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Contractor Name
CareFirst of Maryland INC., Medicare Part A
Contractor Number
00190
Contractor Type
Fiscal Intermediary
LCD Database ID Number
L17540
LCD Title
Skin Substitutes
Contractor’s Determination Number
04-05-R1
AMA/CPT and ADA/CPT Copyright Statement
CPT codes, descriptions, and other data only are copyright 2004 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. CDT-4 codes and descriptions are Ó2004 American Dental Association. All rights reserved.
CMS National Coverage Policy
· Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines.
· Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
· Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
· Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.
Primary Geographic Jurisdiction
Secondary Geographic Jurisdiction
Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming
Oversight Region
Region III
CMS Consortium
Northeast
DMERC Region LCD Covers
N/A
Original Determination Effective Date
Revision Effective Date
Indications and Limitations of Coverage and/or Medical Necessity
Several types of skin substitutes are available which are indicated for a variety of conditions. Some skin substitutes are metabolically active, others are inert. Some are a single layer, essentially replacing either the epidermal or dermal component of the skin. Others are multi-layered, and may represent a full-thickness skin replacement. Depending on the product, autograft, allograft, and xenograft elements may be used in the production of these skin substitutes. Skin substitutes may have different functions at the wound site, including maintaining a moist wound environment (essentially acting as a dressing), providing a structural support for tissue regeneration, and/or providing cellular products that promote growth in the wound bed.
Depending on the product, skin substitutes may be used in a variety of conditions. Some are applied once, others are applied at regular intervals. Some are left in place, others removed when healing has progressed. The most common uses include replacing areas of the integument damaged by burns, replacing skin in donor graft sites, treating areas of pressure ulcers, diabetic ulcers, or venous stasis ulcers. Generally the treatment of ulcers should be restricted to those that have proven recalcitrant to other treatments over at least 6 weeks. Ulcers that are showing progress in healing should not be treated with these products. Skin substitutes should be applied and reapplied, when applicable, according to the prescribing information supplied with the product. Some products also require removal at designated times.
Skin substitutes with FDA 510(k) or Pre-market Approval include the following:
|
Alloderm® |
|
Donated freeze-dried
de-cellularized human dermal tissue |
|
Apligraft® |
|
A bilayer product composed
of a dermal layer made of bovine collagen and human fibroblasts, and an
epidermal layer composed of human keratinocytes |
|
BioBrane® |
|
A silicon film with nylon
threads embedded to which collagen has been bound |
|
Dermagraft® |
|
A dermal substitute with
fibroblasts, an extracellular matrix, and a bioabsorbable scaffold |
|
EZ Derm™ |
|
A porcine-derived xenograft
of collagen crosslinked with aldehyde |
|
Integra® |
|
A bilayer product composed of
a dermal layer of bovine collagen and chondroitan sulfate, and an epidermal
synthetic polymer |
|
Oasis® |
|
A porcine-derived acellular
small intestine submucosa |
|
Orcel® |
|
A bilayer product with
allogeneic epidermal keratinocytes and dermal fibroblasts which is used for
the donor site of a split-thickness skin graft |
|
Transcyte® |
|
A porcine dermal
collagen-coated nylon mesh on a silicone membrane with human fibroblasts |
Alloderm®, Biobrane®, Integra®, and Oasis® are acellular whereas the other products have cellular components.
