{"id":15550,"date":"2022-07-25T12:21:35","date_gmt":"2022-07-25T12:21:35","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=15550"},"modified":"2025-05-29T15:32:10","modified_gmt":"2025-05-29T15:32:10","slug":"coding-guidelines-for-skin-substitute-grafts","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/coding-guidelines-for-skin-substitute-grafts\/","title":{"rendered":"Coding Guidelines for Skin Substitute Grafts"},"content":{"rendered":"<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">Coding guidelines can be seen as a sort of general best practice for the coding profession. Recently on July 7, 2022, the Centers for Medicare &amp; Medicaid Services (CMS) issued a proposed rule that announces the proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2023. <\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">This proposed rule also suggested some changes for skin substitute products to streamline the coding, billing, and payment rules. Before discussing those proposed changes, let&#8217;s understand the coding guidelines for skin substitute grafts.\u00a0<\/span><\/p>\n<h2 style=\"text-align: left;\"><strong>Coding Guidelines Skin Substitute Grafts<\/strong><\/h2>\n<ul style=\"text-align: left;\">\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">As per the Current Procedural Terminology (CPT) definition, skin substitute grafts include non-autologous skin (dermal or epidermal, cellular, and acellular) grafts (e.g., homograft, allograft), non-human skin substitute grafts (i.e., xenograft), and biological products that form a sheet scaffolding for skin growth.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Skin substitute graft codes are not to be reported for application of non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid) or injected skin substitutes.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Non-graft wound dressings or injected skin substitute codes are not used with skin replacement surgery application codes and are considered incorrect coding. Such products are bundled into other standard management procedures if medically necessary and not separately payable.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><a href=\"tel:888-357-3226\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-18871\" src=\"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-content\/uploads\/2024\/05\/Legacy-AR-MBC-2.jpg\" alt=\"Legacy AR - MBC\" width=\"700\" height=\"200\" \/><\/a><\/p>\n<ul style=\"text-align: left;\">\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Claims reporting skin substitute grafts must contain the presence of an appropriate application CPT code.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">If the service for the application code is denied, the service for the skin substitute will also be denied.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">When billing for Part B drugs and biologicals (except those provided under the Competitive Acquisition Program [CAP] for Part B drugs and biologicals), the use of the JW modifier to identify unused drugs or biologicals from single-use vials or single-use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patient\u2019s medical record.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Payers expect that where multiple sizes of a specific product are available, the size that best fits the wound with the least amount of wastage will be utilized.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">When a portion of a drug\/biological is discarded, the medical record must clearly document the amount administered and the amount wasted. The documentation must include the date, time, amount of medication wasted, and the reason for the wastage.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">In situations where a portion of a single-use package must be discarded, payment will be made for the portion discarded along with the amount applied up to the amount of the product on the package label. Medical record documentation must clearly indicate the information noted above.<\/span><\/li>\n<\/ul>\n<h2 style=\"text-align: left;\"><strong>Documentation Requirements<\/strong><\/h2>\n<ul style=\"text-align: left;\">\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">All <a href=\"https:\/\/www.medicalbillersandcoders.com\/articles\/outsource-medical-billing\/wound-care-documentation-examples.html?utm_source=blog-coding-guidelines-for-skin-substitute-grafts&amp;utm_medium=blog-WC&amp;utm_campaign=AP\">documentation<\/a> must be maintained in the patient&#8217;s medical record and made available to the contractor upon request.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]).\u00a0 The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient.<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">The submitted medical record must support the use of the selected <a href=\"https:\/\/www.medicalbillersandcoders.com\/ICD-10.aspx\">ICD-10<\/a>-CM code(s). The submitted CPT\/HCPCS code must describe the service performed.<\/span><\/li>\n<\/ul>\n<h2 style=\"text-align: left;\"><strong>Medicare Physician Fee Schedule Proposed Rule CY 2023<\/strong><\/h2>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">CMs are proposing several changes to policies for skin substitute products to streamline the coding, billing, and payment rules and to establish consistency in <a href=\"https:\/\/www.medicalbillersandcoders.com\/blog\/wound-care-reimbursement\/?utm_source=blog-coding-guidelines-for-skin-substitute-grafts&amp;utm_medium=blog-WC&amp;utm_campaign=AP\">coding and reimbursements<\/a>. <\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">Specifically, CMS is proposing to change the terminology of skin substitutes to \u2018<a href=\"https:\/\/www.medicalbillersandcoders.com\/speciality\/wound-care-medical-billing-services.html\">wound care<\/a> management products in order to accurately reflect how clinicians use these products, to provide a more consistent and transparent approach to coding for these products, and to treat and pay for these products as incident to supplies under the PFS beginning on <strong>January 1, 2024<\/strong>.