Summary of Package Insert 1 for PuraPly Wound Matrix For NGS Indications Indicated for the management of wounds including: Partial and full-thickness wounds Venous ulcers Diabetic ulcers Drainage wounds Pressure ulcers Chronic vascular ulcers Trauma wounds (abrasions, lacerations, second-degree burns, skin tears) Surgical wounds (donor sites/grafts, post-mohs surgery, post-laser surgery, podiatric, wound dehiscence) Coding CPT/HCPCS 1,2 Q4172:PuraPly, per square centimeter JW Modifier: Effective January 1, 2017 For all sites service. Claims for discarded drug or biological amount not administered to any patient, shall be submitted using the JW modifier. This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological. Providers must document the discarded drugs or biologicals in patient's medical record. Application Codes 15271: Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area 15272: Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) 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 15274: Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part therof (List separately in addition to code for primary procedure) Application Codes 15275: Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
Summary of Package Insert 1 for PuraPly (continued) genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area 15276: 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; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) 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 15278: 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; each additional 100 sq cm wound surface area, or part therof (List separately in addition to code for primary procedure) 1 This document is for informational purposes only. Use of this information does not guarantee coverage or payment for these services by Medicare or other payors. Physicians and other providers should use independent judgment when selecting codes that most appropriately describe the services provided to a patient. Physicians and hospitals are solely responsible for compliance with Medicare and other payors laws, rules, and requirements. 2 CPT American Medical Association. All Rights Reserved.
Hospital 123 Medical Drive, NJ 00000 01011935 2017 NGS PI PuraPly Sample UB-04 Claim Form HIC 012345678A 01-2345678 07012016 07012016 111 Maple Avenue NJ 00000 131 All dates should be in eight digit format. Jane Smith 111 Maple Avenue, NJ 00000 636 PuraPly, per sq cm Q4172 01012017 24 636 PuraPly, Per sq cm Q4172 JW 01012017 1 360 Application, first 25 sq cm 15271 01012017 1 Enter appropriate revenue codes for all services provided. Revenue code 636 should be used when billing for Puraply. 15271 should be used based on the size of the wound. 24 sq cm of the product was used on the wound. 1 sq cm of product was discarded and documented as wastage and therefore billed with a JW Modifier. 5x5 piece of Puraply Medicare A987654 xxx.xx
2017 NGS PI Puraply Sample CMS-1500 Claim Form Physician Services in an Outpatient Setting 123-45-6789A 12 13 35 00000 (973) 555-1234 00000 973 555-1234 SIGNATURE ON FILE 01 01 17 01 01 17 22 15271 15271 should be used based on the size of the wound. 01-2345678 012345678
2017 Medicare PuraPly/ PuraPly AM Sample CMS-1500 Claim Form Physician Services in an Office Setting 123-45-6789A 12 13 35 00000 (973) 555-1234 00000 973 555-1234 SIGNATURE ON FILE In Box 19 please include name of product, (PuraPly Antimicrobial or PuraPly), and size of product. 01 01 17 01 01 17 11 Q4172 01 01 17 01 01 17 11 Q4172 JW 01 01 17 01 01 17 11 15271 15271 should be used based on the size of the wound. 24 1 1 5x5 piece of Puraply 24 sq cm of the product was used on the wound. 1 sq cm of product was discarded and documented as wastage and therefore billed with a JW Modifier. 01-2345678 012345678
Model Documentation Form for NGS / Summary of Package Insert for PuraPly Wound Matrix Treatment: 1. PuraPly should not be applied until excessive exudates, bleeding, acute swelling and infection are controlled and documented 2. Duration of ulcer weeks 3. Describe adequate treatment of the underlying disease process contributing to the ulcer 4. Diagnosis of patient 5. Document measurement of ulcer (width and length or circumference and depth) immediately prior to application of PuraPly sq cm 6. Document whether this is an initial application of PuraPly or a reapplication. 7. For PuraPly reapplications, document that applications have been successful (e.g. decrease in size or depth, increase in granulation tissue) 8. Document the wound dressing changes and the standard conservative measures accompanying the wound treatment with PuraPly 9. Document how the wound site was prepared, and how PuraPly was fixated on the wound. Modifiers: JW- Skin substitute not applied to wound, wastage. Product Wastage Documentation Requirements: Date and Time: Location of ulcer: Approximate amount of product unit used:
Approximate amount of product unit discarded: Reason for the wastage: Manufacture s serial/lot/batch number This document is for informational purposes only. Use of this information does not guarantee coverage or payment for these services by Medicare or other payors. LCDs are updated by Medicare and Medicare contractors on a regular basis. Physicians and other providers should regularly refer to the applicable Medicare local coverage determinations (LCDs) for complete information on medical necessity documentation requirements. Physicians, providers and hospitals are solely responsible for compliance with Medicare and other payors laws, rules, and requirements.