Coding & Reimbursement

2013

MatriStem® is a unique extracellular matrix derived from a porcine urinary bladder. It has been shown to be effective in the treatment of acute and recalcitrant ulcers in a variety of clinical settings. When used in the hospital, reimbursement varies by payer, contract terms and site of service. To help answer common coding and reimbursement questions from physicians, coders and hospital administrators, the following information is shared for educational and strategic planning purposes only. While ACell believes this information to be correct, coding information is subject to change without notice and providers are encouraged to speak regularly with their payers. For more information about ACell and MatriStem, please speak with your local sales professional or call the ACell Reimbursement Help Line at (800) 826-2926 x7.

DISCLAIMER: The payments specified in this document are Centers for Medicare & Medic-aid Services (CMS) national unadjusted averages. Actual payment rates will vary based on geographical adjustment to payments. As such, all codes provided herein are for illustrative purposes only and shall not be construed as a warranty, statement, promise or guarantee that these codes are accurate or that the product will be covered in all instances, and if covered, that reimbursement in the amounts specified will be received. Coding practice will vary by site of care, patient condition, range of services provided, local payer instructions and other factors. The decision as how to complete a reimbursement claim form, including codes and amounts to bill, is exclusively the responsibility of the provider. Coding requirements are subject to change at any time-check with your local payer regularly. Current Procedural Terminology (CPT) is registered trademark of the American Medical Association (AMA).

2013 Coding and Reimbursement

1

MatriStem MicroMatrix® (particles) is intended for the management of topical wounds including: partial and full- thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor sites/grafts, post-Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns and skin-tears), and draining wounds. The device is intended for one-time use. K060888

MatriStem Wound Matrix (fenestrated sheets) is intended for the management of wounds including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor sites/grafts, post-Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns and skin-tears), and draining wounds. The device is intended for one-time use. K112409

MatriStem Multilayer Wound Matrix (meshed sheets) is intended for the management of wounds including: partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/ undermined wounds, surgical wounds (donor sites/grafts, post- Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, second-degree burns and skin-tears), and draining wounds. The device is intended for one-time use. K092926

MatriStem Burn Matrix (meshed sheets) is intended for the management of wounds including: second-degree burns, partial and full-thickness wounds, pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled/undermined wounds, surgical wounds (donor sites/grafts, post-Mohs surgery, post-laser surgery, podiatric, wound dehiscence), trauma wounds (abrasions, lacerations, skin tears) and draining wounds. The device is intended for one-time use. K092926

MatriStem Surgical Matrix RS, PSM, PSMX, & Thick (surgical mesh) are intended for implantation to reinforce soft tissue where weakness exists in urological, gynecological, and gastrointestinal anatomy including, but not limited to the following procedures: pubourethral support, tissue repair, body wall repair and esophageal repair. The device is intended for one-time use. K041140

MatriStem Pelvic Floor Matrix (surgical mesh) is intended for implantation to reinforce soft tissue where weakness exists in gynecological anatomy including vaginal prolapse repair and reconstruction of pelvic floor. The device is intended for one-time use. K041140

Indications

2

Surgeons and professional coders are encouraged to review a current copy of AMA’s CPT 2013 for the complete definition of Integumentary System surgery codes. For educational purposes only, common procedures include, but are not limited to, the following considerations:

Physician & Outpatient FacilityWound Care Coding Considerations

CPT Codes Debridement Codes

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if per-formed); first 20 sq cm or less

11045 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcuta-neous tissue, if performed); first 20 sq cm or less

11046 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

11047 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

Surgical Preparation Codes For Skin Replacement SurgeryUsed For Burns, Traumatic Wounds Or Necrotizing Infection

15002 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children

15003 each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)

15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children

15005 each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)

3

CPT Codes Skin Substitutes

15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area.

15272 each; additional 25 sq. cm wound surface area, or part thereof. (List separately in addition to code for primary procedure)

15273 Application of skin substitute graft to trunk, arms, legs, 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.

15274 each additional 100 sq. cm wound surface area, or part thereof, or each addi-tional 1% of body area of infants and children, or part thereof. (List separately in addition to code for primary procedure)

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.