Coverage Topic
Bill Type Codes
12X, 13X, 18X, 21X, 22X, 23X, 75X, 83X
Revenue Codes
036X, 045X, 051X, 0636, 0761
CPT/HCPCS Codes
The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:
|
C1305 |
|
Apligraf, per 44 sq cm (OPPS only) |
|
C9123 |
|
Transcyte, per 247 sq cm (OPPS only) |
|
C9200 |
|
Orcel, per 36 sq cm (OPPS only) |
|
C9201 |
|
Dermagraft, per 37.5 sq cm
(OPPS only) |
|
J3490 |
|
Unclassified drugs |
|
J7340 |
|
Dermal and epidermal
tissue, human, metabolically active, per sq cm |
|
J7342 |
|
Dermal tissue, human,
metabolically active, per sq cm |
|
J7350 |
|
Dermal tissue, human,
without metabolically active, per sq cm |
|
Q0182 |
|
Dermal and epidermal,
non-human, without metabolically active, per sq cm |
|
Q0183 |
|
Dermal, of human origin,
without metabolically active, per sq cm |
|
15000 |
Ó |
Surgical prep, recipient,
first 100 sq cm |
|
15001 |
Ó |
Surgical prep, recipient,
each additional 100 sq cm |
|
15342 |
Ó |
Application of bilaminate
skin substitute/neodermis 25 sq cm |
|
15343 |
Ó |
Application of bilaminate
skin substitute/neodermis, each additional 25 sq cm |
Ó
CPT American Medical Association
NOTE:
“C” CODES ARE ONLY USED WHERE THE OUTPATIENT PERSPECTIVE
PAYMENT SYSTEM (OPPS) IS APPLICABLE.
The
15000 and 15001 codes include debridement.
Does the "CPT 30% Coding Rule" Apply?
N/A
ICD-9-CM Codes that Support Medical Necessity
ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.
It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.
Medicare is establishing the following limited coverage for Alloderm®:
|
707.00 |
|
Decubitus ulcer,
unspecified |
|
707.01 |
|
Decubitus ulcer, elbow |
|
707.02 |
|
Decubitus ulcer, upper back |
|
707.03 |
|
Decubitus ulcer, lower back |
|
707.04 |
|
Decubitus ulcer, hip |
|
707.05 |
|
Decubitus ulcer, buttock |
|
707.06 |
|
Decubitus ulcer, ankle |
|
707.07 |
|
Decubitus ulcer, heel |
|
707.09 |
|
Decubitus ulcer, other site |
|
941.20- 941.21 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.24- 941.29 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.30- 941.31 |
|
Burn of face, head, and neck, full thickness skin loss (third degree NOS) |
|
941.34- 941.39 |
|
Burn of face, head, and neck, full thickness skin loss (third degree NOS) |
|
941.40- 941.41 |
|
Burn of face, head, and neck, deep necrosis of underlying tissues (deep third degree) without mention of loss of a body part |
|
941.44- 941.49 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) without mention
of loss of a body part |
|
941.50- 941.51 |
|
Burn of face, head, and neck,
deep necrosis of underlying tissues (deep third degree) with loss of a body
part |
|
941.54- 941.59 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) with loss of a
body part |
|
942.20- 942.29 |
|
Burn of trunk, blisters,
epidermal loss (second degree) |
|
942.30 - 942.39 |
|
Burn of trunk,
full-thickness skin loss (third degree NOS) |
|
942.40 - 942.49 |
|
Burn of trunk, deep necrosis
of underlying tissues (deep third degree) without mention of loss of a body
part |
|
942.50 - 942.59 |
|
Burn of trunk, deep
necrosis of underlying tissues (deep third degree) with loss of a body part |
|
943.20 - 943.29 |
|
Burn of upper limb, except
wrist and hand, blisters, epidermal loss (second degree) |
|
943.30 - 943.39 |
|
Burn of upper limb, except
wrist and hand, full-thickness skin loss (third degree NOS) |
|
943.40 - 943.49 |
|
Burn of upper limb, except wrist and hand, deep necrosis of underlying tissues (deep third degree) without mention of loss of a body part |
|
943.50 - 943.59 |
|
Burn of upper limb, except
wrist and hand, deep necrosis of underlying tissues (deep third degree) with
