2015 Coding & Reimbursement 2015 Coding and Reimbursement The MatriStem® line of products are unique extracellular matrix devices derived from porcine urinary bladder. These devices have been shown to be effective in the treatment of acute and recalcitrant ulcers in a variety of clinical settings. When used in the hospital, reimbursement for the products varies by payer, contract terms and site of service. To help answer common coding and reimbursement questions from physicians, coders and hospital administrators, the following information is shared for educational and strategic planning purposes only. While ACell believes this information to be correct, coding information is subject to change without notice and providers are encouraged to speak regularly with their payers. For more information about ACell and MatriStem, please speak with your local sales professional or call the ACell Reimbursement Help Line at (800) 826-2926 x7. DISCLAIMER: The payments specified in this document are Centers for Medicare & Medicaid Services (CMS) national unadjusted averages. Actual payment rates will vary based on geographical adjustment to payments. As such, all codes provided herein are for illustrative purposes only and shall not be construed as a warranty, statement, promise or guarantee that these codes are accurate or that the product will be covered in all instances, and if covered, that reimbursement in the amounts specified will be received. Coding practice will vary by site of care, patient condition, range of services provided, local payer instructions and other factors. The decision as how to complete a reimbursement claim form, including codes and amounts to bill, is exclusively the responsibility of the provider. Coding requirements are subject to change at any time-check with your local payer regularly. Current Procedural Terminology (CPT) is registered trademark of the American Medical Association (AMA). 1 Indications MatriStem MicroMatrix® (particles) is intended for the management of topical wounds including: partial and full- thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor sites/grafts, post-Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns and skin-tears), and draining wounds. The device is intended for one-time use. K060888 MatriStem Wound Matrix (fenestrated sheets) is intended for the management of wounds including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor sites/grafts, post-Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns and skin-tears), and draining wounds. The device is intended for one-time use. K112409 MatriStem Multilayer Wound Matrix (meshed sheets) is intended for the management of wounds including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/ undermined wounds, surgical wounds (donor sites/grafts, post- Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, seconddegree burns and skin-tears), and draining wounds. The device is intended for one-time use. K092926 MatriStem Burn Matrix (meshed sheets) is intended for the management of wounds including: second-degree burns, partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor sites/grafts, post-Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, skin tears) and draining wounds. The device is intended for one-time use. K092926 MatriStem Surgical Matrix (surgical sheets) are intended for implantation to reinforce soft tissue where weakness exists in urological, gynecological, and gastroenterological anatomy including, but not limited to the following procedures: tissue repair, body wall repair and esophageal repair. Note: MatriStem Surgical Matrix devices are not for transvaginal placement or treatment for pelvic organ prolapse or stress urinary incontinence. The devices are intended for one time use. K041140 MatriStem Pelvic Floor Matrix (surgical sheets) is intended for implantation to reinforce soft tissue where weakness exists in urological and gynecological anatomy including vaginal prolapse repair, reconstruction of pelvic floor, and pubourethral support. The device is intended for one time use. K041140 2 Physician & Outpatient Facility Wound Care Coding Considerations Surgeons and professional coders are encouraged to review a current copy of AMA’s CPT 2015 for the complete definition of Integumentary System surgery codes. For educational purposes only, common procedures may include, but are not limited to, the following considerations: CPT Codes Surgical Preparation Codes For Skin Replacement Surgery 15002 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children +15003 each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) 15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children +15005 each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) CPT Codes 11042 3 Used For Burns, Traumatic Wounds Or Necrotizing Infection Debridement Codes Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less + 11045 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less + 11046 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less + 11047 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) CPT Codes HCPCS C-Codes Skin Substitutes 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 wound surface area. +15272 +C5272* 15273 C5273* Application of skin substitute graft to trunk, arms, legs, 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. +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, 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 +C5276* each additional 25 sq. cm wound surface area, or part thereof. (List separately in addition to code for primary procedure) 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, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, 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, or part thereof. (List separately in addition to code for primary procedure) * New 2015 CMS HCPCS C-Codes for HOPD and ASC (low cost skin substitutes) + Denotes add-on codes CPT Codes 97597 +97598 97602 Wound Management Codes Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Removal of