Here’s a new and surprising reason for denial of Medicare payment by Novitas Solutions for amniotic tissue applied to a chronic ulcer. The reason given that the products, “…are for infants and children.” I am providing 2 screen shots from the Novitas Solutions denial letter with the brand name of the product and Q code redacted. It seems likely that this mistaken interpretation is the result of a typographical or grammatical error in which the words “are for” were substituted for the word “of.” (See more information below)
It is important to know that CPT 15273 is not limited to infants or children.
The official descriptor is:
“Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; or 1% of total body area of infants and children (first 100 sq cm or 1% of body area).”
Key points to understand:
- No age restriction is stated in the code descriptor.
- The phrase “or 1% of total body area of infants and children” introduces an additional measurement method for pediatric patients; it does not confine the entire code to pediatric use.
- In practice, Medicare and AMA guidance treat 15273 as applicable to adults, with the 1% total body surface area (TBSA) clause being applicable only when the patient is an infant/child and thus when TBSA is the more appropriate metric.
In other words, the “1%” statement expands the code to also accommodate infants/children, rather than limiting it to them.
However, due to this error, the auditor has misinterpreted the code and thus denied the claim for a specific amniotic tissue used on a Medicare beneficiary (a person who is obviously NOT an infant) for a chronic ulcer. I am curious if any of your followers have seen this before.
Regards,
Michael
Michael J. Crouch, CPC, CPMA, CHT-ADMIN
michaelcrouch@cplushealthcareconsulting.com
Sources for this interpretation:
- AMA CPT Professional Edition (current year): official descriptor for 15273 (no age limitation; dual measurement standard).
- AAPC CPT code lookup and coding guidance: describes 15273 in terms of wound size and TBSA, without restricting it to pediatric patients.
- CMS Physician Fee Schedule / HCPCS crosswalks: list 15273 without an age‑based limitation and allow its use for adult beneficiaries.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
