2014 OPPS FINAL RULE UPDATE
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Introduction
• Pamela McKeown – Director of Health Policy
• Colleen DeSantis – Director of Reimbursement
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Overview
• CMS Overview
• CMS 2014 HOPD/ASC Final Rule Summary
• Final Rule Impact on EpiFix® Billing and
Reimbursement in 2014
• MiMedx® Hotline and Available Resources
• Future Webinar Topics in 2014
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CMS Proposed and Final Rule Overview
• Each year CMS publishes a proposed rule for Medicare
changes to the upcoming year and requests comments.
• When the comment period ends CMS reviews all comments
and issues a final rule with an effective date of January 1 in
the new year.
• Physician offices fall under a different Final Rule than
HOPD/ASC facilities.
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CMS 2014 OPPS/ASC Final Rule
Summary of skin substitute changes
• Effective January 1, 2014, skin substitute products will be packaged
into the application codes EXCEPT for those products that have passthrough status.
 Products above $32.00 per sq cm – high cost group
 Products at or below $32.00 per sq cm – low cost group
• High cost skin substitutes use existing CPT codes 15271-15278
• Low cost skin substitutes use New CPT C-codes C5271-C5278
• Add-on codes (additional sq cm after first 25 sq cm or first 100 sq cm)
are bundled into the application codes 15271-15278 or C5271-C5278.
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2014 OPPS/ASC Update: Application codes
CPT High
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CPT Low
15271
C5271
+15272
+C5272
15273
C5273
+15274
+C5274
15275
C5275
+15276
+C5276
15277
C5277
+15278
+C5278
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Descriptor
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 up to 100 sq cm; first 25 sq cm or
less wound surface area
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
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
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.
each additional 100 sq cm wound surface area, or part thereof (List separately in
addition to code for primary procedure)
CMS 2014 Final Rule: Payment Rates
High
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Low
CPT
2014 National
Rate HOPD/ASC
CPT
2014 National
Rate HOPD/ASC
15271
$1,371/$757
C5271
$409/$226
+15272
Bundled
+C5272
Bundled
15273
$2,260/$1,249
C5273
$1,371/$757
+15274
Bundled
+C5274
Bundled
15275
$1,371/$757
C5275
$409/$226
+15276
Bundled
+C5276
Bundled
15277
$1,371/$757
C5277
$409/$226
+15278
Bundled
+C5278
Bundled
Final Rule Impact on EpiFix® Billing
and Reimbursement in 2014
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EpiFix® 2014 Billing and Reimbursement
• Effective January 1, 2014, skin substitute products will be packaged into
the application codes EXCEPT for those products that have pass-through
status.
• Pass-through payments are intended to facilitate the adoption of certain
new products for a period of at least 2, but not more than 3 years.
• EpiFix® has an additional year of pass-through status and remains
separately payable in 2014. The reimbursement methodology is ASP
(Average Sales Price) +6%, and is updated quarterly.
• The reimbursement for EpiFix® is not subject to a co-payment amount in
the HOPD or ASC in 2014.
• The co-payment is applied to the application code.
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EpiFix® 2014 Billing and Reimbursement
• Sites not included in the CMS Final Rule:
 Critical Access Hospitals (CAH) are not included in the CMS Final Rule
 The state of Maryland
 Physician Offices
• Physicians retain separate reimbursement for the application of the
product in a HOPD/ASC setting.
• The physician offices will have no change to EpiFix® billing in 2014 and
Q4131 will be subject to the 20% co-payment.
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Setting Overview
Setting
15275
Co-payment
Q4131
Co-payment
Physician Office
$154.75
20%
$213.20 cm2
20%
Setting
15275
Co-payment
Q4131
Co-payment
$102.81
20%
N/A
N/A
HOPD Facility
$1,371.19
20%
$213.20 cm2
0%
ASC Facility
$757.47
20%
$213.20 cm2
0%
Physician in HOPD/ASC
Application rates are annual and Q4131 is updated quarterly
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Company Confidential – Do Not Disseminate
Pass Through Offset Amount
• During the pass-through, biologicals eligible for separate payment are
subject to an offset (reduction) to the total paid for the product and
procedure in the Hospital Outpatient Department only.
• EpiFix® will be reimbursed ASP plus 6% minus an offset designed to ensure
grafts are not paid for twice.
• The table below depicts amount of APC payment associated with the
packaged biological which is the offset amount.
