Current Coding FAQ For PROKERA - Bio-Tissue, Inc.

1 PRMI Management & Consulting Services Practice Appraisal & Valuation Services 5435 Southwood Drive Practice Resource Medical Audit Representation Lake Oswego, OR 97035. Management, Inc. Professional Continuing Education Services Direct: Dr. John M. B. Rumpakis Fax: Coding Brief Current Coding FAQ For PROKERA (July 2014). 1. PROKERA is class II medical device composed of amniotic membrane in a thermoplastic ring set. PROKERA is a unique, active, treatment option for ocular surface and corneal wound healing due to its anti-inflammatory and anti-scarring 2. Key features of PROKERA are: - Active wound healing - Key components responsible for tissue regeneration are retained using the CryoTek processing method.

2 - Intuitive - PROKERA is designed to conform snugly to the ocular surface and can be inserted in the office. - Innovative - PROKERA delivers the unique healing properties of cryopreserved amniotic membrane in a convenient, sutureless, thermoplastic ring set. - NEW PROKERA SLIM with ComfortRING Technology. 3. PROKERA is indicated for the following conditions2: - Neurotrophic Persistent Corneal Epithelial Defect - Dry Eye Syndrome, Exposure Keratopathy - Filamentary Keratitis - Infectious Keratitis - Recurrent Corneal Erosion - Salzmann's Nodular Degeneration - Post-DSEK for Bullous Keratopathy - Post-PRK Haze 4. PROKERA was originally included in the CPT 3 in 2011 with CPT Code 65778.

3 The original CPT definition in 2011 was described as: 2011 Placement of amniotic membrane on the ocular surface for wound healing;. self-retaining. In the 2014 CPT the description was amended to eliminate the words wound healing . and self-retaining and simply states without sutures . 2014 Placement of amniotic membrane on the ocular surface; without sutures4. 1. 2. 3. CPT codes, descriptions and other data are copyright 1966, 1970, 1973, 1977, 1981, 1983-2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 4. CPT Professional Edition, 2014, , Copyright American Medical Association. Coding Brief - PROKERA - Biologic Corneal Bandage Page 2 of 2.

4 5. The CPT characteristics of PROKERA are as follows: Active Center For Medicare & Medicaid Services (CMS) Code With Reimbursement - CMS provides coverage for application of PROKERA when medically indicated. Bilateral 150% Procedure - 150% payment adjustment for bilateral procedures applies. - If the code is billed with the bilateral modifier or is reported twice on the same day by any other means ( , with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b). 150% of the fee schedule amount for a single code. - If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

5 Total Non-Facility Relative Value Unit (RVU) Value = Global Period = 10 Days - CPT code 65778 is considered to be minor surgery by the CPT and follows all rules surrounding minor surgical procedures. - In accordance with minor surgical rules, an office visit (either 920XX or 992XX) is generally not separately billable when performed on the same date of service as CPT code 65778, as reimbursement for the 65778 code itself already includes compensation for the office visit related to the decision to perform minor surgery. - Use of modifier -25 should be very rare when used in conjunction with the application of PROKERA . 2014 National Average CMS Reimbursement is $ 6.

6 CMS does not pay for the supply of materials separately or in addition to the procedure code 65778 by using HCPCS code V2790, Amniotic membrane for surgical reconstruction, per procedure. Carriers other than Medicare may not necessarily follow CMS's policies. This Coding brief is not an official document, nor is it a complete reference on all matters relating to third party reimbursement. Information can and does change quite frequently and all readers are highly encouraged to review Current rules, regulations and guidelines specific to their practice location. 2014 Practice Resource Management, Inc. and Dr. John Rumpakis. No part of the publication may be reproduced or distributed in any form or by any means, or stored in a database retrieval system without the written permission of the author.

7 Practice Resource Management, Inc. 503-968-7595. Management, Consulting, Audit, Appraisal, Education & Software Services For The Health Care Professions Provided Courtesy of Bio-Tissue (888) 296-8858.