Skin Substitute Procedure Edits

CY2015 MPFS ASC Payment rate Key Updates

The payment for skin substitute products that do not qualify for OOPS pass-through status are packaged into the OPPS payment for the associated skin substitute application procedure. This policy is also implemented in the ASC payment system. The skin substitute products are divided into two groups:

1) High cost skin substitute products, and
2) Low cost skin substitute products for packaging purposes.

Table 5 lists the skin substitute products and their assignment as either a high cost or a low cost skin substitute product, when applicable. ASCs should not separately bill for packaged skin substitutes (ASC PI=N1).
High cost skin substitute products should only be utilized in combination with the performance of one of the skin application procedures described by CPT codes 15271-15278. Low cost skin substitute products should only be utilized in combination with the performance of one of the skin application procedures described by HCPCS code C5271-C5278. All OPPS pass-through skin substitute products (ASC PI=K2) should be billed in combination with one of the skin application procedures described by CPT codes 15271-15278.

Table 5 - Skin Substitute Product Assignment to High Cost/Low Cost Status for CY 2015

CY 2015 HCPCS Code	CY 2015 Short Descriptor	ASC PI	Low/High Cost Skin Substitute
C9349	Fortaderm, fortaderm antimic	N1	High
C9358	SurgiMend, fetal	N1	Low
C9360	SurgiMend, neonatal	N1	Low
C9363	Integra Meshed bil Wound Mat	N1	High
Q4100	Skin substitute, NOS	N1	Low
Q4101	Apligraf	N1	High
Q4102	Oasis wound matrix	N1	Low
Q4103	Oasis burn matrix	N1	Low
Q4104	Integra BMWD	N1	High
Q4105	Integra DRT	N1	High
Q4106	Dermagraft	N1	High
Q4107	Graftjacket	N1	High
Q4108	Integra Matrix	N1	High
Q4110	Primatrix	N1	High
Q4111	Gammagraft	N1	High
Q4112	Cymetra injectable	N1	N/A
Q4113	GraftJacket Xpress	N1	N/A
Q4114	Integra Flowable Wound Matrix	N1	N/A
Q4115	Alloskin	N1	Low
Q4116	Allodern	N1	High
Q4117	Hyalomatrix	N1	Low
Q4118	Matristem Micromatrix	N1	N/A
Q4119	Matristem Wound Matrix	N1	Low
Q4120	Matristem Burn Matrix	N1	Low
Q4121	Theraskin	K2	High
Q4122	Dermacell	K2	High
Q4123	Alloskin	N1	High
Q4124	Oasis Tri-layer Wound Matrix	N1	Low
Q4125	Arthroflex	N1	High
Q4126	Memoderm/derma/tranz/integup	N1	High
Q4127	Talymed	K2	High
Q4128	Flexhd/Allopatchhd/matrixhd	N1	High
Q4129	Unite Biomatrix	N1	High
Q4131	Epifix	N1	High
Q4132	Grafix core	N1	High
Q4133	Grafix prime	N1	High
Q4134	Hmatrix	N1	High
Q4135	Mediskin	N1	Low
Q4136	Ezderm	N1	Low
Q4137	Amnioexcel or Biodexcel, 1 cm	N1	High
Q4138	BioDfence DryFlex, 1 cm	N1	High
Q4139	Amniomatrix or Biodmatrix, 1cc	N1	N/A
Q4140	Biodfence 1 cm	N1	High
Q4141	Alloskin ac, 1 cm	N1	Low
Q4142	Xcm biologic tiss matrix 1cm	N1	Low
Q4143	Repriza, 1cm	N1	Low
Q4145	Epifix, 1mg	N1	N/A
Q4146	Tensix, 1cm	N1	Low
Q4147	Architect ecm px fx 1 sq cm	N1	High
Q4148	Neox 1k, 1cm	N1	High
Q4149	Excellagen, 0.1 cc	N1	N/A
Q4150	Allowrap DS or Dry 1 sw cm	N1	Low
Q4151	AmnioBand, Guardian 1sq cm	N1	Low
Q4152*	Dermapure 1 sq cm	N1	High
Q4153	Dermavest 1 sq cm	N1	Low
Q4154	Biovance 1 square cm	N1	High
Q4155	NeoxFlo or Clarix Flo 1 mg	N1	N/A
Q4156	Neox 100 1 square cm	N1	High
Q4157	Revitalon 1 square cm	N1	Low
Q4158	MariGen 1 square cm	N1	Low
Q4159	Affinity 1 square cm	N1	High
Q4160	NuShield 1 square cm	N1	High

*HCPCS code Q4152 was assigned to the low cost group in the CY 2015 OPPS/ASC final rule with comment period. Upon submission of updated pricing information, Q4152 is assigned to the high cost group for CY 2015.

• Drugs and Biological Based on ASP Methodology with Restated Payment Rates

Some drugs and biologicals based on ASP methodology may have payment rates that are corrected retroactivetly. These retroactive corrections typically occur on a quarterly basis. Suppliers, who think they may have received an incorrect payment for drugs and biologicals impacted by these corrections, may request their MAC's adjustment of the previously processed claims.

• CY 2015 ASC Wage index
As discussed and finalized in the CY 2015 OPPS/ASC final rule with comment (79 FR 66937), in CY 2015, CMS is using the new Core Based Statistical Area (CBSA) delineations issued by the Office of Management and Budget (OMB) in OMB Bulletin 13-01, dated February 28, 2013 for the IPPS hospital wage index. Therefore, because the ASC wage indexes are the pre-floor and pre-reclassified IPPS hospital wage indexes, the CY 2015 ASC wage indexed reflect the new OMB deline actions.

In CY2015, where the CY 2015 ASC wage index value with the CY 2015 CBSAs is lower than the CY 2014 CBSA values, CMS calculates, or blends, the CY 2015 ASC wage index adjusted payment rates such that it will equal 50 percent of the ASC wage index based in the CY 2014 CBSA value and 50 percent of the ASC wage index based on the new CY 2015 CBSA value. The blending of these specific wage index values will mitigate any short-term instability to ASC payments. CY 2015 CBSAs with wage index value that are higher than the CY 2015 are not transitioned or blended and reflect the full higher wage index value.

• Coverage Determinations

The fact that a drug, device, procedure, or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary's condition and whether it is excluded from payment.