loss of a body part |
|
944.20 - 944.28 |
|
Burn of wrist(s) and
hand(s), blisters, epidermal loss (second degree) |
|
944.30 - 944.38 |
|
Burn of wrist(s) and
hand(s), full-thickness skin loss (third degree NOS) |
|
944.40 - 944.48 |
|
Burn of wrist(s) and hand(s),
deep necrosis of underlying tissues (deep third degree) without mention of
loss of a body part |
|
944.50 - 944.58 |
|
Burn of wrist(s) and
hand(s), deep necrosis of underlying tissues (deep third degree) with loss of
a body part |
|
945.20 - 945.29 |
|
Burn of lower limb(s),
blisters, epidermal loss (second degree) |
|
945.30 - 945.39 |
|
Burn of lower limb(s),
full-thickness skin loss (third degree NOS) |
|
945.40 - 945.49 |
|
Burn of lower limb(s), deep
necrosis of underlying tissues (deep third degree) without mention of loss of
a body part |
|
945.50 - 945.59 |
|
Burn of lower limb(s), deep
necrosis of underlying tissues (deep third degree) with loss of a body part |
|
946.2 - 946.5 |
|
Burns of multiple specified
sites |
|
948.00 - 948.99 |
|
Burns classified according
to extent of body surface involved (Note: these codes may only be used to justify
payment for skin substitutes when they include areas of second and/or third
degree burns) |
Medicare is establishing the following limited coverage for Apligraf®:
|
250.80 |
|
Diabetes with other specified manifestations, type II, not stated as uncontrolled |
|
250.81 |
|
Diabetes with other specified manifestations, type I, not stated as uncontrolled |
|
250.82 |
|
Diabetes with other specified manifestations, type II, uncontrolled |
|
250.83 |
|
Diabetes with other specified manifestations, type I, uncontrolled |
|
454.0 |
|
Varicose veins of lower extremity, with ulcer |
|
454.2 |
|
Varicose veins of lower extremity, with ulcer and inflammation |
|
707.12 |
|
Ulcer of lower limb, except decubitus, calf |
|
707.13 |
|
Ulcer of lower limb, except decubitus, ankle |
|
707.14 |
|
Ulcer of lower limb, except decubitus, heel and midfoot |
|
707.15 |
|
Ulcer of lower limb, except decubitus, other part of foot |
Medicare is establishing the following limited coverage for BioBrane®:
|
941.20 - 941.21 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.24 - 941.29 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
942.20 - 942.29 |
|
Burn of trunk, blisters,
epidermal loss (second degree) |
|
943.20 - 943.29 |
|
Burn of upper limb, except
wrist and hand, blisters, epidermal loss (second degree) |
|
944.20 - 944.28 |
|
Burn of wrist(s) and
hand(s), blisters, epidermal loss (second degree) |
|
945.20 - 945.29 |
|
Burn of lower limb(s),
blisters, epidermal loss (second degree) |
|
946.2 |
|
Burns of multiple specified
sites, blisters, epidermal loss (second degree) |
|
948.00 - 948.99 |
|
Burns classified according
to extent of body surface involved (Note: these codes may only be used to
justify payment for skin substitutes when they include areas of second degree
burns) |
Medicare is establishing the following limited coverage for Dermagraft®:
|
250.80 |
|
Diabetes with other specified manifestations, type II, not stated as uncontrolled |
|
250.81 |
|
Diabetes with other specified manifestations, type I, not stated as uncontrolled |
|
250.82 |
|
Diabetes with other specified manifestations, type II, uncontrolled |
|
250.83 |
|
Diabetes with other specified manifestations, type I, uncontrolled |
|
707.14 |
|
Ulcer of lower limb, except decubitus, heel and midfoot |
|
707.15 |
|
Ulcer of lower limb, except decubitus, other part of foot |
|
757.39 |
|
Unspecified anomaly of the integument (may be used for epidermolysis bullosa) |
