Q&A: Skin substitute claims hitting edits

April 19, 2017
Medicare Web

Q: We have received rejections for claims reporting the application of skin substitutes, with the edit stating there is a mismatch of the procedure and the skin substitute. We are using the table that was published in the 2017 OPPS final rule. Has something changed?

A: It may be that the skin substitutes you are using changed classification as of April 1. You don’t state which item is involved, but four of the products were reclassified from the low- to high-cost classification and will now be reported with a CPT code for the procedure. The reclassified products are:

  • Q4161, Bio-Connekt per square cm
  • Q4169, Artacent wound, per square cm
  • Q4173, Palingen or palingen xplus, per sq cm
  • Q4175, Miroderm, per square cm

Be sure to check CMS transmittals, as these items are reviewed quarterly against the thresholds to ensure they are classified correctly based on their cost.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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