Grafix® Coding and Payment Information - …

1 grafix Coding and Payment Information - medicare January 1 March 31, 2016 Site of Service: Hospital Outpatient Department grafix grafix is an allograft tissue matrix regulated by the Food and Drug Administration (FDA under 21 CFR Part 1271, Human Cells, Tissues and Cellular and Tissue-based Products (HCT/Ps). grafix PRODUCT Coding - medicare HCPCS Code Descriptor Q4132 grafix Core Q4133 grafix Prime Billing Hint #1: Ensure you bill the appropriate number of units when billing HCPCS Q4132/Q4133. Product Description HCPCS Billable Units grafix PRIME 14mm Disc Q4133, grafix Prime, per sq. cm. 2 grafix PRIME x 2cm 3 grafix PRIME 2 x 3cm 6 grafix PRIME 3 x 4cm 12 grafix PRIME 5 x 5cm 25 grafix CORE 14mm Disc Q4132, grafix Core, per sq.)

2 Cm. 2 grafix CORE x 2cm 3 grafix CORE 2 x 3cm 6 grafix CORE 3 x 4cm 12 grafix CORE 5 x 5cm 25 grafix APPLICATION Coding - medicare Billing Hint #2: + designates and add on code. CPT Code Descriptor 15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area of up to 100 sq cm; first 25 sq. cm. or less of wound surface area +15272 Each additional 25 sq. cm. up to 100 sq. cm. wound surface area, or part thereof (list separately in additional to code for primary procedure) 15273 Application of skin substitute graft to trunk, arms, legs, total wound surface are greater than or equal to 100 sq. cm.; first 100 sq.

3 Cm. wound surface area, or 1% of body area of infants and children +15274 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) 15275 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 +15276 Each additional 25 sq. cm. wound surface area, or part thereof (List separately in addition to code for primary procedure) 15277 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.

4 Cm.; first 100 sq. cm. wound surface area, or 1% of body area of infants and children +15278 Each additional 100 sq. cm. wound surface area, or part thereof (List separately in addition to code for primary procedure) *CPT codes are a registered trademark of the American Medical Association ICD-10 DIAGNOSIS Coding - Refer to the patient s specific coverage policy Diagnosis Coding should be confirmed by the treating physician. Effective October 1st 2015, the ICD-9 Coding system was updated to ICD-10. Scope of coverage: Must be medically necessary as determined by the provider and within the Contractor s specified Coding range. See medicare Coverage Database at or contact your Osiris Reimbursement Manager for the covered Coding range.

5 MODIFIERS-confirm billing requirements-varies by medicare contractor Modifiers may be required, including not limited to JC (skin substitute used as a graft), JW (wastage), and/or KX (requirements in the medical policy have been met). medicare REIMBURSEMENT Quarter 1 2016 IMPORTANT: medicare does not separately reimburse for the majority of skin substitute products, including grafix . Therefore, when grafix is applied in the hospital outpatient department setting, medicare reimburses the CPT code Payment amount listed below only; there is no separate reimbursement for grafix . medicare REIMBURSEMENT Quarter 1 2016 CPT Hospital Outpatient Department 15271, 15275 $1, 15273, 15277 $2, The CPT and the National average Payment amounts for the physician when the physician treats in a Hospital Outpatient Department.

6 CPT Physician Services 15271 $ 15273 $ 15275 $ 15277 $ Note: Rates listed above include a 2% reduction due to the federal budget sequestration. medicare reimburses 80% of the above amounts; the patient or secondary/supplemental is responsible for the remaining 20%. Contact your local Reimbursement Business Manager or the Osiris Reimbursement Hotline for Information on your MAC s local coverage policy requirements. Osiris Reimbursement Hotline Phone: 866-988-3491 Fax: 855-304-6692 Osiris Customer Support 866-352-4540 Osiris Therapeutics, Inc. 7015 Albert Einstein Drive Columbia, MD 21046 This has been prepared for providers using grafix and is intended for informational purposes only.

7 The Information provided in this document is not a guarantee of coverage or Payment . Documentation should always reflect the actual services completed. Please refer to the patient s insurance plan and/or the local medicare Administrative Contractor LCD for additional Information and guidance on Coding , coverage and Payment .