Medicare is establishing the following limited coverage for EZ Derm™:
|
250.80 |
|
Diabetes with other specified manifestations, type II, not stated as uncontrolled |
|
250.81 |
|
Diabetes with other specified manifestations, type I, not stated as uncontrolled |
|
250.82 |
|
Diabetes with other specified manifestations, type II, uncontrolled |
|
250.83 |
|
Diabetes with other specified manifestations, type I, uncontrolled |
|
454.0 |
|
Varicose veins of lower extremity, with ulcer |
|
454.2 |
|
Varicose veins of lower extremity, with ulcer and inflammation |
|
707.0 |
|
Decubitus Ulcer |
|
707.12 |
|
Ulcer of lower limb, except decubitus, calf |
|
707.13 |
|
Ulcer of lower limb, except decubitus, ankle |
|
707.14 |
|
Ulcer of lower limb, except decubitus, heel and midfoot |
|
707.15 |
|
Ulcer of lower limb, except decubitus, other part of foot |
|
941.20 - 941.21 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.24 - 941.29 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
942.20 - 942.29 |
|
Burn of trunk, blisters,
epidermal loss (second degree) |
|
943.20 - 943.29 |
|
Burn of upper limb, except
wrist and hand, blisters, epidermal loss (second degree) |
|
944.20 - 944.28 |
|
Burn of wrist(s) and hand(s),
blisters, epidermal loss (second degree) |
|
945.20 - 945.29 |
|
Burn of lower limb(s),
blisters, epidermal loss (second degree) |
|
946.2 |
|
Burns of multiple specified
sites, blisters, epidermal loss (second degree) |
|
948.00 - 948.99 |
|
Burns classified according
to extent of body surface involved (Note: these codes may only be used to
justify payment for skin substitutes when they include areas of second degree
burns) |
Medicare is establishing the following limited coverage for Integra®:
|
941.20- 941.21 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.24 - 941.29 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.30 - 941.31 |
|
Burn of face, head, and neck, full thickness skin loss (third degree NOS) |
|
941.34 - 941.39 |
|
Burn of face, head, and neck, full thickness skin loss (third degree NOS) |
|
941.40 - 941.41 |
|
Burn of face, head, and neck, deep necrosis of underlying tissues (deep third degree) without mention of loss of a body part |
|
941.44 - 941.49 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) without mention
of loss of a body part |
|
941.50 - 941.51 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) with loss of a
body part |
|
941.54 - 941.59 |
|
Burn of face, head, and neck,
deep necrosis of underlying tissues (deep third degree) with loss of a body
part |
|
942.20 - 942.29 |
|
Burn of trunk, blisters,
epidermal loss (second degree) |
|
942.30 - 942.39 |
|
Burn of trunk,
full-thickness skin loss (third degree NOS) |
|
942.40 - 942.49 |
|
Burn of trunk, deep
necrosis of underlying tissues (deep third degree) without mention of loss of
a body part |
|
942.50 - 942.59 |
|
Burn of trunk, deep
necrosis of underlying tissues (deep third degree) with loss of a body part |
|
943.20 - 943.29 |
|
Burn of upper limb, except
wrist and hand, blisters, epidermal loss (second degree) |
|
943.30 - 943.39 |
|
Burn of upper limb, except wrist and hand, full-thickness skin loss (third degree NOS) |
|
943.40 - 943.49 |
|
Burn of upper limb, except wrist and hand, deep necrosis of underlying tissues (deep third degree) without mention of loss of a body part |
|
943.50 - 943.59 |
|
Burn of upper limb, except
wrist and hand, deep necrosis of underlying tissues (deep third degree) with
loss of a body part |
|
944.20 - 944.28 |
|
Burn of wrist(s) and
hand(s), blisters, epidermal loss (second degree) |
|
944.30 - 944.38 |
|
Burn of wrist(s) and