<\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">Additionally, CMS is collecting feedback on our key objectives related to skin substitute policies, which include:<\/span><\/p>\n<ul style=\"text-align: left;\">\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Ensuring a consistent coding and payment approach for skin substitute products across the physician&#8217;s office and hospital outpatient department setting;\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Ensuring that all skin substitute products are assigned an appropriate HCPCS Level II code, including a proposal regarding what documentation is necessary to provide CMS for currently marketed and future products;\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Using a uniform benefit category across products within the physician&#8217;s office setting, regardless of whether the product is synthetic or comprised of material, so we can incorporate payment methodologies that are more consistent; and\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Maintaining clarity for interested parties on CMS skin substitute policies and procedures.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">You can refer CMS article <\/span><a href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule\"><span style=\"font-weight: 400;\">\u2018Medicare Physician Fee Schedule (MPFS) Proposed Rule CY 2023\u2019<\/span><\/a><span style=\"font-weight: 400;\"> for proposed changes in skin substitute coding. <\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">In case any assistance is needed for medical billing and coding for your wound care practice, contact <\/span><a href=\"https:\/\/www.medicalbillersandcoders.com\/contact-us.aspx?utm_source=blog-coding-guidelines-for-skin-substitute-grafts&amp;utm_medium=blog-WC&amp;utm_campaign=AP\"><b>Medical Billers and Coders (MBC)<\/b><\/a><span style=\"font-weight: 400;\"> at <a href=\"mailto:info@medicalbillersandcoders.com\">info@medicalbillersandcoders.com<\/a> \/ <strong><a href=\"tel:888-357-3226\">888-357-3226<\/a><\/strong> for more information.<\/span><\/p>\n<h2 style=\"text-align: left;\"><strong>FAQs:<\/strong><\/h2>\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1748532667293\"><strong class=\"schema-faq-question\">1. What are skin substitute grafts?<\/strong> <p class=\"schema-faq-answer\">Skin substitute grafts include non-autologous skin grafts, xenografts, and biological products that support skin growth, but do not include non-graft wound dressings.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1748532681213\"><strong class=\"schema-faq-question\">2. How should skin substitute grafts be billed?<\/strong> <p class=\"schema-faq-answer\">Claims must include an appropriate application CPT code; if the application code is denied, the skin substitute service will also be denied.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1748532692283\"><strong class=\"schema-faq-question\">3. What is the JW modifier used for?<\/strong> <p class=\"schema-faq-answer\">The JW modifier identifies unused drugs or biologicals from single-use vials that are discarded, and must be billed on a separate claim line.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1748532701217\"><strong class=\"schema-faq-question\">4. What documentation is required when billing for skin substitutes?<\/strong> <p class=\"schema-faq-answer\">Documentation must include the amount administered and wasted, along with details like date, time, and reason for wastage, and be maintained in the patient\u2019s medical record.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1748532711332\"><strong class=\"schema-faq-question\">5. What proposed changes did CMS suggest for skin substitute products?<\/strong> <p class=\"schema-faq-answer\"><a href=\"https:\/\/cms.gov\/\">CMS<\/a> proposes to rename skin substitutes as &#8220;wound care management products&#8221; and aims for consistent coding and payment policies effective January 1, 2024.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>Coding guidelines can be seen as a sort of general best practice for the coding profession. Recently on July 7, 2022, the Centers for Medicare &amp; Medicaid Services (CMS) issued a proposed rule that announces the proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":15555,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[762],"tags":[51,3567,3565,799,3568,3566,20,806,2054,3204,3554,3564,3570,761,3569],"class_list":["post-15550","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-wound-care-billing-services","tag-cms","tag-coding-and-reimbursements","tag-current-procedural-terminology-cpt","tag-hcpcs","tag-hcpcs-level-ii-code","tag-icd-10-cm-code","tag-medical-billing-and-coding","tag-medicare-part-b","tag-medicare-physician-fee-schedule","tag-physician-fee-schedule","tag-physician-fee-schedule-pfs","tag-skin-substitute-grafts","tag-skin-substitutes-coding","tag-wound-care-billing","tag-wound-care-practice"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v25.5 (Yoast SEO v25.5) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ 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What are skin substitute grafts?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"Skin substitute grafts include non-autologous skin grafts, xenografts, and biological products that support skin growth, but do not include non-graft wound dressings.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\/\/www.medicalbillersandcoders.com\/blog\/coding-guidelines-for-skin-substitute-grafts\/#faq-question-1748532681213\",\"position\":2,\"url\":\"https:\/\/www.medicalbillersandcoders.com\/blog\/coding-guidelines-for-skin-substitute-grafts\/#faq-question-1748532681213\",\"name\":\"2. How should skin substitute grafts be billed?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"Claims must include an appropriate application CPT code; if the application code is denied, the skin substitute service will also be denied.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\/\/www.medicalbillersandcoders.com\/blog\/coding-guidelines-for-skin-substitute-grafts\/#faq-question-1748532692283\",\"position\":3,\"url\":\"https:\/\/www.medicalbillersandcoders.com\/blog\/coding-guidelines-for-skin-substitute-grafts\/#faq-question-1748532692283\",\"name\":\"3. 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