- Change to Roster Claims Information Entry in the Fiscal Intermediary Standard System Direct Data Entry
- Drugs and Biologicals - Coverage and Billing
- Medicare Part B Drug Coverage
- Covered Medicare Part B Drugs/Biologicals
- Self-Administered Drug Exclusion
- Medicare Part B General Billing
- Discarded Drugs/Wastage and JW, JZ Modifier
- Chemotherapy General Infusion Information
- Monoclonal Antibodies in Treatment of Alzheimer’s Disease - Medicare Advantage Plan Responsibility
- Reimbursement for Pre-exposure Prophylaxis Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus Infection
- Unlisted Codes for Drugs and Biologicals (J3490, J3590 and J9999)
- Compound Drugs
- Patient-Supplied or Free-of-Charge Drugs
- Prolonged Drug and Biological Infusions Using an External Pump
- Coding for Sinuva™ Claims
- Radiopharmaceutical Reimbursement
- Dermal Injections for Treatment of Facial Lipodystrophy Syndrome
- Factor VIII Billing
- Intravitreal Beovu (Brolucizumab-dbl) Billing
- Proper Billing for LEQVIO® HCPCS Code J1306
- Erythropoiesis Stimulating Agents: Clinical Indications and Coverage Criteria Overview
- Proper Billing for TEZSPIRE™ HCPCS Code J2356
- Proper Billing Units for HCPCS Code J7320
- Providers Performing Facet Joint Injections (CPT Code 64476)
- Skin Substitutes
- Vaccines
- Related Content
Skin Substitutes
CMS provides pricing for some wound care products; however, there are many that do not have established pricing. When a skin substitute/wound care product does not have established pricing, the pricing for the item will be dependent on the cost of the item.
When billing for these services, the provider must adhere to any applicable MUE values.
When there is not an established fee for the product being billed, the following details are required in the comments section of the Medicare Part B claim:
- An invoice price or acquisition cost for that item
- Total size of the product being used
- The amount must match size type indicated by the HCPCS code. If the code is defined as per square centimeter, the units billed must match the size billed in square centimeters
- For example, Q4100-Q4226 are coded as per square centimeter. If you have a product that is 4x4 square centimeters, 16 units would be entered
When multiple claims are required because charges exceed the threshold of $99,999.99 for Part B claims, utilize the example comments below:
- Claim 1 of 2 List [invoice price] for this claim only, 4x4cm
- Claims 2 of 2 List [invoice price] for this claim only, 4x4cm
Billing Tips:
- When billing subsequent claims, modifier 76 must be appended
- Comment claim one of four, two of four, etc.
- Skin substitutes are excluded from the requirement to use the JZ modifier and will cause rejections when appended
- Only the JW modifier should be used to report drug wastage for skin substitutes
- Rebates/discounts will reduce the amount of reimbursement
- The rebate amount should either be reflected in the total billed amount, or
- The invoice amount for the rebate/discount must be provided in the comment field of the claim
- Ensure units are billed in square units except when a circular product used
- For example, 3x3=9 units, 4x3=12 units, etc.
- Include a wound DX
For additional guidance with claims that exceed the threshold for charges and units of service, view our Medicare Part B Electronic Claims That Exceed the Threshold for Charges and Units of Service.
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Revised 11/8/2024