hand(s), full-thickness skin loss (third degree NOS) |
|
944.40 - 944.48 |
|
Burn of wrist(s) and
hand(s), deep necrosis of underlying tissues (deep third degree) without
mention of loss of a body part |
|
944.50 - 944.58 |
|
Burn of wrist(s) and
hand(s), deep necrosis of underlying tissues (deep third degree) with loss of
a body part |
|
945.20 - 945.29 |
|
Burn of lower limb(s),
blisters, epidermal loss (second degree) |
|
945.30 - 945.39 |
|
Burn of lower limb(s),
full-thickness skin loss (third degree NOS) |
|
945.40 - 945.49 |
|
Burn of lower limb(s), deep
necrosis of underlying tissues (deep third degree) without mention of loss of
a body part |
|
945.50 - 945.59 |
|
Burn of lower limb(s), deep
necrosis of underlying tissues (deep third degree) with loss of a body part |
|
946.2 - 946.5 |
|
Burns of multiple specified
sites |
|
948.00 - 948.99 |
|
Burns classified according
to extent of body surface involved (Note: these codes may only be used to
justify payment for skin substitutes when they include areas of second and/or
third degree burns) |
Medicare is establishing the following limited coverage for Oasis®:
|
250.80 |
|
Diabetes with other specified manifestations, type II, not stated as uncontrolled |
|
250.81 |
|
Diabetes with other specified manifestations, type I, not stated as uncontrolled |
|
250.82 |
|
Diabetes with other specified manifestations, type II, uncontrolled |
|
250.83 |
|
Diabetes with other specified manifestations, type I, uncontrolled |
|
454.0 |
|
Varicose veins of lower extremity, with ulcer |
|
454.2 |
|
Varicose veins of lower extremity, with ulcer and inflammation |
|
707.00 |
|
Decubitus ulcer,
unspecified |
|
707.01 |
|
Decubitus ulcer, elbow |
|
707.02 |
|
Decubitus ulcer, upper back |
|
707.03 |
|
Decubitus ulcer, lower back |
|
707.04 |
|
Decubitus ulcer, hip |
|
707.05 |
|
Decubitus ulcer, buttock |
|
707.06 |
|
Decubitus ulcer, ankle |
|
707.07 |
|
Decubitus ulcer, heel |
|
707.09 |
|
Decubitus ulcer, other site |
|
707.12 |
|
Ulcer of lower limb, except decubitus, calf |
|
707.13 |
|
Ulcer of lower limb, except decubitus, ankle |
|
707.14 |
|
Ulcer of lower limb, except decubitus, heel and midfoot |
|
707.15 |
|
Ulcer of lower limb, except decubitus, other part of foot |
|
941.20 - 941.21 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.24 - 941.29 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
942.20 - 942.29 |
|
Burn of trunk, blisters,
epidermal loss (second degree) |
|
943.20 - 943.29 |
|
Burn of upper limb, except
wrist and hand, blisters, epidermal loss (second degree) |
|
944.20 - 944.28 |
|
Burn of wrist(s) and
hand(s), blisters, epidermal loss (second degree) |
|
945.20 - 945.29 |
|
Burn of lower limb(s),
blisters, epidermal loss (second degree) |
|
946.2 |
|
Burns of multiple specified
sites, blisters, epidermal loss (second degree) |
|
948.00 - 948.99 |
|
Burns classified according
to extent of body surface involved (Note: these codes may only be used to
justify payment for skin substitutes when they include areas of second degree
burns) |
Medicare is establishing the following limited coverage for OrCel®:
|
941.20 - 941.21 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.24 - 941.29 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.30 - 941.31 |
|
Burn of face, head, and neck, full thickness skin loss (third degree NOS) |
|
941.34 - 941.39 |
|
Burn of face, head, and neck, full thickness skin loss (third degree NOS) |
|
941.40 - 941.41 |
|
Burn of face, head, and neck, deep necrosis of underlying tissues (deep third degree) without mention of loss of a body part |
|
941.44 - 941.49 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) without mention
