Apligraf

[efuhrmann]

I am following the Apligraf rep's advice when coding apligraf application. The skin substitute(Q4101) is getting paid just fine but not the application(15340). Anyone care to help? Denied for med necessity and I am using the same diag codes as for the product.

[mitchellde]

Were there any other procedure codes on your claim? and what dx code did you use?

[Cheri CPC]

What were the diagnosis codes? Usually only indicated for venous insufficiency/stasis ulcers, and diabetic ulcers.

Also what payer, some Medicare FI's are requiring the sequencing of the ulcer first.

Do you have the denial reason on the EOB?

[mitchellde]

If it is a diabetic ulcer you are required to sequence the diabetes code first.

[Cheri CPC]

Yes, per ICD-9 guidelines the diabetes would be coded first, but I know of a Medicare payer that states in their LCD to sequence the ulcer first. Sometimes we have to code per payer requirements especially if it is in writing.

That is why I asked if the payer was known.

[mitchellde]

I disagree, the coding guidelines are not Medicare or any other payer specific guidelines, If you read on the first page of the guidelines it will state that adherance to the guidelines is mandated by HIPPA. Medicare canot dicate that in the case of a diabetic complication you must code the complication first, they can however tell us that if the ulcer is not a complication the sequence the ulcer first. We cannot code for payment we must always do what is correct.

[lelswick]

If you are in Colorado, I assume you submit claims to the J4 MAC TrailBlazer? If so, as of 10.15.2009 you must report the application CPT code and Q4101 code with modifier KX providing the documentation reflects the physician secured the graft per manufacturer guidelines. Is the KX modifier on the claim? TrailBlazer also requires the facility to report how much of the product was wasted with the JW modifier.

[efuhrmann]

an update--per my initial post, the problem is not with the Q4101-Medicare reimbursed for these. It is the application code(15340) that is denied. Yes, we are billing with the KX modifier and using the diag codes 459.31 and 707.12 which are the codes used and reimbursed with the Q4101. The reason for denial is CO-50 the everloving medical necessity(or lack thereof) code. Presently, we are working with the company that supplies the Apligraft since we do participate and are registered for assistance with their staff that research such issues. We have used them in the past and have had good results in resolving such issues.