Reimbursement

As part of our commitment to providing the most advanced regenerative medicine products available, we also provide resources to assist with reimbursement inquiries.

Organogenesis currently provides information on coding, coverage and reimbursement in addition to other tools for our Advanced Wound Care products. Additional information is also available on the Centers for Medicare and Medicaid Services website.

The Reimbursement Hotline is committed to providing physician and facility providers with general information regarding coding and patient benefit verification results.

You can reach out to an Organogenesis representative today at 1-888-432-5232 (option #3) for answers to any questions regarding reimbursement.

Or write to us at

Coverage, Coding, and Payment Information for the Organogenesis Advanced Wound Care Products

While the Provider is responsible for appropriate coding, billing and for handling and solving the related challenges, our goal is to make this process as easy as 1,2,3. We strive to make reimbursement for PuraPly® AM, PuraPly®, Affinity®, NuShield®, Apligraf®, and Dermagraft® consistent and reliable.

Three elements are needed to secure reliable product and procedure reimbursement
  1. Coverage
  2. Coding
  3. Payment

The Organogenesis Wound Care products have all three.

Coverage for the Organogenesis Wound Care products depends on each patient's particular medical insurance. However, the process to determine coverage is simple and straightforward.

Step 1 | Determining Coverage

Medicare
  • The Organogenesis Wound Care products are covered by the Medicare Administrative Contractors (MACs) and some have local coverage determinations (LCDs)
Commercial Insurances
  • More than 1500 commercial health insurance plans cover the Organogenesis Wound Care products
Medicaid
  • The Organogenesis Wound Care products are covered by approximately 90% of state programs
  • Each individual state determines coverage
No Health Insurance
  • Organogenesis offers a Patient Assistance Program (PAP) to help patients access our products
  • To qualify, patients must meet certain financial criteria

Medicare

Medicare contracts with regional insurance companies to serve as an administrative function, including handling claims. These contractors establish coverage, process claims, and make payments for a particular geographic area of the country.

These contractors were once known as fiscal intermediaries (FIs) and carriers. Now Medicare Administrative Contractors (MACs) have replaced FIs and Carriers.

Current Medicare Contractors

  • CGS
  • FCSO (First Coast Service Options)
  • NGS (National Government Services)
  • Novitas
  • Noridian
  • Palmetto
  • WPS (Wisconsin Physicians Service)

Individual contractors can establish and publish coverage in an LCD, which stands for "local coverage determination". LCDs establish coverage, or non coverage, for products, procedures, and other medical interventions. LCDs typically include the following sections: Indications, Limitations, Documentation Requirements and Coding.

Organogenesis can help Customers with understanding the Medicare coverage for its Wound Care Portfolio

  • LCD summaries for general wound care
  • LCD summaries for our products
  • LCD specific model documentation forms
  • LCD specific sample claim forms
    • Physician's Office (1500)
    • Hospital Outpatient (UB-04)

Step 2 | Coding for accuracy and efficiency

Coding Details for the Organogenesis Advanced Wound Care Portfolio

PuraPly AM and PuraPly Affinity NuShield Apligraf Dermagraft HCPCS Product Codes Procedure Codes (CPT) Place of Service (POS) Codes

Step 3 | Securing Payment

A | Medicare

Product Payment - Physician

The Medicare payment rate for our Advanced Wound Care products is calculated based on Average Sales Price (ASP) and is paid per sq cm. The Medicare payment rates for our product codes are updated quarterly based on reported ASP and are not geographically adjusted.

Product Payment - Hospitals and ASCs

Medicare instituted bundled payments in the hospital outpatient and ASC setting for skin substitutes in 2014. Our Advanced Wound Care products are assigned to the high cost skin substitute product group. The bundle payment rate is updated annually and geographically adjusted.

Pass-through Payment

Current Medicare rates are based on claims adjudicated two years prior. Therefore new product's costs are not included in the prior claims on which current payments are based. In order to foster innovative medical devices, drugs and biologicals, Medicare created pass-through payment to include these new innovative medical devices in the current Medicare rate. Medicare for a limited amount of time (typically 2-3 years) will reimburse on top of a facility fee, a "pass-through payment" for the medical device, drug or biological. This helps a facility give its Medicare patients access to novel therapies without increasing the hospital's costs or overall spending.

Procedure Payment - All products

The Medicare payment rates for procedures are updated annually and are geographically adjusted. The geographical adjustments account for factors such as cost of living for difference areas of the country.
The geographical adjustments account for both CPT codes for physicians and APC codes for Hospital Outpatient Departments..

B | Commercial Insurers

Commercial insurers contract with each participating provider and model their contracted allowables on Medicare payment rates. Some providers have specific negotiated allowables. Commercial insurers determine the contracted allowable by region and by provider. Providers should check with their commercial insurer to determine their contracted allowable. Contracts with insurance companies are confidential, so it's the Provider's responsibility to understand the fee schedule by insurance company by insurance plan.

C | Medicaid

Medicaid payment rates and covered provider types are determined by each State's Medicaid program. Some States may bundle payment for product and procedure, so it is always recommended to check with each State program for payment rates, coverage and benefits. Some Medicaid patients may have a spend down, which they will have to meet before Medicaid will pay for services. Organogenesis provides assistance to check the benefits through the BV/PA Program.

You can reach out to an Organogenesis representative today at 1-888-432-5232 (option #3) for answers to any questions regarding reimbursement.

Or write to us at