 based upon location and size of the defect. For multiple wounds, sum the
surface area of all wounds from all anatomic sites that are grouped together into the same code descriptor.
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of
®
any non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation
assumes no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since
reimbursement laws, regulations, and payer policies change frequently, it is recommended that providers consult with their
payers, coding specialists, and/or legal counsel regarding coverage, coding, and payment issues. 14
Physician’s Reimbursement
Surgical Preparation Codes* for Skin Replacement Surgery –
Used for burns, traumatic wounds or necrotizing infection
CPT
Code
15002
+15003
15004
+15005
Description (Based on Size of Wound)
Surgical preparation or creation of recipient site by excision of open wounds, burn
eschar or scar (including subcutaneous tissues), or incisional release of scar
contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and
children
Each additional 100 sq cm, or part thereof, or each additional 1% of body area of
infants and children (List separately in addition to code for primary procedure)
Surgical preparation or creation of recipient site by excision of open wounds, burn
eschar, or scar (including subcutaneous tissues), or incisional release of scar
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet
and/or multiple digits; first 100 sq cm or 1% of body area of infants and children
Each additional 100 sq cm, or part thereof, or each additional 1% of body area of
infants and children (List separately in addition to code for primary procedure)
2012 Medicare
Base Payment
Rate in Facility
$228.05
2012 Medicare
Base Payment
Rate Non Facility
$343.44
$45.95
$75.22
$271.96
$396.88
$91.90
$124.24
*Codes 15002-15005 are typically used for the initial excision of a wound bed for a graft. Use debridement codes
11042-11047, or 97597-97602 for removal of non-viable tissue/debris in a chronic wound when the wound is left to
heal by secondary intention when appropriate.
Topical Placement of Skin Substitute
CPT
Code
15271
+15272
15273
+15274
15275
+15276
15277
+15278
Description (Based on Size of Wound)
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)
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
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)
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
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)
15
2012 Medicare
Base Payment
Rate - Facility
2012 Medicare
Base Payment
Rate –
Non –Facility
$87.82
$144.32
$17.36
$27.23
$209.33
$296.47
$44.25
$69.78
$101.77
$154.87
$24.85
$33.70
$216.14
$298.17
$54.80
$82.03
Physician’s Reimbursement
Epidermal Autograft Procedure***
CPT
Code
15110
+15111
15115
+15116
Description (Based on Size of Wound)
Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area
of infants and children
Each additional 100 sq cm, or each additional 1% of body area of infants and
children, or part thereof (List separately in addition to code for primary procedure)
Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of
infants and children
Each additional 100 sq cm, or each additional 1% of body area of infants and
children, or part thereof (List separately in addition to code for primary procedure)
2012 Medicare
Base Payment
Rate - Facility
$754.61
2012 Medicare
Base Payment
Rate –
Non -Facility
$865.58
$102.45
$114.37
$764.48
$870.34
$155.55
$171.21
***Modifier -59 should be used if the epidermal autograft or another skin substitute product is applied as part
of a staged procedure during a different surgical encounter after the initial placement of a skin substitute
C Code for Physician’s Office – Not Applicable
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of any
®
non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation assumes
no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since reimbursement
laws, regulations, and payer policies change frequently, it is recommended that providers consult with their payers, coding
specialists, and/or legal counsel regarding coverage, coding, and payment issues. .
16
Physician’s Reimbursement
______________________________________________________________
CPT
Code
15002
Global
Period
000
Physician
Work RVU’s
2.65
+15003
ZZZ
0.80
15004
000
4.58
+15005
ZZZ
1.60
15271
000
1.50
+15272
ZZZ
0.33
3.50
15273
000
+15274
ZZZ
0.80
15275
000
1.83
+15276
ZZZ
0.50
15277
000
4.00
+15278
ZZZ
1.00
15110
090
10.97
+15111
ZZZ
1.85
15115
090
11.28
+15116
ZZZ
2.50
Components of a Global Surgical Package as Defined by the Medicare Manual
The Medicare approved amount for these procedures includes payment for the following services related to the surgery
when furnished by the physician who performs the surgery. The services included in the global surgical package may
be furnished in any setting, e.g., in hospitals, ASC’s, physicians’ offices. Visits to a patient in an intensive care unit are
also included if made by the surgeon. However, critical care services (99291 and 99292) are payable separately in
some situations.
