© 2019 by BioLab Sciences Inc.

REIMBURSEMENT

CPT Coding Guide

MyOwn Skin™ is an autologous partial-thickness skin graft intended for homologous uses of skin tissues which may include the repair, reconstruction, replacement, or supplementation of skin tissues and the integumentary system. Qualified medical providers may use MyOwn Skin™ to treat patients who have suffered from an event, disease, process or acquired deficit that results in the functional loss or void of skin tissues and the integumentary system in place of or in combination with split-thickness grafting, full-thickness grafting, temporizing skin coverage and/or skin substitute products.

2019 Coding Guide: Provider

Provider Coding Procedures Using MyOwn Skin™

The application of MyOwn Skin™ is performed in two phases: a harvest phase and an application phase. Performing these phases may be covered by Current Procedural Terminology (CPT©1) and Healthcare Common Procedure Coding System (HCPCS) codes. 

  1. Current Procedural Terminology (CPT) is a registered trademark of the American Medical Association (AMA). Copyright 2019 AMA. All rights reserved.

*Important Billing Instructions:

MyOwn Skin™ is not included on the Medicare Part B Average Sales Price (ASP) Pricing File published by the Centers for Medicare and Medicaid Services (CMS) at this time. Per Chapter 17 of the Medicare Claims Processing Manual, MyOwn Skin™ is paid based on invoice instead.  Since the product cannot be ordered in sizes exactly to fit the graft, payers expect to pay for wastage.

       • Box 19 on the CMS-1500 claim form allows the provider to include the invoice cost and product details (name, size and amount $).

       • Payment based on invoice cost does not delay the electronic processing of claims. 

       • Providers should check with local payers to determine if an invoice is required to be submitted with the claim. If the invoice is required, it will be specified in the LCD or Medical Policy.

       • Providers should check with local payers regarding appropriate use of modifiers and MAY include:

  •  JC – Material used as a graft (enter cm² used for graft) 

  • JW – Wastage not used for graft (enter cm² trimmed and/or discarded)

  • Use 2 lines of QCode to separate the material used from wastage.

  • KX – Used on both Q code and CPT Code to indicate requirements of medical policy have been met.

       • Note: CPT Codes in the 15271-15278 series have a 0-day Global Period.

       • Providers should check additional procedure codes that may be performed as part of the MyOwn Skin™ patient’s care. Some of these procedures may include:

  • 11043-11047: Debridement

  • 15002-15005: Wound Prep 

  • 16020-16030: Burn Debridement

  • 97597-97598: Removal of Devital Tissue

Billing Units

**Units Billed - Check units billed – Due to cross contamination issues, payers generally reimburse for the entire square cm piece, as it is typically reasonable and necessary to discard a portion of the product.  It is recommended that providers document wastage in the patient’s chart, and separate the used product and the discarded product into separate billing lines using the appropriate modifiers. Minimum Order size is 25cm².

Pre-Authorization

Documentation of a patient’s history, conservative therapies and reason for any service or procedure is the key to a positive reimbursement scenario. When a skin substitute graft procedure is indicated by the physician, the patient’s medical record should clearly state the reason for the procedure as well as the outcomes and recommended therapies to follow. This documentation will support claim review and pre-authorization alike.

 

Clinical notes should contain the following details: 

 

  • Reason for the procedure based on physical exam 

  • All conservative therapies previously used in the treatment of the current disease 

  • Specific reason why this treatment is indicated for this patient 

  • Anticipated outcomes 

  • Recommended therapies or treatments 

 

Operational and office visit notes might include the following: 

 

  • History of patient encounters including conservative therapies 

  • Current diagnosis or history of disease state 

  • Details of findings on exam 

  • Reason for procedure relevant to condition 

  • Usual details of procedure 

  • Explanation of technology specific to MyOwn Skin™ 

  • Findings and any anticipated further treatments 

 

A letter of medical necessity (LMN) may be required for pre-authorization of a skin substitute graft procedure or for supporting documentation following a request for a claim review. Details of the LMN should include the items on the checklist above.

© 2019 BioLab Sciences, Inc. All rights reserved. All trademarks used herein are trademarks of their respective owners.