15276 each additional 25 sq. cm wound surface area, or part thereof. (List separately in addition to code for primary procedure)

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.

15278 each additional 100 sq. cm wound surface area, or part thereof, or each addi-tional 1% of body area of infants and children, or part thereof. (List separately in addition to code for primary procedure)

15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforce-ment (eg, breast, trunk) (List separately in addition to code primary procedure).

Wound Management Codes

97597 Debridement (eg, high pressure waterjet with/without suction, sharp selective de-bridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

97598 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

97602 Removal of devitalized tissue from wound(s); non-selective debridement, without anesthesia (eg, wet to-moist dressings, enzymatic, brasion), including topical appli-cation(s), wound assessment, and instruction(s) for ongoing care, per session

97605 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

97606 total wound(s) surface area greater than 50 square centimeters

4

For educational purposes only, common Pelvic Floor, Hernia Repair, and Burns surgical procedures include, but are not limited to, the following considerations:

Outpatient Facility Surgical Coding Considerations

CPT Codes Burns

16020 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)

16025 medium (e.g., whole face or whole extremity, or 5% to 10% total body surface area)

16030 large (e.g., more than 1 extremity, or greater than 10% total body surface area)

16035 Escharotomy; initial incision

16036 each additional incision (List separately in addition to code for primary procedure)

Hernia Repair

43332 Repair, paraesophageal hiatal hernia (including fundoplication); via laparoto-my, except neonatal; without implantation of mesh or other prosthesis

43333 with implantation of mesh or other prosthesis

43334 Repair, paraesophageal hiatal hernia (including fundoplication); via thoracoto-my, except neonatal; without implantation of mesh or other prosthesis

43335 with implantation of mesh or other prosthesis

43336 Repair, paraesophageal hiatal hernia (including fundoplication); via thoracoabdomi-nal incision, except neonatal; without implantation of mesh or other prosthesis

43337 with implantation of mesh or other prosthesis

49560 Repair initial incisional or ventral hernia; reducible

49561 incarcerated or strangulated

49565 Repair recurrent incisional or ventral hernia; reducible

49566 incarcerated or strangulated

49568 Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection

49585 Repair umbilical hernia, age 5 yrs or older; reducible

49587 incarcerated or strangulated

5

CPT Codes Pelvic Floor

57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele.

57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy.

57260 Combined anteroposterior colporrhaphy.

57265 with enterocele repair.

57267 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach. (List separately in addi-tion to code for primary procedure)

57268 Repair of enterocele, vaginal approach (separate procedure).

57282 Colpopexy, vaginal, extra –peritoneal approach (sacrospinous, iliococygeus)

57283 Colpopexy, vaginal, intra –peritoneal approach (uterosacral, levator myorrha-phy)

57284 Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach

57423 Paravaginal defect repair (including repair of cystocele, if performed); laparoscopic approach

57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy.

57260 Combined anteroposterior colporrhaphy.

57265 with enterocele repair.

57267 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach. (List separately in addi-tion to code for primary procedure)

57268 Repair of enterocele, vaginal approach (separate procedure)

57282 Colpopexy, vaginal, extra –peritoneal approach (sacrospinous, iliococygeus)

57283 Colpopexy, vaginal, intra –peritoneal approach (uterosacral, levator myorrha-phy)

57284 Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach

57423 Paravaginal defect repair (including repair of cystocele, if performed); laparoscopic approach

6

The site of service is dependent upon the patient’s clinical presentation and determined at the discretion of the surgeon. Hospital inpatient facilities use Internal Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) Procedure Codes (Volume 3) to describe procedures administered in the inpatient setting. ICD-9-CM Procedure Codes that appear relevant for wound care include, but are not limited to, the following considerations:

Inpatient Reimbursement:

ICD-9-CM Common Primary Procedures for Wounds and/or Burns

86.22 Excisional debridement of wound, infection, or burn

86.28 Nonexcisional debridement of wound, infection, or burn

86.65 Heterograft to skin

86.89 Other repair and reconstruction of skin and subcutaneous tissues

93.57 Application of other wound dressing

Common Primary Procedures for Pelvic Floor

70.50 Repair of cystocele and rectocele

70.54 Repair of cystocele with graft or prosthesis

70.78 Vaginal suspension and fixation with graft or prosthesis

70.77 Vaginal suspension and fixation

Common Primary Procedures for Hernia Repair

53.41 Repair initial incisional or ventral hernia; reducible

53.49 incarcerated or strangulated

53.51 Repair recurrent incisional or ventral hernia; reducible

53.59 incarcerated or strangulated

53.61 Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection

53.69 Repair umbilical hernia, age 5 yrs or older; reducible

Source: ICD-9-CM 2013, American Medical Association, Chicago, IL

7

The ICD-9-CM Diagnosis Code(s) (principal diagnosis and secondary diagnoses) and primary ICD-9-CM Procedure Code(s), along with other factors, determine the Diagnosis Related Group (DRG) that may apply to an inpatient discharge. If the procedure is performed in the outpatient setting (hospital outpatient department or ambulatory surgery center), the facility would select the appropriate CPT code. Relevant CPT codes, along with the corresponding Ambulatory Payment Classification (APC) and/or Ambulatory Surgical Center (ASC) payment rates, are also displayed below:

Potential MS-DRG and Ambulatory Payment Classification (APC):

MS-DRG - Wounds and Burns

463 Wound Debridement and Skin Graft except Hand, for Musculo-Connective Tissue Disorders with MCC

464 Wound Debridement and Skin Graft except Hand, for Musculo-Connective Tissue Disorders with CC

573 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis with MCC

574 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis with CC

575 Skin Grafts and/or Debridement for Skin Ulcer or Cellulitis without CC/MCC

576 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis with MCC

577 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis with CC

578 Skin Grafts and/or Debridement Except for Skin Ulcer or Cellulitis without CC/MCC

622 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with MCC

623 Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders with CC

Ambulatory Payment Classification (APC) - Wounds and Burns

133 Level I Skin Repair

134 Level II Skin Repair

135 Level III Skin Repair

136 Level V Skin Repair

8

MS-DRG - Pelvic Floor

662 Minor Bladder Procedures with MCC

663 Minor Bladder Procedures with CC

664 Minor Bladder Procedures without CC/MCC

748 Female Reproductive System Reconstructive Procedures

Ambulatory Payment Classification (APC) - Pelvic Floor

195 Level VI Female Reproductive Procedures

202 Level VII Female Reproductive Procedures

MS-DRG - Hernia Repair

353 Hernia Procedures Except Inguinal and Femoral with MCC

354 Hernia Procedures Except Inguinal and Femoral with CC

355 Hernia Procedures Except Inguinal and Femoral without CC/MCC

907 Other O.R. Procedures for Injuries with MCC

908 Other O.R. Procedures for Injuries with CC

909 Other O.R. Procedures for Injuries without CC/MCC

Ambulatory Payment Classification (APC) - Hernia Repair

154 Hernia/Hydrocele Procedures

MS-DRG - Burns

570 Skin Debridement with MCC

571 Skin Debridement with CC

572 Skin Debridement without CC/MCC

9

Ambulatory Payment Classification (APC) - Burns

013 Level II Debridement & Destruction

015 Level III Debridement & Destruction

Code Description CMS Allowable

Q4118 MatriStem MicroMatrix Please see website for current reimbursement rates.

Q4119 MatriStem Wound Matrix MatriStem Multilayer Wound Matrix

Please see website for current reimbursement rates.

Q4120 MatriStem Burn Matrix

C1763* Connective tissue, non-human (includes synthetic)

C1781* Mesh (implantable)

Source: AMA. 2013 HCPCS Level II For additional information and personal assistance, please call the ACell Reimbursement Help Line at (800) 826-2926 x7.

Medicare Addendum B - Final OPPS Payment by HCPCS Code for CY 2013

Notes:

*Most commonly used with MatriStem Surgical Matrix RS, PSM, PSMX, & Thick

10

ACell, Inc.6640 Eli Whitney Drive

Suite 200Columbia, MD 21046

www.acell.com

MK-0019.8 10/2013