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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAmeriHealth Caritas LA Skin Coverage | OpenPayer
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    CurrentAmeriHealth Caritas LouisianaPolicy RPC.0073.2100

    Implants, Devices, Skin Substitutes

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    This reimbursement policy governs outpatient claims for implants, devices, skin substitutes, and associated procedures submitted on CMS-1500 or UB-04 forms or their electronic equivalents. It establishes same-date billing and reimbursement requirements and may require prior authorization for certain skin substitute applications.

    Policy Summary
    PayerAmeriHealth Caritas Louisiana
    PolicyImplants, Devices, Skin Substitutes
    Policy CodePolicy RPC.0073.2100
    Change TypeSkin Substitute section added
    Effective DateN/A
    Last ReviewFeb 1, 2025
    Next Review DateJan 1, 2026
    Key ActionBill skin substitute application claims with the corresponding supply code on the same date of service.
    SourceLink
    POLICY UPDATE CHANGES

    A Skin Substitute section was added during the January 2025 annual review.

    The policy preamble was revised in April 2025.

    Formatting and syntax were updated in June 2025.

    2Outpatient claim form types addressed
    C5271-C5278Low-cost application codes requiring supply codes
    Q4100-Q4310Low-cost supply-code range

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    A2001-A2010High-cost supply-code range
    H, UStatus indicators requiring qualifying procedures

    Implants, Devices, and Skin Substitute Requirements

    Implants and devices

    Covered for reimbursement when all of the following billing requirements are met:

    ALL of the following

    • Device or implant billing

      • ALL of the following

        • The device- or implant-dependent procedure and the corresponding device or implant are billed on the same date of service.

          A procedure submitted without the associated device or implant will not be reimbursed.

    • When status indicator H or U applies

      • ALL of the following

        • The claim includes a procedure code with OCE status indicator J1, S, or T on the same claim and same date of service as the service with status indicator H or U.
      • If the claim includes status indicator H or U without a qualifying J1, S, or T procedure code on the same claim and date of service, the H or U claim is denied.

    Skin substitutes

    Covered for reimbursement when all applicable requirements are met:

    ALL of the following

    • Application category

      • Low-cost skin substitute

        • When application code C5271-C5278 is billed, the claim includes a low-cost skin substitute supply code Q4100-Q4310.

          Prior authorization may be required for application of low-cost skin substitute grafts.

      • High-cost skin substitute

        • When application code 15271-15278 is billed, the claim includes the applicable high-cost skin substitute supply code A2001-A2010.
    • The applicable low-cost or high-cost skin substitute supply code is paid on the same date of service as the related application code.

    Code Sets and Billing Relationships

    Low-cost skin substitute application codesHCPCS
    C5271-C5278Application of low-cost skin substitute graft
    Low-cost skin substitute supply codesHCPCS
    Q4100-Q4310Supply codes for low-cost skin substitutes
    High-cost skin substitute application codesCPT
    15271-15278Application of high-cost skin substitute graft
    High-cost skin substitute supply codesHCPCS
    A2001-A2010Supply codes for high-cost skin substitutes
    Device and brachytherapy status indicatorsRevenueNot Covered
    HPass-through device category; separate cost-based pass-through payment and not subject to copayment
    UBrachytherapy sources
    Qualifying OCE procedure status indicatorsRevenueCovered
    J1Hospital Part B services paid through a comprehensive APC
    SProcedure or service not subject to multiple-procedure discounting
    TProcedure or service subject to multiple-procedure discounting
    Same claim and date-of-service requirement
    Applicable servicesH or U services
    Required pairingA procedure code with OCE status indicator J1, S, or T
    Claim and date requirementThe qualifying procedure code must be billed on the same claim and same date of service
    Denial consequenceH or U claims will be denied when billed without the required J1, S, or T procedure code
    Same-date supply-code payment requirement
    Applicable claimsLow-cost or high-cost skin substitute application claims

    Required Billing and Authorization Actions

    Prior Authorization

    Prior Authorization for Low-Cost Skin Substitutes

    Obtain prior authorization when required by the plan before applying a low-cost skin substitute graft.

    • Low-cost skin substitute graft application codes: C5271-C5278
    Billing Rule

    Pair Device and Brachytherapy Status Indicators

    Bill a qualifying procedure on the same claim and date of service when billing a pass-through device or brachytherapy source. Claims with status indicator H or U will be denied without a procedure code with OCE status indicator J1, S, or T.

    • H: pass-through device category
    • U: brachytherapy source

    Status Indicator Definitions

    H status indicator
    Status indicatorH
    DefinitionPass-through device category with separate cost-based pass-through payment and no copayment
    J1 status indicator
    Status indicatorJ1
    DefinitionHospital Part B services paid through a comprehensive APC
    S status indicator
    Status indicatorS
    Policy Summary
    PayerAmeriHealth Caritas Louisiana
    PolicyImplants, Devices, Skin Substitutes
    Policy CodePolicy RPC.0073.2100
    Change TypeSkin Substitute section added
    Effective DateN/A
    Last ReviewFeb 1, 2025
    Next Review DateJan 1, 2026
    Key ActionBill skin substitute application claims with the corresponding supply code on the same date of service.
    SourceLink
    On This Page
    Implants, Devices, and Skin Substitute RequirementsCode Sets and Billing RelationshipsRequired Billing and Authorization ActionsStatus Indicator Definitions

    If the supply code is not paid or is denied, the related application code is also denied.

    Required supply codeThe applicable low-cost or high-cost skin substitute supply code
    Payment timingThe supply code must be paid on the same date of service as the related application code
    Denial consequenceIf the supply code is not paid or is denied, the related application code will also be denied
  1. Qualifying procedure status indicators: J1, S, or T
    2. Denial Risk

    Bill Implants and Devices With Dependent Procedures

    Bill the corresponding device or implant on the same date of service as any procedure that is device- or implant-dependent. Procedures submitted without the associated device or implant will not be reimbursed.

    • Include the corresponding device or implant with the dependent procedure on the same claim and date of service.
    Billing Rule

    Include Low-Cost Skin Substitute Supplies

    Include the corresponding low-cost skin substitute supply code with every low-cost graft application claim.

    • Low-cost application codes: C5271-C5278
    • Low-cost skin substitute supply codes: Q4100-Q4310
    Billing Rule

    Include High-Cost Skin Substitute Supplies

    Include the corresponding high-cost skin substitute supply code for reimbursement of high-cost skin substitute graft application claims.

    • High-cost application codes: 15271-15278
    • High-cost skin substitute supply codes: A2001-A2010
    Denial Risk

    Supply Payment Required for Application Reimbursement

    Ensure the applicable low-cost or high-cost skin substitute supply code is paid on the same date of service as the application. If the supply code is not paid or is denied for that date, the related application code will also be denied.

    • Verify payment of the supply code on the same date of service as the application.
    • A denied or unpaid supply code may result in denial of the application code.
    DefinitionProcedure or service not subject to multiple-procedure discounting
    T status indicator
    Status indicatorT
    DefinitionProcedure or service subject to multiple-procedure discounting
    U status indicator
    Status indicatorU
    DefinitionBrachytherapy sources