of loss of a body part |
|
941.50 - 941.51 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) with loss of a
body part |
|
941.54 - 941.59 |
|
Burn of face, head, and neck,
deep necrosis of underlying tissues (deep third degree) with loss of a body
part |
|
942.20 - 942.29 |
|
Burn of trunk, blisters,
epidermal loss (second degree) |
|
942.30 - 942.39 |
|
Burn of trunk,
full-thickness skin loss (third degree NOS) |
|
942.40 - 942.49 |
|
Burn of trunk, deep
necrosis of underlying tissues (deep third degree) without mention of loss of
a body part |
|
942.50 - 942.59 |
|
Burn of trunk, deep
necrosis of underlying tissues (deep third degree) with loss of a body part |
|
943.20 - 943.29 |
|
Burn of upper limb, except
wrist and hand, blisters, epidermal loss (second degree) |
|
943.30 - 943.39 |
|
Burn of upper limb, except wrist and hand, full-thickness skin loss (third degree NOS) |
|
943.40 - 943.49 |
|
Burn of upper limb, except
wrist and hand, deep necrosis of underlying tissues (deep third degree)
without mention of loss of a body part |
|
943.50 - 943.59 |
|
Burn of upper limb, except wrist and hand, deep necrosis of underlying tissues (deep third degree) with loss of a body part |
|
944.20 - 944.28 |
|
Burn of wrist(s) and
hand(s), blisters, epidermal loss (second degree) |
|
944.30 - 944.38 |
|
Burn of wrist(s) and
hand(s), full-thickness skin loss (third degree NOS) |
|
944.40 - 944.48 |
|
Burn of wrist(s) and
hand(s), deep necrosis of underlying tissues (deep third degree) without
mention of loss of a body part |
|
944.50 - 944.58 |
|
Burn of wrist(s) and
hand(s), deep necrosis of underlying tissues (deep third degree) with loss of
a body part |
|
945.20 - 945.29 |
|
Burn of lower limb(s),
blisters, epidermal loss (second degree) |
|
945.30 - 945.39 |
|
Burn of lower limb(s),
full-thickness skin loss (third degree NOS) |
|
945.40 - 945.49 |
|
Burn of lower limb(s), deep
necrosis of underlying tissues (deep third degree) without mention of loss of
a body part |
|
945.50 - 945.59 |
|
Burn of lower limb(s), deep
necrosis of underlying tissues (deep third degree) with loss of a body part |
|
946.2 - 946.5 |
|
Burns of multiple specified
sites |
|
948.00 - 948.99 |
|
Burns classified according
to extent of body surface involved (Note: these codes may only be used to
justify payment for skin substitutes when they include areas of second and/or
third degree burns) |
Medicare is establishing the following limited coverage for Transcyte®:
|
941.20 - 941.21 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.24 - 941.29 |
|
Burn of face, head, and neck, blisters, epidermal loss (second degree) |
|
941.30 - 941.31 |
|
Burn of face, head, and neck, full thickness skin loss (third degree NOS) |
|
941.34 - 941.39 |
|
Burn of face, head, and neck, full thickness skin loss (third degree NOS) |
|
941.40 - 941.41 |
|
Burn of face, head, and neck, deep necrosis of underlying tissues (deep third degree) without mention of loss of a body part |
|
941.44 - 941.49 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) without mention
of loss of a body part |
|
941.50 - 941.51 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) with loss of a
body part |
|
941.54 - 941.59 |
|
Burn of face, head, and
neck, deep necrosis of underlying tissues (deep third degree) with loss of a
body part |
|
942.20 - 942.29 |
|
Burn of trunk, blisters,
epidermal loss (second degree) |
|
942.30 - 942.39 |
|
Burn of trunk,
full-thickness skin loss (third degree NOS) |
|
942.40 - 942.49 |
|
Burn of trunk, deep
necrosis of underlying tissues (deep third degree) without mention of loss of
