Coding, Coverage, and Payment for Dermagraft
Q1, 2016 Dermagraft Medicare Coding & Reimbursement
Coding and Coverage for Dermagraft When Used to Treat DFUs Greater Than 6 Weeks Duration
Covered Sites of Service: Physician Office, Hospital Outpatient Department, & Ambulatory Surgery Center
|Q4106:||Skin Substitute, DERMAGRAFT, per square centimeter|
|Modifier – JC*:||Skin substitute used as graft|
|Modifier – JW*:||Drug amount discarded/not administered to any patient|
|Modifier – KX*:||Requirements in the medical policy have been met **This modifier may also apply to application code**|
|CPT 15275:||Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area|
|CPT 15276:||Each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)|
|CPT 15277:||Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children|
|CPT 15278:||Each additional 100 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)|
Check units billed – Dermagraft is a single-use product – CMS and private payers generally reimburse for the entire 37.5 sq cm piece, even where it is reasonable and necessary to discard a portion.
**Check your Local Coverage Determination (LCD) for additional billing information**
Product Wastage Documentation Requirements
Any amount of wasted material should be clearly documented in the medical record with the following information:
- Date, time, and location of ulcer treated
- Approximate amount of product unit used
- Approximate amount of product unit discarded
- Reason for the wastage
- Manufacturer’s serial/lot/batch or other unit identification number of graft material
Check to see if modifiers are required with HCPCS Q4106 – common modifiers include – JC – skin substitute used as a graft, JW – wastage, KX – requirements in the medical policy have been met. Check to see if modifiers are required with CPT 15275.
When determining the wound location and surface area, it is important to select the appropriate CPT code.
Ulcer(s) less than 100 sq cm: Utilize CPT 15275 and the add-on code of 15276 as necessary.
Ulcer(s) greater than or equal to 100 sq cm: Utilize CPT 15277 and the add-on code of 15278 as necessary.
Debridement is considered a component code of 15275/15277.
Diagnosis Codes Order
Check the LCD or private payer policy to ensure diagnoses are in the proper order.
Commercial Insurers Contract
Check your payer contracts prior to applying Dermagraft – coding and coverage is not a guarantee of payment.
CPT is a registered trademark of the American Medical Association. The listed CPT codes apply to all skin substitute products.
It is at the provider’s discretion to decide when Dermagraft is a medical necessity. Organogenesis, Inc. will not solicit the use of Dermagraft outside of FDA-approved indications. Please refer to your CPT 2013 book for descriptors regarding CPT codes for other ulcer locations.
Organogenesis, Inc. cannot guarantee reimbursement. It is the provider’s responsibility to determine the appropriate utilization of products and services along with the appropriate coding.
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Dermagraft is indicated for use in the treatment of full-thickness diabetic foot ulcers greater than six weeks duration, which extend through the dermis, but without tendon, muscle, joint capsule, or bone exposure. Dermagraft should be used in conjunction with standard wound care regimens and in patients that have adequate blood supply to the foot. Dermagraft is contraindicated for use in ulcers that have signs of clinical infection or in ulcers with sinus tracts. Dermagraft is contraindicated in patients with known hypersensitivity to bovine products, as it may contain trace amounts of bovine proteins from the manufacturing medium and storage solution.
In clinical studies evaluating Dermagraft for the treatment of ulcers in patients with diabetes, Dermagraft was applied weekly for up to a total of 8 applications over a 12-week period.
Dermagraft is supplied as a single-use application.
Refer to Dermagraft Directions for Use for full prescribing information.