Pricing for Skin Substitutes and Wound Care Products

Published 02/15/2021

Some skin substitute and wound care products are on the Average Sales Pricing (ASP) Medicare Part B drug pricing file or the Not Otherwise Classified (NOC) pricing file. When they are not, Palmetto GBA must price them manually. We use the published wholesale acquisition cost (WAC) or invoices to price these codes.

When an invoice is required, it must clearly identify the product and the acquisition cost. Some of these products are available in several different shapes and sizes. For example, the same skin substitute product may be available in 1x1 cm, 1x2 cm, 4x8 cm and 8x8 cm sources. It must be clear on the invoice what version of the product was purchased so we can use the invoice to properly price your claim. Unclear or incomplete invoices could result in claim rejections.

Most skin substitute and wound care product codes are brand specific. Q4100 should be used to bill for not otherwise specified skin substitute products. Please be sure you use the most appropriate code when billing for skin substitute and wound care products to avoid claim rejections.

More information on payment allowances and methodologies for the drug and biological products that are not included in the ASP Medicare Part B drug pricing file or the NOC pricing file can be found in IOM
Publication 100-04 Chapter 17 Drugs and Biologicals § 20.1.3 Exceptions to the Average Sales Pricing (ASP) Payment Methodology (PDF, 493 KB).

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