Grafix® Coding and Payment Information - Medicare

1 Grafix Coding and Payment Information - Medicare January 1 March 31, 2016. Site of Service: Physician Office 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 2. Grafix PRIME x 2cm Q4133, 3. Grafix PRIME 2 x 3cm Grafix Prime, per sq. cm. 6. Grafix PRIME 3 x 4cm 12. Grafix PRIME 5 x 5cm 25.)

2 Grafix CORE 14mm Disc 2. Grafix CORE x 2cm Q4132, 3. Grafix CORE 2 x 3cm Grafix Core, per sq. cm. 6. Grafix CORE 3 x 4cm 12. Grafix CORE 5 x 5cm 25. GRAFIX APPLICATION Coding - Medicare . Billing Hint #2: + designates an 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.

3 Cm.;. first 100 sq. 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 Q1 2016. Product Reimbursement Grafix is not currently included on the CMS Medicare Part B average sales price (ASP) list published by Center for Medicare and Medicaid Services (CMS). Therefore, Grafix is instead paid based on submitted invoice cost when administered in the physician's office. However, some Medicare Administrative Contractors (MAC) may also list their own ASP. Please check with your MAC and/or the Osiris Reimbursement Hotline for detailed Information .

6 Physician Services Reimbursement The CPT and the National average Payment amounts for the physician when the physician treats in their office. CPT Physician Office 15271 $ 15273 $ 15275 $ 15277 $ Note: Box 19 on the CMS 1500 claim form should include the following Information : product, size of graft, invoice cost. 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.

7 Osiris Reimbursement Hotline Phone: 866-988-3491. Fax: 855-304-6692. Osiris Customer Support 866-352-4540. This has been prepared for providers using Grafix and is intended for informational purposes only. 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 . Osiris Therapeutics, Inc. 7015 Albert Einstein Drive Columbia, MD 21046.