Wiki MOHS and Skin Substitute - I'm looking for assistance

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My doctor started billing Q4101. I am having trouble getting Q4101 to pay. We billed 17313, 15220, and Q4101 with KX/LT mods. Documentation states skin substitute, but it is still denying. Can someone please give me some advise on where to look for help getting these claims paid. It will be much appreciated.
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9
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Naches, WA
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Hello,

I'm looking for assistance with a denial we received from Medicare today. I billed MOHS for a patient with +BCC and the new skin substitute graft code. The codes on the claim were 17311, 17312, and 15275 with 173.31 as the diagnosis (01/09/12 surgery). Medicare paid 17311 and 17312, but denied 15275 with remark codes M25 and N115. M25 basically states "The information furnished does not substantiate the need for this level of service....." N115 states the decision was based on a LMRP or LCD.

Problem is, I am in Washington state and Noridian doesn't have a policy for this code. The best I can find is a skin substitute policy for lower extremety ulcers. Any ideas where to go from here?
 
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9
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Naches, WA
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uh oh

Update: As of this morning (02/01/12) CMS has added 15275 to Noridian LCD L23684 and updated the coverage requirement for skin substitute grafting. I read it to mean 15275 can't be used with MOHS and is not seperatly payable. Here is a blurb from the referenced LCD:

7. Coverage will not be provided under this LCD for any wound treatment that does not meet the definition of Q4101, Q4102, or Q4106. All other such products, unless they are specifically FDA-labeled as "skin substitutes" and for use in the types of ulcers considered in this LCD, will be denied coverage under this LCD. All such products will be considered to be, at most, "biologic wound dressings." Dressings, by definition, are part of the relevant Evaluation & Management (E/M) service provided and not separately payable. Examples of products considered to fall under this distinction are: Q4100, Q4103, Q4104, Q4105, Q4107, Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, Q4116, Q4117, Q4118, Q4119, Q4120, Q4121, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4129, and Q4130.

As examples of such non-covered "wound dressing" products Biovance™ (Biovance™ is described in its FDA-labeling as "wound covering") and Integra™ are considered wound dressings, not skin substitutes, and are not separately payable by Medicare. Use of these products is included within the appropriate level of E/M service, and to code as "skin substitutes" would be inappropriate coding.

If and as literature in support of the use of the non-covered products noted in this LCD becomes available, and as that literature concerning their use sufficiently matures, NAS will welcome requests for reconsideration of this coverage decision. However, these requests for reconsideration must be submitted as formal reconsideration requests (See www.noridianmedicare.com for the reconsideration process.) and must be accompanied by complete copies of relevant peer-reviewed literature that support the recommendation as well as complete copies of FDA labeling for their uses (providers are reminded that abstracts are not acceptable - by Medicare rule - for this purpose).

(Providers are again reminded that the application of the dressings noted above is not separately paid, such as if billed with CPT codes 15271-15278).
 

bmanus

Guru
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126
Location
Concord NC
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I was wondering if you could help me with some coding questions. I'm new to Dermatology billing. We have our own lab and path on site. My doctors like to add the word handling next to 88305. If we are using our lab can we bill the handling? I thought that this was only used for out going samples to outside labs.
If you coud point me to a good resource I would be very grateful.

Thank you in advance.

Beth Manus CPC
 
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