Reimbursement guide for Medicare, Private Insurance and Medicaid
The cornerstone of wound care for diabetic foot ulcers is aggressive debridement, infection control, off-loading the offending pressure area, and restoring circulation to the lower extremity when necessary.

For complete information regarding coding information, please click on the following link (Code it Wright). The information below provides additional information on the Place of Service (POS) Guidance and billing requirements for medical facilities, physician providers and their billing staff.

• Physician Office
• Hospital Outpatient Department (HOPD)
• Hospital Inpatient
• Ambulatory Surgical Center (ASC)

GRAFTJACKET® Regenerative Tissue Matrix is represented by HCPCS code J7344. Medicare reimburses separately for this product in the physician office in some states and not in others. Please note that this code is a "per sq cm" code; the correct number of units must be reported on the claim.

Private Insurance
Private payor coverage and payment vary from plan-to-plan and state-to-state. Precertification or prior authorization for the treatment will confirm coverage, billing codes, and likely payment amount(s) during this process. Confirmation of the specific coverage and coding requirements for the patient’s plan may be obtained directly by the provider.

Medicaid
Medicaid coverage, coding, and payment policies for GRAFTJACKET® Matrix and the GRAFTJACKET® XPRESS Scaffold product will vary by setting and by state. Confirmation of the specific coverage and coding requirements for the patient’s plan may be obtained directly by the provider.

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Hospital Outpatient Department (HOPD)
Medicare
GRAFTJACKET® Regenerative Tissue Matrix is represented by HCPCS code J7344. Medicare reimburses separately for this product in the hospital outpatient setting in some states and not in others. Please note that this code is a "per sq cm" code; the correct number of units must be reported on the claim.

The CPT® codes (15000, 15300, 15320, 15330, 15335 & 15175) are also possible reported codes. It is the provider's responsibility to select codes that accurately reflect the services provided.

Private Insurance
Private payor coverage and payment varies. Pre-certification or prior authorization for the treatment will confirm coverage, billing codes, and likely payment amount(s) during this process. Your specific facility should be able to confirm the coverage and coding requirements, co-pay amounts, and billing units for your individual patients.

Medicaid
Medicaid coverage, coding, and payment policies for GRAFTJACKET® Matrix and the XPRESS Scaffold product will vary by setting and by state. The facility should be able to confirm the specific coverage and coding requirements for your state.

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Hospital Inpatient
Medicare
In the hospital inpatient setting, Medicare reimburses the hospital for the services associated with the patient’s stay under the MS-DRG system. In general, drugs and biologics provided to inpatients are considered a part of the MS-DRG. Medicare pays separately for only a limited type of drugs and biologics administered in an inpatient setting. The GRAFTJACKET® Matrix and the XPRESS Scaffold products are not paid separately in the inpatient setting.

Private Insurance
Private insurers usually reimburse based on contracted rates or per diem rates. In some cases, hospitals may negotiate separate carve-out payments for certain high-cost drugs and biologicals. Please contact the individual insurer for precertification assistance for the inpatient stay.

Medicaid
Medicaid coverage, coding, and payment policies for GRAFTJACKET® Matrix and the XPRESS Scaffold product will vary by setting and by state. The facility should be able to confirm the specific coverage and coding requirements for your state.

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Ambulatory Surgical Center (ASC)
Medicare
GRAFTJACKET® Regenerative Tissue Matrix is represented by HCPCS code J7344. Medicare reimburses separately for this product in the ASC setting in some states and not in others. Please note that this code is a "per sq cm" code; the correct number of units must be reported on the claim.

The CPT® codes (15000, 15300, 15320, 15330, 15335 & 15175) are also possible reported codes. It is the provider's responsibility to select codes that accurately reflect the services provided.

Private Insurance
Freestanding surgery centers may have contracts with private insurers. Such a facility may obtain payment for the procedure and/or product based on its contract with a particular payor. Your specific facility should be able to confirm the coverage and coding requirements, co-pay amounts, and billing units for your individual patients.

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