Skip to main content

Biologics Coding

Reimbursement Policy:

Biologics Coding (Synthetic Skin Grafts/Substitutes)

Effective Date:

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).
  • COB


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.

Policy 152_v5.0_11282022