Biologics Coding (Synthetic Skin Grafts/Substitutes)
April 3, 2023
Provide guidelines for the appropriate billing of Synthetic Skin Grafts/Substitutes services using surgical revenue code (636). This policy applies to institutional providers.
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
Horizon BCBSNJ shall consider Synthetic Skin Grafts/Substitutes (Biologics) for reimbursement only when submitted with revenue code 636. Synthetic Skin Grafts/Substitute services submitted using any other revenue code shall not be considered eligible for reimbursement.
This policy is consistent with industry standard coding and each year CMS publishes a list of Synthetic Skin Grafts/Substitutes that states that these items should be billed as Biologics under Revenue Code 636.
This policy is “date-of-service driven” and these guidelines will only be applied to claims with a date of service on or after April 3, 2023.
Horizon BCBSNJ shall consider facility claims for Synthetic Skin Grafts/Substitutes (biologics) for reimbursement when submitted with revenue code 636.
Horizon BCBSNJ will deny facility claims submitted for Synthetic Skin Grafts/Substitutes (biologics) with a revenue code other than 636. The facility is responsible for resubmitting with the appropriate coding in accordance with industry standard guidelines.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
11/22/2021: Policy approved
10/17/2022: Policy implementation delayed until further notice. Policy guidelines to be available at the time of our future announcement.
11/28/2022: Policy name updated. Effective date changed to April 3, 2023. Scope updated to include all products except COB and secondary claims.