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2015 Medicare National Fee Schedule* Hospital Outpatient Departments / ASCs / Qulified Health Care Professionals Settings HOPD - Clinic Payment ASC Payment MatriStem Wound Matrix Product HCPCS Codes Q4118, Q4120 *Q4119 Q4118, Q4120 *Q4119 2 2 2 2 2 2 2 Add'l 25 cm HCPCS C Code C5272 APC 0327 Packaged First 100 cm HCPCS C Code C5273 APC 0328 $1,407.42 Add'l 100 cm HCPCS C Code C5274 APC 0327 Packaged First 25 cm HCPCS C Code C5275 APC 0327 $430.12 Add'l 25 cm HPCPS C Code C5276 APC 0327 Packaged First 100 cm HCPCS C Code C5277 APC 0327 $430.12 Add'l 100 cm HCPCS C Code C5278 APC 0327 Packaged $235.69 Packaged $771.20 Packaged $235.69 Packaged $235.69 Packaged CPT 15271 CPT 15272 CPT 15273 CPT 15274 CPT 15275 CPT 15276 CPT 15277 CPT 15278 $87.24 $17.88 $208.81 $47.20 $99.04 $25.39 $232.76 $59.00 Q4118, Q4119 CPT 15271 CPT 15272 CPT 15273 CPT 15274 CPT 15275 CPT 15276 CPT 15277 CPT 15278 Carrier Dependent $143.02 $27.53 $302.13 $72.22 $151.60 $34.68 $328.94 $86.53 Qualified Health Care Professionals Facility Qualified Health Care Professionals Non-Facility (Doctors Office) 2 First 25 cm HCPCS C Code C5271 APC 0327 $430.12 Skin Subsitutes Application Coding Guidelines Code based on total wound surface and anatomical site 15271 (C5271) - Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area 15272 (C5272) - Each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) 15273 (C5273) - Application of skin substitute graft to trunk, arms, legs, total wound surface greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children 15274 (C5274) - 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 (C5275) - Application of skin substitute graft to face, scalp, feet, etc., total wound surface area up to 100 sq cm; first 25 sq cm or less 15276 (C5275)- Each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) 15277 (C5277) - Application of skin substitute graft to face, scalp, feet, etc., total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children 15278 (C5278)- Each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) Providers are responsible for verifying coverage with the patient’s insurance carrier, including the applicability of any non-coverage decision that may exist for ACell MatriStem® Wound Matrix and MicroMatrix®. Since reimbursement laws, regulations and payer policies change frequently, it is recommended that providers consult with their payers, coding specialists and/or legal counsel regarding coverage, coding and payment issues. ACell assumes no responsibility for the timeliness, accuracy and completeness of the coding information suggested to the Provider/Physician's and their Billing Staff. *Payments are nationally unadjusted average amounts and do not account for differences in payment due to geographic variation. QHP fees are those applicable to participating QHPs. The allowed rate for non-participating QHPs is set at 95% of the allowable for participating QHPs. Non-participating QHPs are subject to the limiting charge rules. Drugs and biologicals are paid on a mandatory assignment-related basis. Sources CPT 2015, AMA, ICD-9-CM 2015, Ingenix Encoder Pro for Payers Professionals 2015, 2015 CMS OPPS, Physician & Part B National Medicare Fee Schedules ACell, Inc. 6640 Eli Whitney Drive Columbia, MD 21046 www.acell.com 1-800-826-2926 #7 RC-0001.8 4/2015
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