devitalized tissue from wound(s); non-selective debridement, without anesthesia (eg, wet to-moist dressings, enzymatic, brasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session 97605 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters 97606 total wound(s) surface area greater than 50 square centimeters 4 Outpatient Facility Surgical Coding Considerations For educational purposes only, common pelvic floor, hernia repair, and burns surgical procedures may include, but are not limited to, the following considerations: CPT Codes 43332 Repair, paraesophageal hiatal hernia (including fundoplication); via laparotomy, except neonatal; without implantation of mesh or other prosthesis 43334 Repair, paraesophageal hiatal hernia (including fundoplication); via thoracotomy, except neonatal; without implantation of mesh or other prosthesis 43336 Repair, paraesophageal hiatal hernia (including fundoplication); via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis 49560 Repair initial incisional or ventral hernia; reducible 49561 Repair initial incisional or ventral hernia; incarcerated or strangulated 49565 Repair recurrent incisional or ventral hernia; reducible 49566 Repair recurrent incisional or ventral hernia; incarcerated or strangulated +49568 5 Hernia Repair Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection 49585 Repair umbilical hernia, age 5 yrs or older; reducible 49587 Repair umbilical hernia, age 5 yrs or older; incarcerated or strangulated Outpatient Facility Surgical Coding Considerations Continued CPT Codes Pelvic Floor 57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele. 57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy. 57260 Combined anteroposterior colporrhaphy. 57265 Combined anteroposterior colporrhaphy; with enterocele repair. 57267 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach. (List separately in addition to code for primary procedure) 57268 Repair of enterocele, vaginal approach (separate procedure). 57282 Colpopexy, vaginal, extra –peritoneal approach (sacrospinous, iliococygeus) 57283 Colpopexy, vaginal, intra –peritoneal approach (uterosacral, levator myorrhaphy) 57284 Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach 57423 Paravaginal defect repair (including repair of cystocele, if performed); laparoscopic approach 6 Inpatient Reimbursement: The site of service is dependent upon the patient’s clinical presentation and determined at the discretion of the surgeon. Hospital inpatient facilities use Internal Classification of Disease, Ninth Revision, Clinical Modification (ICD9-CM) Procedure Codes (Volume 3) to describe procedures administered in the inpatient setting. ICD-9-CM Procedure Codes that appear relevant for wound care may include, but are not limited to, the following considerations: ICD-9-CM 86.65 ICD-9-CM Common Primary Procedures Heterograft to skin (for implantation of surgical graft) Common Procedures for Hernia Repair 53.51 Repair of incisional or hernia without graft or prosthesis 53.59 Repair of incisional or hernia without graft or prosthesis; incarcerated or strangulated Source: ICD-9-CM 2015, American Medical Association, Chicago, IL 7 Potential MS-DRG and Ambulatory Payment Classification (APC): The ICD-9-CM Diagnosis Code(s) (principal diagnosis and secondary diagnoses)and primary ICD-9-CM Procedure Code(s), along with other factors, determine the Diagnosis Related Group (DRG) that may apply to an inpatient discharge. If the procedure is performed in the outpatient setting (hospital outpatient department or ambulatory surgery center), the facility may select the appropriate CPT code. Potentially relevant CPT codes, along with the corresponding Ambulatory Payment Classification (APC) and/or Ambulatory Surgical Center (ASC) payment rates, are also displayed below: MS-DRG - Wounds 463 Wound Debridement and Skin Graft except Hand, for Musculo-Connective Tissue Disorders with MCC 464 Wound Debridement and Skin Graft except Hand, for Musculo-Connective Tissue Disorders with CC 573 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis with MCC 574 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis with CC 575 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC 576 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis with MCC 577 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis with CC 578 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC 622 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC 623 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC Ambulatory Payment Classification (APC) - Wounds 0327 Level II Skin Repair 8 Potential MS-DRG and Ambulatory Payment Classification (APC) Continued: MS-DRG - Hernia Repair 353 Hernia Procedures Except Inguinal and Femoral with MCC 354 Hernia Procedures Except Inguinal and Femoral with CC 355 Hernia Procedures Except Inguinal and Femoral without CC/MCC 907 Other O.R. Procedures for Injuries with MCC 908 Other O.R. Procedures for Injuries with CC 909 Other O.R. Procedures for Injuries without CC/MCC MS-DRG - Burns 9 570 Skin Debridement with MCC 571 Skin Debridement with CC 572 Skin Debridement without CC/MCC HCPCS Code for CY 2015 Code Description Q4118 MatriStem MicroMatrix Q4119† MatriStem Wound Matrix (Low Cost Skin Substitute) MatriStem Multilayer Wound Matrix (Low Cost Skin Substitute) Q4120† MatriStem Burn Matrix (Low Cost Skin Substitute) C1763* Connective tissue, non-human (includes synthetic) C1781* Mesh (implantable) Please see website for current bundled payments and reimbursement rates. † Bundled under new HCPCS C-Codes for HOPD and ASC. * Most commonly used with MatriStem Surgical Matrix RS, PSM, PSMX, & Thick Code HCPCS Revenue Codes 0272 Medical/Surgical Supplies and Devices 0278 Medical/Surgical Supplies, Other Implants Modifiers JW JC JD KX Source: AMA. 2014 HCPCS Level II For additional information and personal assistance, please call the ACell Reimbursement Help Line at (800) 826-2926 x7. 10 ACell, Inc. 6640 Eli Whitney Drive Columbia, MD 21046 www.acell.com MK-0019.13 05/2015