Skin Substitute Codes

If the CMS quarterly ASP file does not contain pricing for a skin substitute code that is within the Q41XX-Q42XX range, the claim must include the total invoice price (amount physician paid, per invoice, for patient's specific item).

We may reimburse for the total invoice price plus shipping but no additional fees (tax, handling fees, delivery fees, administrative fees).

Total invoice price is the net amount a provider pays for an item/service, taking into account ALL discounts, rebates, refunds, or other adjustments. *

ASP File Contains Code

  • Enter number of units in Item 24G of CMS-1500 claim form or Loop 2400/SV104 for EMC

ASP File Does Not Contain Code

  • Enter procedure code and total invoice price in Item 19 of CMS-1500 claim form or Loop 2400/SV101-7 for EMC
    • 'Invoice' or 'Inv' followed by the price in a currency format using a decimal
      • Examples:
        • Invoice $130 - claim priced at $1.30
        • Invoice $130.00 - claim priced at $130.00
        • Invoice 13000 - claim priced at $130.00
        • Invoice $13000 - claim priced at $130.00
        • Invoice $1,300 - claim priced at $1,300.00

A provider may bill wastage using the JW modifier. However, it is Noridian’s expectation where there are multiple sizes of a specific product available, the size that best fits the wound with the least amount of wastage will be utilized by the provider. JW modifier is for single use only packaging and remnants billed as wastage may not be utilized on other patients.

If a provider intends to bill for wastage and total invoice price, please bill invoice price of the portion administered separately from invoice price of the portion discarded along with the JW modifier.

Example: Q41XX Invoice $XXX, Q41XX-JW Invoice $XXX

Any use of skin substitute codes must be accompanied on the same claim by a CPT/application procedure code consistent with use of the product. For example, CPT 15271-15278.

Products billed with Q4100 (skin substitute, not otherwise specified) must be at a minimum accompanied by the actual name of the product, number of units used, and total invoice price. In addition, Q4100 must be accompanied on the same claim by a CPT procedure/application code consistent with use of the product.

If the claim does not include the required information, the item will deny as unprocessable.

Providers must maintain an invoice copy within the patient's file, and it must be made available to Noridian upon request

Note: CMS ASP pricing does not equate to coverage, as provision of any item or service must also meet all Medicare statutory requirements.

References

(include but not limited to)

 

Last Updated Dec 09 , 2022