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September 10, 2019

Invoice Filing Instructions for Skin Substitutes/Wound Care Products

Claims for skin substitutes or wound care products should be submitted with a Q code. The applicable codes are HCPCS codes Q4100 – Q4204External website. HCPCS code Q4100 is for not otherwise specified skin substitute.

Some of the Q codes for skin substitutes contain pricing on the ASP Drug Pricing files. If there is not an allowable listed on the CGS or CMS ASP or Not Otherwise Classified Drug Fee Schedule, include invoice information when submitting claims.

If the allowable is not listed for skin substitutes and wound care products on the CGS or CMS ASP or Not Otherwise Classified Drug Fee Schedule, please follow the instructions below:

Electronic Media Claims:

  • If the billed amount for the Q code matches the actual invoice cost, note "Actual Invoice Cost" in the Loop 2400 SV101-7, NTE Segment (line level). You are not required to submit invoice information with the claim; however, it must be available if requested.
  • If the billed amount for the Q code is greater than the actual invoice cost, include the following information in Loop 2400 SV101-7, NTE Segment (line level). If additional space is needed, Loop 2400 NTE 02 may be utilized in addition to SV101-7], using these abbreviations:
    • Des = Description/Name of product if the Q code is Q4100
    • QS = Quantity shipped (e.g., QS= 6X8 sheet X 1 = 48 sq.cm.)
    • TA = Total amount charged for quantity shipped (e.g., TA=$5,600.00)
    • DG = Amount used (e.g., DG=24 sq. cm.)
  • In lieu of submitting the invoice information, you may use the Paperwork (PWK) process and send a copy of the invoice via fax or mail. Details on the PWK Segment Process.

Paper Claims: (If you are approved to submit paper claims)

  • If the billed amount for the Q code matches the actual invoice cost, note "Actual Invoice Cost – (Please note claim line number)" in block 19. You are not required to submit invoice information with the claim; however, it must be available if requested.
  • If the billed amount for the Q code is greater than the actual invoice cost, note "Invoice Attached – (Please note claim line number)" in block 19. Include the invoice when submitting the claim.

Reference

Billing and Coding: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (A56696)

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