Coding Guidelines for Skin Substitute Grafts

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Coding Guidelines for Skin Substitute Grafts

• Coding guidelines can be seen as a sort of
  general best practice for the coding profession.
  Recently on July 7, 2022, the Centers for
  Medicare Medicaid Services (CMS) issued a
  proposed rule that announces the proposed policy
  changes for Medicare payments under the Physician
  Fee Schedule (PFS), and other Medicare Part B
  issues, effective on or after January 1, 2023.
• This proposed rule also suggested some changes
  for skin substitute products to streamline the
  coding, billing, and payment rules. Before
  discussing those proposed changes, lets
  understand the coding guidelines for skin
  substitute grafts. 
• Coding Guidelines Skin Substitute Grafts
• As per the Current Procedural Terminology (CPT)
  definition, skin substitute grafts include
  non-autologous 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. 
• Skin substitute graft codes are not to be
  reported for application of non-graft wound
  dressings (e.g., gel, powder, ointment, foam,
  liquid) or injected skin substitutes.

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Coding Guidelines for Skin Substitute Grafts

• Non-graft wound dressings or injected skin
  substitute codes are not used with skin
  replacement surgery application codes and are
  considered incorrect coding. Such products are
  bundled into other standard management procedures
  if medically necessary and not separately
  payable.
• Claims reporting skin substitute grafts must
  contain the presence of an appropriate
  application CPT code.
• If the service for the application code is
  denied, the service for the skin substitute will
  also be denied.
• When billing for Part B drugs and biologicals
  (except those provided under the Competitive
  Acquisition Program CAP for Part B drugs and
  biologicals), the use of the JW modifier to
  identify unused drugs or biologicals from
  single-use vials or single-use packages that are
  appropriately discarded is required. The
  discarded amount shall be billed on a separate
  claim line using the JW modifier. Providers are
  required to document the discarded drug or
  biological in the patients medical record.

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Coding Guidelines for Skin Substitute Grafts

• Payers expect that where multiple sizes of a
  specific product are available, the size that
  best fits the wound with the least amount of
  wastage will be utilized.
• When a portion of a drug/biological is discarded,
  the medical record must clearly document the
  amount administered and the amount wasted. The
  documentation must include the date, time, amount
  of medication wasted, and the reason for the
  wastage.
• In situations where a portion of a single-use
  package must be discarded, payment will be made
  for the portion discarded along with the amount
  applied up to the amount of the product on the
  package label. Medical record documentation must
  clearly indicate the information noted above.
• Documentation Requirements
• All documentation must be maintained in the
  patients medical record and made available to
  the contractor upon request.
• Every page of the record must be legible and
  include appropriate patient identification
  information (e.g., complete name, dates of
  services).  The documentation must include the
  legible signature of the physician or
  non-physician practitioner responsible for
  providing the care to the patient.
• The submitted medical record must support the use
  of the selected ICD-10-CM code(s). The submitted
  CPT/HCPCS code must describe the service
  performed.

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Coding Guidelines for Skin Substitute Grafts

• Medicare Physician Fee Schedule Proposed Rule CY
  2023
• CMs are proposing several changes to policies for
  skin substitute products to streamline the
  coding, billing, and payment rules and to
  establish consistency in coding and
  reimbursements.
• Specifically, CMS is proposing to change the
  terminology of skin substitutes to wound
  care management products in order to accurately
  reflect how clinicians use these products, to
  provide a more consistent and transparent
  approach to coding for these products, and to
  treat and pay for these products as incident to
  supplies under the PFS beginning on January 1,
  2024.
• Additionally, CMS is collecting feedback on our
  key objectives related to skin substitute
  policies, which include
• Ensuring a consistent coding and payment approach
  for skin substitute products across the
  physicians office and hospital outpatient
  department setting 
• Ensuring that all skin substitute products are
  assigned an appropriate HCPCS Level II code,
  including a proposal regarding what documentation
  is necessary to provide CMS for currently
  marketed and future products 

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Coding Guidelines for Skin Substitute Grafts

• Using a uniform benefit category across products
  within the physicians office setting, regardless
  of whether the product is synthetic or comprised
  of material, so we can incorporate payment
  methodologies that are more consistent and 
• Maintaining clarity for interested parties on CMS
  skin substitute policies and procedures.
• You can refer CMS article Medicare Physician Fee
  Schedule (MPFS) Proposed Rule CY 2023 for
  proposed changes in skin substitute coding.
• In case any assistance is needed for medical
  billing and coding for your wound care practice,
  contact Medical Billers and Coders
  (MBC) at info_at_medicalbillersandcoders.com / 888-35
  7-3226 for more information.
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