Services included in Global Surgical Package:
•
Preoperative Visits – Preoperative visits after the decision is made to operate beginning with the day before
the day of surgery for major procedures and the day of surgery for minor procedures;
•
Intra-Operative Services – Intra-operative services that are normally a usual and necessary part of a surgical
procedure;
•
Complications Following Surgery – All additional medical or surgical services required of the surgeon during
the postoperative period of the surgery because of complications which do not require additional trips to the
operating room;
•
Postoperative Visits – Follow-up visits during the postoperative period of the surgery that are related to
recovery from the surgery;
•
Postsurgical Pain Management – By the surgeon
•
Supplies – Except for those identified as exclusions; and
•
Miscellaneous Services – Items such as dressing changes; local incisional care; removal of operative pack;
removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation
and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and
changes and removal of tracheostomy tubes.
17
Physician’s Reimbursement
_________________________________________________________________
Services Not Included in the Global Surgical Package
Payers do not include the services listed below in the payment amount for a procedure with the appropriate indicator in Field
16 of the MFSDB (Medicare Fee Schedule Data Base). These services may be paid for separately.
•
The initial consultation or evaluation fo the problem by the surgeon to determine the need for surgery. Please not
that this policy only applies to major surgical procedures. The initial evaluation is always included in the
allowance for a minor surgical procedure;
•
Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care.
This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC
record;
•
Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to
complications of the surgery;
•
Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from
surgery;
•
Diagnostic tests and procedures, including diagnostic radiological procedures;
•
Clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for
complications (a new postoperative period begins with the subsequent procedure). This includes procedures
done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the
first procedure. Examples of this are procedures to diagnose and treat epilepsy (codes 61533,61534-61536,
61539, 61541, and 61543) which may be performed in succession within 90 days of each other;
•
Treatment for postoperative complications which requires a return trip to the operating room (OR). An OR for this
purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing
procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not
include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s
condition was so critical there would be insufficient time for transportation to an OR);
•
If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable
separately
•
For certain services performed in a physician’s office, a separate payment can no longer be made for a surgical
tray (code A4550). This code is now a Status B and is no longer a separately payable service on or after January
1, 2002. However, splints and casting supplies are payable separately under the reasonable charge payment
methodology;
•
Immunosuppresive therapy for organ transplants; and
•
Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned
patient is critically ill and requires constant attendance of the physician
Source: Medicare Claims Processing Manual, Chapter 12, section 40.1.
**Integra has used reasonable efforts to provide accurate information, but the information should not be construed as
providing clinical advice, dictating reimbursement policy, or substituting the judgment of a practitioner. It is always the
Provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are
rendered. Provider is responsible for verifying coverage with the patient’s insurance carrier, including the applicability of
®
any non-coverage decision that may exist for Integra Meshed Bilayer Wound Matrix. Integra LifeSciences Corporation
assumes no responsibility for the timeliness, accuracy, and completeness of the information contained herein. Since
reimbursement laws, regulations, and payer policies change frequently, it is recommended that providers consult with their
payers, coding specialists, and/or legal counsel regarding coverage, coding, and payment issues. 18
Integra® Meshed Bilayer Wound Matrix – Reimbursement Manual
Q3 2012
Integra LifeSciences Corporation
311 Enterprise Drive ● Plainsboro, NJ 08536
800-654-2873 (toll free) ● 609-275-0500 (telephone)
609-275-5363 (fax)
www.integralife.com (corporate website)
www.ilstraining.com (physician training website)
Integra and the Integra logo are registered trademarks of
Integra LifeSciences Corporation in the United States and/or
other countries. ©2012 Integra LifeSciences Corporation.
All rights reserved.
00002265 – 7/12 19