Reimbursement

Reimbursement Instructions

Coding, Coverage, and Payment

Download Keramatrix Billing Guide (PDF)
Download Keramatrix Billing - Physician Office Setting (PDF)

Covered Sites of Service:
Physician Office, Hospital Outpatient Department, & Ambulatory Surgery Center

Q4165:Skin Substitute, KERAMATRIX, per square centimeter
Modifier - JC*:Skin substitute used as graft
Modifier - JW*:Drug amount discarded/not administered to any patient
Modifier - KX*:Requirements in the medical policy have been met **This modifier may also apply to application code**
CPT 15271:Application of skin substitute graft to trunk, arms, legs, total wound surface area of up to 100 sq. cm; first 25 sq. cm or less of wound surface area
CPT 15272:Each additional 25 sq. cm up to 100 sq. cm wound surface area, or part thereof. List separately in addition to code 15271 for primary procedure.
CPT 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
CPT 15274:Each additional 100 sq. cm wound surface area or part thereof, or each additional 1% of body area of infants and children or part thereof. List separately in addition to code 15273 for primary procedure.
CPT 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 cm or less wound surface area
CPT 15276:Each additional 25 sq. cm wound surface area, or part thereof. List separately in addition to code 15275 for primary procedure.
CPT 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
CPT 15278:Each additional 100 sq. cm wound surface area, or part thereof. List separately in addition to code 15277 for primary procedure
Units Billed
Check units billed - Keramatrix is a single-use product - CMS and private payers generally reimburse for the entire piece, even where it is reasonable and necessary to discard a portion.

Product DescriptionBillable UnitsHCPCS
Keramatrix 5x5cm (25cm²)25Q4165
Keramatrix 10x10cm (100cm²)100Q4165
**Check your Local Coverage Determination (LCD) for additional billing information**

Product Wastage Documentation Requirements
Any amount of wasted material should be clearly documented in the medical record with the following information:

1. Date, time, and location of ulcer treated
2. Approximate amount of product unit used
3. Approximate amount of product unit discarded
4. Reason for the wastage
5. Manufacturer's serial/lot/batch or other unit identification number of graft material

Modifiers
Check to see if modifiers are required with HCPCS Q4165 - common modifiers include:

JC - skin substitute used as a graft
JW - wastage
KX - requirements in the medical policy have been met.

Check to see if modifiers are required with CPT 15275.

Wound Size
When determining the wound location and surface area, it is important to select the appropriate CPT code.

Ulcer(s) less than 100 sq cm: Utilize CPT 15275 and the add-on code of 15276 as necessary.

Ulcer(s) greater than or equal to 100 sq cm: Utilize CPT 15277 and the add-on code of 15278 as necessary.

Debridement
Debridement is considered a component code of 15275/15277.

Diagnosis Codes Order
Check the LCD or private payer policy to ensure diagnoses are in the proper order.

Commercial Insurers Contract
Check your payer contracts prior to applying Keramatrix coding and coverage is not a guarantee of payment.

CPT is a registered trademark of the American Medical Association. The listed CPT codes apply to all skin substitute products.

It is at the provider's discretion to decide when Keramatrix is a medical necessity. Molecular Biologicals will not solicit the use of Keramatrix outside of FDA-cleared indications. Please refer to your CPT 2016 book for descriptors regarding CPT codes for other ulcer locations.

Molecular Biological cannot guarantee reimbursement. It is the provider's responsibility to determine the appropriate utilization of products and services along with the appropriate coding.

Phone1-844-793-9933
Fax1-281-998-3331
Emailinfo@molecularbiologicals.com
Hours of operation: 8am - 5pm CST

Keramatrix is indicated for use in the treatment of full thickness acute wounds, Donor sites/grafts and Diabetic foot ulcers and nonhealing ulcers, which extend through the dermis. Keramatrix should be used in conjunction with standard wound care regimens. Keramatrix is contraindicated for use in ulcers that have signs of clinical infection. Keramatrix is contraindicated in patients with known hypersensitivity to ovine products.