Wiki How to bill Epifix and any other skin susbtitutes + app fee

[mayra.zambrano]

I have a feeling that we are missing information when we are billing skin substitutes to Medicare. I have a patient who we either gets denials for the product itself or for the application fee. Denial states that the reason this is being denied is because it does not qualify per LCD guidelines. Patient's wound is on the chest and LCD only covers lower extremities. Pharm rep has told the provider that this product is covered as long as we can prove medical necessity. He has also stated that the reason the claim may be denying is because we have included a CLIA number to the claim. Patient has been receiving the product for over a year. My question is this, is there something I need to add to the claim in order to indicate that the the patient has received the product? When will Medicare stop covering this product? lastly does the anatomical site of the application matter when it comes to reimbursement?

 

[glcornett]

Are you billing for professional or technical? If PB, you would only bill the application code. If HB, you would bill both the application code and the product code. For Medicare, reimbursement for the product is bundled with reimbursement for the application. Product should be applied according to FDA approval and package insert. Continued application for over a year is likely way beyond the anticipated use of the product (most LCDs limit the number of applications); would question if documentation supports medical necessity.