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EpiFix® Billing Examples
An EpiFix® 2x3 (6 cm2) allograft is applied to a venous leg ulcer with a total
wound surface of 5 sq cm:
HOPD
Billing
Code
Billing
CoQuantity Payment
15271
1
20%
Q4131
6
0%
Total
EpiFix
Cost
Medicare
Payment
Patient or
Secondary
Payment
$1,371.19
$1,279.20-$778.42 = $500.78
$1,096.95
$274.24
$500.78
$0.00
$1,871.97
$1,597.73
$274.24
Medicare Allowable
Medicare
Payment
Patient or
Secondary
Payment
Medicare Allowable
$1,322.00
TOTAL
ASC
Billing
Code
Billing
CoQuantity Payment
15271
1
20%
$757.47
$605.98
$151.49
Q4131
6
0%
$1,279.20
$1,279.20
$0.00
$2,036.67
$1,885.18
$151.49
TOTAL
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Total
EpiFix
Cost
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$1,322.00
EpiFix® Billing Examples
An EpiFix® 14mm (2 cm2, rounded) disc is applied in a HOPD to a diabetic foot
ulcer with a total wound surface of 1.2 sq cm:
Billing
Code
Billing
Quantity
CoPayment
15275
1
20%
Q4131
2
(rounded)
TOTAL
Total
EpiFix
Cost
0%
$331.00
Medicare Allowable
Medicare
Payment
Patient or
Secondary
Payment
$1,371.19
$1,096.95
$274.24
$0.00
$0.00
$1,096.95
$274.24
$426.40-$778.42 (offset) =
$0.00
$1,371.19
In this example, the total Medicare allowable for Q4131 (2 units) is $426.40 less
the $778.42 (offset amount) which is why $0.00 amount would be paid for Q4131;
however, facilities would be paid a total of $1,371.19.
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EpiFix® Billing Examples
Two (2) EpiFix 4x4 (16 cm2) allografts are applied to a large ulcer
on the calf in the HOPD with a total wound surface of 31 sq cm:
15
20%
n/a
$1,371.19
$0.00
$1,096.95
$0.00
Patient or
Secondary
Payment
$274.24
$0.00
0%
$6,822.40-$778.42 = $6,043.98
$6,043.98
$0.00
$7,415.17
$7,140.93
$274.24
Billing
Quantity
CoPayment
15271
15272
1
1
Q4131
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TOTAL
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Medicare Allowable
Medicare
Payment
Billing
Code
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Total
EpiFix
Cost
$7,058.00
CMS Example with Wage Index Adjustor
The APC offset amount is subtracted from the payment for the pass-through skin substitute
in a HOPD.
Example shows a hospital with the wage index of .7552 applied. The product is not wage
adjusted but the offset is.
Offset amount => $1,169 x 56% = $664
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Reimbursement Summary
• EpiFix® continues pass-through status in 2014, which means, it is eligible for
additional payment over and above the packaged rate.
• In MAC areas that reimburse, facilities will not lose money on EpiFix®, even if copay is unable to be collected.
• No loss in reimbursement on available sizes of EpiFix® referenced below.
The table below represent Medicare allowable and payment for the application and
EpiFix® product.
Total HOPD Reimbursement at 0.7438 low wage index adjustor
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2% Sequestration
• As required by law, President Obama issued a sequestration
order which results in 2% reduction in Medicare payment for
all products and services. This was for all Medicare Fee-ForService claims with dates of service on or after April 1, 2013.
• The 2% sequestration will continue in 2014.
• Since it affects all products and services, we did not include
the 2% sequestration in the presentation examples.
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EpiFix® Allograft Sizes
• The mean size of a diabetic foot ulcer is 1.35 sq cm and
venous leg ulcer is 2.32 sq cm.
• MiMedx® will continue to manufacture EpiFix® in size
appropriate grafts to accommodate the size of the patient’s
wound.
• The wastage factor will remain negligible with EpiFix® due to
product size availability.
Size
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Billing Units
EpiFix 14 mm (1.54 sq cm)
2
EpiFix 2x3 sq cm
6
EpiFix 4x4 sq cm
16
EpiFix 5x6 sq cm
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Reimbursement Reminders
• Make sure you bill the correct number of units
purchased on the claim form.
• Bill the product code with the application code.
• When you receive the Medicare payment remember
that the “offset” is applied to the product code only
for applications in a HOPD setting.
• The new payment methodology is unrelated to
coverage. Refer to your Medicare Administrative
Contractor (MAC) Local Coverage Determination
(LCD).
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MiMedx® Resources
EpiFix® Reimbursement Hotline
1-855-822-8480
 Benefits and Prior Authorizations
 Appeal Assistance
 Billing Questions
http://mimedx.wistia.com/medias/9haceupwnq
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Questions
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Disclaimer
The coding and reimbursement information provided is
gathered from third party sources and has not been verified
with any entity responsible for coding policy, such as the
AMA or the ICD-9 Committee, or any payer. As such,
MiMedx® makes no guarantee that any payer will agree
with the choice of codes described. MiMedx® also does not
guarantee coverage or payment of procedures by any payer
involving EpiFix®. Reimbursement policies change
frequently and can vary considerably from one insurer to
another. MiMedx® strongly recommends that you consult
your payers for interpretation of local coding, coverage and
reimbursement policies. The ultimate responsibility for
coding and claims submissions lies with the physician,
clinician, hospital or other facility.
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