5160-4-35 Skin substitutes for wound treatment and healing.

(A) The following skin substitutes are covered in an office setting in conjunction with standard wound care regimens for the treatment of burns or ulcers:

(1) Q4101, skin substitute, apligraf, per square centimeter; and

(2) Q4102, skin substitute, oasis wound matrix, per square centimeter; and

(3) Q4103, skin substitute, oasis burn matrix, per square centimeter; and

(4) Q4106, skin substitute dermagraft, per square centimeter; and

(5) Q4110, skin substitute, primatrix, per square centimeter.

(B) Skin substitutes may be used on burns when skin grafting is not the appropriate option. These covered bioengineered skin substitutes are expected to function as a permanent replacement for lost or damaged skin. They may be used for temporary wound coverage or wound closure as appropriate and medically necessary.

(C) Skin substitutes are not separately reimbursable in any institutional setting, including long-term care facility, hospital inpatient, outpatient, or emergency room place of service.

(D) If skin substitute applications and re-applications show no significant improvement after three separate treatments, additional re-applications are inappropriate and other treatment modalities should be considered. Skin substitute treatments should not last more than twelve weeks. Improvement of fifty per cent or greater must be documented in the medical records for the reimbursement of additional re-applications after twelve weeks of treatment. If after twelve weeks the medical records do not support the significant improvement of the wound using the skin substitute treatments, the Ohio department of job and family services may recoup any inappropriate reimbursement.

(E) Wound preparation is considered part of the procedure. All products, including dressings, are included in the evaluation and management service and are not separately reimbursable.

Cite as Ohio Admin. Code 5160-4-35

Effective: 08/02/2011
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02