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Biologics Correct Coding

Reimbursement Policy:

Biologics Correct Coding

Effective Date:

November 1, 2022

Purpose:

Provide guidelines for the correct billing of Synthetic Skin Grafts/Substitutes services using surgical revenue code (636). This policy applies to institutional providers.

Scope:

All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • FEP, SHBP, ITS

Policy:

Horizon BCBSNJ shall consider for reimbursement Synthetic Skin Grafts/Substitutes (Biologics) 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 correct coding and each year CMS publishes a list of Synthetic Skin Grafts/Substitutes that states that these products should be billed as Biologics under Revenue Code 636.

Procedure:

Horizon BCBSNJ shall consider for reimbursement facility claims for Synthetic Skin Grafts/Substitutes (biologics) when submitted with revenue code 636.

Horizon BCBSNJ shall deny facility claims for Synthetic Skin Grafts/Substitutes (biologics) when these services are submitted with revenue codes other than 636.

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.

History:

11/22/2021: Policy approved

Policy 152_v3.0_11222021