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