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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