Last updated on 4/13/25 | First published on 4/13/25 | Literature review current through Mar. 2025
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CODING, COVERAGE AND REIMBURSEMENT
This section currently focuses primarily on Medicare. It may be expanded in the future to include information on private insurers as well.
Medicare hospital outpatient prospective payment system (OPPS) cost category assignment:
Frequency of replacement allowed by Medicare:
| Medicare Administrative Contractor (MAC) | Frequency of replacement if requirements met |
Novitas Solutions, Inc. CGS Administrators, LLC First Coast Service Options, Inc. (FCSO) Palmetto
Noridian Wisconsin Physicians Service Insurance Corporation (WPS) National Government Services, Inc. (NGS) | Carrier discretion
|
More details on requirements, medical necessity and documentation in specific Medicare Local Coverage Determinations (if available). See section on Coding, Coverage and Reimbursement in topic "Cellular and/or Tissue Products".
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
CLINICALIndicationsNEOX 1k is a thicker cryopreserved amniotic membrane tissue that is intended for use when durable tensile strength is indicated.NEOX 1k can be used for tectonic support as a surgical covering, wrap or barrier.
FDARegulated under PHS 361 [21 CFR 1270 & 1271]: Human cells, tissues, and cellular and tissue-based products. Creates a unified registration and listing system for establishmen
Grafix is a cryopreserved placental membrane comprised of an extracellular matrix (ECM) rich in collagen, growth factors, fibroblasts, mesenchymal stem cells (MSCs), and epithelial cells native to the tissue
CLINICALIndicationsIntended for homologous use in acute and chronic wound care.FDARegulated under PHS 361 [21 CFR 1270 & 1271]: Human cells, tissues, and cellular and tissue-based products. Creates a unified registration and listing system for establishments that manufacture HCT/Ps and establishes donor eligibility, current good tissue practice, and other procedures to pre
Dermagraft is indicated for use in the treatment of full-thickness diabetic foot ulcers greater than six weeks duration, which extend through the dermis, but without tendon, muscle, joint capsule, or bone exposure.Dermagraft should be used in conjunction with standard wound care regimens and in patients that have ad
