Find These Coding Options for Skin Substitutes
Question: My provider does wound care for patients, including Medicare beneficiaries, with skin substitutes. What are the appropriate codes to document these services? Washington, DC Subscriber Answer: According to MLN Matters MM14091, released June 23, the Centers for Medicare & Medicaid (CMS) has two categorizations for skin substitutes, and has recently added 13 new HCPCS codes and reassigned one HCPCS code to high cost from low cost. These went into effect July 1. For payment purposes, there are two groups: high cost and low cost. MLN says that CMS assigns new skin substitute HCPCS codes into the low-cost skin substitute group “unless we have pricing data demonstrating the product cost is above either the mean unit cost of $50 or the per-day cost of $833 for [calendar year] CY 2025.” The 13 new codes are all in the low-cost group: The HCPCS code reassigned to high cost from the low-cost group is Q4309 (Via matrix, per square centimeter). Don’t forget that just because a HCPCS code exists does not mean that Medicare covers the cost. MLN says that the existence of a code “… only indicates how we pay for the product, procedure, or service if covered. MACs decide whether a drug, device, procedure, or other service meets program requirements for coverage.” Look to your respective Medicare Administrative Contractor (MAC) to find whether the skin substitute in question is reasonable and necessary for the patient’s condition — and whether it’s excluded from payment. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
