Last updated on 11/10/22 | First published on 11/12/17 | Literature review current through Sep. 2024
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Unbiased information for educational purposes only. WoundReference does not produce, market, advertise, re-sell or distribute healthcare goods or services consumed by, or used on patients. For information about specific products, please contact the manufacturer directly.
Endoform Dermal Template Dressing is a collagen dressing.
INTENDED USES: Can be used to treat chronic wounds from day one.
CLAIMED FEATURES: Material - 90% Native,Intact Collagen /10% Extracellular Matrix Components UNSPSC Code 42311604. Features Broad spectrum MMP reduction. May be reapplied as infrequently as once per week.
OPTIONS: 5 cm x 5 cm, 10/box
Manufacturer: Aroa Biosurgery Ltd. (distributed in the U.S. by Appulse Medical)
Information retrieved from manufacturer and/or FDA-approved labels
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ESSENTIALS
Product
Estimated
Out-of-pocket
Cost
HCPCS Class
HCPCS
Collagen dressing, sterile, size 16 sq. in. or less, each
A6021
Collagen dressing, sterile, size 16 sq. in. or less, each
A6021
Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each
A6022
Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each
A6022
* Hover on the information button next to each header for detailed explanation on the type of information provided by the table
Select your state for Medicare
DME coverage and co-payment
Product
Estimated
Out-of-pocket
Cost
Patient DME Co-Payment per Billable Unit
DME Reimbursement to Suppliers
Frequency Replacement if Requirements Met
Office and/or Facility - Product reimbursement
$5.14
each
$25.72
1 changes/week
$5.14
each
$25.72
1 changes/week
$5.14
each
$25.72
1 changes/week
$5.14
each
$25.72
1 changes/week
* Every effort has been made to ensure the accuracy of the product information, however you should visit the manufacturer's website for the latest information.
* Hover on the information button next to each header for detailed explanation on the type of information provided by the table
Product
Estimated
Out-of-pocket
Cost
Recom / Evidence
FDA Safety
Quality Measures
Cost Effectiveness
Product
Estimated
Out-of-pocket
Cost
Application: Can be used as primary dressing
Depth: Full thickness (deep)
Depth: Partial thickness (shallow)
Exudate: Low
Exudate: Moderate
Exudate: High
Indications: May be applied over infected tissue
Indications: May be used to pack deep wounds
Indications: May be used under compression
Medicare freq of replacement: 1/week
Wear time: Up to 7 days
Application: Can be used as primary dressing
Depth: Full thickness (deep)
Depth: Partial thickness (shallow)
Exudate: Low
Exudate: Moderate
Exudate: High
Indications: May be applied over infected tissue
Indications: May be used to pack deep wounds
Indications: May be used under compression
Medicare freq of replacement: 1/week
Wear time: Up to 7 days
Application: Can be used as primary dressing
Depth: Full thickness (deep)
Depth: Partial thickness (shallow)
Exudate: Low
Exudate: Moderate
Exudate: High
Indications: May be applied over infected tissue
Indications: May be used to pack deep wounds
Indications: May be used under compression
Medicare freq of replacement: 1/week
Wear time: Up to 7 days
Application: Can be used as primary dressing
Depth: Full thickness (deep)
Depth: Partial thickness (shallow)
Exudate: Low
Exudate: Moderate
Exudate: High
Indications: May be applied over infected tissue
Indications: May be used to pack deep wounds
Indications: May be used under compression
Medicare freq of replacement: 1/week
Wear time: Up to 7 days
- Based on national averages
- Medicare payments for participating qualified health professionals (QHP) for services performed in their Offices (*) or at a Facility (** i.e., hospital outpatient department or ambulatory service center). Payments are nationally unadjusted average amounts, and do not account for differences in payment due to geographic variation. The allowed rate for non-participating physicians is set at 95% of the allowable for participating physicians. Non-participating physicians are subject to the limiting charge rules. The coinsurance is limited to 20% of the allowable fee.
- When covered by the Medicare contractor, this manufacturer product is separately payable in a QHP office based on the Average Sales Price (ASP) as reported by the manufacturer on a quarterly basis.
- Hover on the information button next to each header for detailed explanation on the type of information provided by the table
- The information provided on this website is informational only. This is not a guarantee of Reimbursement Rates, nor is it intended to make recommendations regarding clinical practices. Information on this website is subject to change with out notice due to changes in reimbursement laws, regulations, rules and policies. The ultimate responsibility for correct coding lies with the provider of services. Please contact the appropriate payer for their interpretation of the appropriate code to use for the procedure.
- CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2018, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced on Wound Reference are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the American Medical Association prior to the submission of claims for reimbursement of covered services.
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CLINICAL
Indications
For single use in the treatment of the following wounds: 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); draining wounds.
FDA
EndoForm Dermal Template (Mesynthes, Ltd., North Attleboro, MA, USA, and Wellington, New Zealand) was cleared for marketing under the 510(k) process (K092096) in January 2010. EndoForm Dermal Template is included in FDA product code KGN (dressing, wound, collagen)
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