a body part |
|
942.50 - 942.59 |
|
Burn of trunk, deep
necrosis of underlying tissues (deep third degree) with loss of a body part |
|
943.20 - 943.29 |
|
Burn of upper limb, except
wrist and hand, blisters, epidermal loss (second degree) |
|
943.30 - 943.39 |
|
Burn of upper limb, except wrist and hand, full-thickness skin loss (third degree NOS) |
|
943.40 - 943.49 |
|
Burn of upper limb, except
wrist and hand, deep necrosis of underlying tissues (deep third degree)
without mention of loss of a body part |
|
943.50 - 943.59 |
|
Burn of upper limb, except
wrist and hand, deep necrosis of underlying tissues (deep third degree) with
loss of a body part |
|
944.20 - 944.28 |
|
Burn of wrist(s) and
hand(s), blisters, epidermal loss (second degree) |
|
944.30 - 944.38 |
|
Burn of wrist(s) and
hand(s), full-thickness skin loss (third degree NOS) |
|
944.40 - 944.48 |
|
Burn of wrist(s) and
hand(s), deep necrosis of underlying tissues (deep third degree) without
mention of loss of a body part |
|
944.50 - 944.58 |
|
Burn of wrist(s) and
hand(s), deep necrosis of underlying tissues (deep third degree) with loss of
a body part |
|
945.20 - 945.29 |
|
Burn of lower limb(s),
blisters, epidermal loss (second degree) |
|
945.30 - 945.39 |
|
Burn of lower limb(s),
full-thickness skin loss (third degree NOS) |
|
945.40 - 945.49 |
|
Burn of lower limb(s), deep
necrosis of underlying tissues (deep third degree) without mention of loss of
a body part |
|
945.50 - 945.59 |
|
Burn of lower limb(s), deep
necrosis of underlying tissues (deep third degree) with loss of a body part |
|
946.2 - 946.5 |
|
Burns of multiple specified
sites |
|
948.00 - 948.99 |
|
Burns classified according
to extent of body surface involved (Note: these codes may only be used to
justify payment for skin substitutes when they include areas of second and/or
third degree burns) |
Diagnoses that Support Medical Necessity
N/A
ICD-9-Codes that DO NOT Support Medical Necessity
N/A
Diagnoses that DO NOT Support Medical Necessity
N/A
Documentation Requirements
·
Documentation
supporting the medical necessity should be legible, maintained in the patient's
medical record, and available to Medicare upon request. The documentation
should include:
o
Diagnosis with
date of onset and prior treatment, when applicable
o
Extent and
severity of area to be treated
o
Skin substitute
used, including number of units when applicable
·
Reevaluations
should be documented on a regular basis (at least weekly initially, sooner for
certain treatments).
Utilization Guidelines
· Medicare will monitor the utilization of this service through the Medical Review process.
Sources of Information and Basis for Decision
·
American Diabetes
Association (1999). Consensus Development Conference of Diabetic Foot Wound
Care. Diabetes Care, 22, 1354-1360.
·
Bello, Y.M.,
Falabella, A. F., Eaglstein, W.H. (2001) "Tissue-Engineered Skin. Current Status
in Wound Healing." American Journal of Clinical Dermatology, 2(5),
305-313.
·
Bertek
Pharmaceuticals, Inc., BioBrane Prescribing Information.
·
Brem, H.,
Balledux, J., Sukkarieh, T., Carson, P., Falanga, V. (2001). "Healing of
Venous Ulcers of Long Duration with a Bilayered Living Skin Substitute: Results
from a General Surgery and Dermatology Department." Dermatologic
Surgery, 27 (11), 915-9.
·
Curran, M.P.,
Plosker, G.L.(2002) "Bilayered Bioengineered Skin Substitute (Apligraf): A
Review of Its Use in the Treatment of Venous Leg Ulcers and Diabetic Foot
Ulcers." Biodrugs, 16 (6), 439-55.
·
Eisenbud, D., et
al. (2004). "Skin Substitutes and Wound Healing: Current Status and
Challenges." Wounds, 16(1), 2-17.
