Wiki Skin Substitutes

[priceam]

I work for a payer. We are working on a new policy for skin substitute reimbursement. Are there specific skin substitute codes that can be reimbursed in physicians offices/wound care clinics? I am not finding anything published by CMS. The only lists I am finding are for high-cost and low-cost codes. From my limited knowledge these apply to facilities, is that correct? Thank you for any guidance on this. It is not something I specialize in.

 

[thomas7331]

As far as I'm aware, any skin substitutes that are reimbursed in a facility could also be reimbursed in an office. The reason that you see the high- vs. low-cost distinction for facility is because facilities are paid under OPPS which pays a case rate for similar procedures and CMS uses these cost categories to set the facility's rates. In an office setting, though, these products are reimbursed on a fee schedule based on average sales price similar to the way drugs are reimbursed to a physician - you can look up the same HCPCS codes in the Medicare ASP Drug pricing files to find the office reimbursement. Hope that helps with the information you're looking for.

 

[priceam]

Thank you, that confirms everything I have found in my research.