·
Falanga, V. &
Sabolinski, M. (1999). "A Bilayered Living Skin Construct (Apligraf
Accelerates Complete Closure of Hard-to-Heal Venous Ulcers." Wound
Repair and Regeneration, 7, 201-207.
·
Hansbrough, J.F.,
et al. (1997) "Clinical Trials of a Biosynthetic Temporary Skin
Replacement, Dermagraft-Transitional Covering, Compared with Cryopreserved
Human Cadaver Skin for Temporary Coverage of Excised Burn Wounds." Journal
of Burn Care and Rehabilitation, 18(1 Pt.1), 43-51.
·
Healthpoint, Ltd.
(2002) Oasis Prescribing Information.
·
Integra Life
Sciences Corporation. Integra Prescribing Information.
·
Marston, W.A., et
al. (2003) "The Efficacy and Safety of Dermagraft in Improving the Healing
of Chronic Diabetic Foot Ulcers: Results of a Prospective Randomized
Trial." Diabetes Care, 26 (6), 1701-5.
·
Noordenbos, J.
Dore C. , & Hanbrough, J.F. (1999) "Safety and Efficacy of TransCyte
for the Treatment of Partial-Thickness Burns." Journal of Burn Care and
Rehabilitation, Vol. 20, Number 4: 275-281.
·
Organogenesis,
Inc. (2003) Apligraf Prescribing Information.
·
Ortec International,
Inc. (2001) Orcel Instructions for Use for Managing Donor Sites in Burn
Patients.
·
Phillips, T.J.,
et al. (2002) "The Longevity of a Bilayered Skin Substitute after
Application to Venous Ulcers." Archives of Dermatology, 138 (8),
1079-81.
·
Purdue, G.F., Et
al. (1997). "A Multi-Center Clinical Trial of a Biosynthetic Skin
Replacement Derm TC, Compared with Cryopreserved Human Cadaver Skin for
Temporary Coverage of Burn Wounds." Journal of Burn Care and
Rehabilitation, Vol. 18, Number 1, Part 1, 52-57.
·
Rennekampff,
H.O., Kiessig, V. Griffrey, S., Greenleaf, G. Hanbrough, J.F. (1997)
"Acellular Human Dermis Promotes Cultured Keratinocyte Engraftment." Journal
of Burn Care and Rehabilitation, Vol. 18, 535-44.
·
Smith &
Nephew, Inc., Dermagraft Essential Prescribing Information.
·
Steed, D. (1999)
"Nonoperative Management of Venous Leg Ulcers: Evolving Role of Skin
Substitutes." Vascular Surgery, 33(2), 197-210.
·
TrialBlazer
Health Services LCD
·
Wainwright, D.
J., (1995) "Use of an Acellular Allograft Dermal Matrix (Alloderm) in the
Management of Full-Thickness Burns." Burns, 21, 243-48.
·
Wainwright, D.J.,
et al. (1996) "Clinical Evaluation of an Acellular Allograft Dermal Martix
in Full-Thickness Burns." Journal of Burn Care and Rehabilitation,
Vol. 17, 124-136.
·
Waymack, P.,
Duff, R.G., Sabolinski, M. (2000). The Effect of a Tissue Engineered Bilayered
Living Skin Analog Over Meshed Split-Thickness Autografts on the Healing of
Excised Burn Wounds. The Apligraf Burn Study Group." Burns, 26 (7),
609-19.
·
List includes
abstracts.
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or
contractor medical director. Although the final decision rests with the
contractor, this policy was developed in cooperation with representatives from
wound care clinics in
Start Date if Comment Period
End Date of Comment Period
Start Date of Notice Period
Revision History Number
Revision History Explanation
|
R1 |
|
Annual ICD-9 update, ICD-9 code 707.0 expanded to |
|
|
|
5 digits, 707.00-707.09. Per Transmittal 210, CR 3303. |
THIS BULLETIN SHOULD BE SHARED WITH ALL
HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER
STAFF. BULLETINS ISSUED AFTER
Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 2004 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.