2020 REIMBURSEMENT GUIDE for Hernia Repair Procedures Using Ovitex® Reinforced Tissue Matrix

2020 REIMBURSEMENT GUIDE for Hernia Repair Procedures Using OviTex® Reinforced Tissue Matrix

TABLE OF CONTENTS

Component Separation Technique and Hiatal Hernia Repair...... 08 Hernia Repair...... 03

Laparoscopic Stoma Procedures...... 11 Repair – Hernia...... 06 ICD-10 HCPCS MOD ICD-10 HCPCS MOD CODES CODES CODES $ CODES CODES CODES $

ICD-10ICD-10 HCPCSHCPCS MODMOD CODESCODES CODESCODES CODESCODES $$ ICD-10 HCPCS MOD ICD-10 HCPCS MOD CODES CODES HCPCSCODES Level II Codes$ ...... 13 CODES ICD-10-PCSCODES CodesCODES...... 14$

Medicare Hospital ICD-10 HCPCS MOD ICD-10 HCPCS MOD Inpatient Payment CODES CODES CODES CODESModifiers...... CODES CODES13 $ $ (MS-DRG)...... 16 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix

OviTex Reinforced Tissue Matrices are implants purposefully designed for hernia and abdominal wall reconstruction that combine biologic and synthetic materials in a unique embroidered construction. OviTex products are intended for use as a surgical mesh to reinforce and/or repair soft tissue where weakness exists. Indications for use include the repair of hernias and/or abdominal wall defects that require the use of reinforcing or bridging material to obtain the desired surgical outcome. OviTex products are available in various shapes, sizes, and configurations to suit surgeon preference and the complexity of the soft tissue repair. The device may be trimmed to a desired shape to further accommodate an individual patient’s requirements.

OviTex is compatible with all surgical techniques: open, laparoscopic, and robotic approaches.

PHYSICIAN, HOSPITAL OUTPATIENT, AND ASC CODING AND MEDICARE REIMBURSEMENT

The following table provides 2020 national average Medicare Physician Fee Schedule (MPFS), Hospital Outpatient

Ambulatory Payment Classifications (APC), and Ambulatory Surgery Center (ASC) payment rates for the CPT codes relating to hernia and abdominal repair procedures identified in this guide. Payments will vary by geographic locality.

CPT® 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

2 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Component Separation Technique

15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk (Note: Physicians report bilateral $1,573.87 5055 $2,977.29 $1,504.38 procedures with modifier -50 or with RT & LT)

Hernia Repair

+11008** Removal of mesh in abdominal wall for infection Excluded From Payment $288.36 — Inpatient Only (List separately in addition to in ASCs for CY 2020 code for primary procedure)

49500 Repair initial inguinal hernia, age 6 months to younger $432.71 5341 $3,109.34 $1,377.21 than 5 years, with or without hydrocelectomy; reducible

49501 Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without $636.26 5341 $3,109.34 $1,377.21 hydrocelectomy; incarcerated or strangulated

49505 Repair initial inguinal hernia, age 5 years or older; $547.48 5341 $3,109.34 $1,377.21 reducible

**As with most add-on codes, this code is approved to be used with only certain primary procedures. Please refer to your CPT manual for approved primary procedures.

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 3

ICD-10 HCPCS ICD-10MOD HCPCS ICD-10ICD-10MOD HCPCSHCPCS MODMOD CODES CODES CODESCODES CODES$ CODESCODES CODES$CODES CODESCODES $$ 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Hernia Repair (continued)

49507 Repair initial inguinal hernia, age 5 years or older; $616.05 5341 $3,109.34 $1,377.21 incarcerated or strangulated

49520 Repair recurrent inguinal $664.05 5341 $3,109.34 $1,377.21 hernia, any age; reducible

49521 Repair recurrent inguinal hernia, any age; incarcerated or $753.91 5341 $3,109.34 $1,377.21 strangulated

49525 Repair inguinal hernia, $603.06 5341 $3,109.34 $1,377.21 sliding, any age

49540 Repair lumbar hernia $708.80 5361 $4,833.71 $2,194.07

49560 Repair initial incisional or $775.93 5341 $3,109.34 $1,377.21 ventral hernia; reducible

49561 Repair initial incisional or ventral hernia; incarcerated or $977.67 5341 $3,109.34 $1,377.21 strangulated

49565 Repair recurrent incisional $807.69 5361 $4,833.71 $2,194.07 or ventral hernia; reducible

49566 Repair recurrent incisional or ventral hernia; incarcerated or $986.69 5361 $4,833.71 $2,194.07 strangulated

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 4

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Hernia Repair (continued) +49568** Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh Packaged Service/Item; Packaged Service/Item; for closure of debridement for $281.50 — No Separate No Separate necrotizing soft tissue infection Payment Made Payment Made (List separately in addition to code for the incisional or ventral hernia repair)

49570 Repair epigastric hernia (eg, preperitoneal fat); reducible $437.41 5341 $3,109.34 $1,377.21 (separate procedure)

49572 Repair epigastric hernia (eg, preperitoneal fat); $543.51 5341 $3,109.34 $1,377.21 incarcerated or strangulated

49580 Repair umbilical hernia, $349.71 5341 $3,109.34 $1,377.21 younger than age 5 years; reducible

49582 Repair umbilical hernia, younger than age 5 years; $507.06 5341 $3,109.34 $1,377.21 incarcerated or strangulated

49585 Repair umbilical hernia, $467.72 5341 $3,109.34 $1,377.21 age 5 years or older; reducible

49587 Repair umbilical hernia, age 5 years or older; incarcerated $500.20 5341 $3,109.34 $1,377.21 or strangulated

49590 Repair spigelian hernia $601.97 5341 $3,109.34 $1,377.21

**As with most add-on codes, this code is approved to be used with only certain primary procedures. Please refer to your CPT manual for approved primary procedures.

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 5

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Laparoscopic Repair – Hernia

49650 Laparoscopy, surgical; $451.12 5361 $4,833.71 $2,194.07 repair initial inguinal hernia

49651 Laparoscopy, surgical; $587.54 5361 $4,833.71 $2,194.07 repair recurrent inguinal hernia

49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia $782.78 5361 $4,833.71 $2,194.07 (includes mesh insertion, when performed); reducible

49653 Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia $977.31 5361 $4,833.71 $2,194.07 (includes mesh insertion, when performed); incarcerated or strangulated

49654 Laparoscopy, surgical, repair, incisional hernia (includes $888.89 5362 $8,413.11 $3,588.58 mesh insertion, when performed); reducible

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 6

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Laparoscopic Repair – Hernia (continued)

49655 Laparoscopy, surgical, repair, incisional hernia (includes $1,087.02 5362 $8,413.11 $3,588.58 mesh insertion, when performed); incarcerated or strangulated

49656 Laparoscopy, surgical, repair, recurrent incisional hernia $964.31 5362 $8,413.11 $3,588.58 (includes mesh insertion, when performed); reducible

49657 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when $1,390.17 5362 $8,413.11 $3,588.58 performed); incarcerated or strangulated

49659* Unlisted lap procedure, Excluded from Payment hernioplasty, herniorrhaphy, Contractor Priced 5361 $4,833.71 in ASCs for CY 2020 herniotomy

44346 Revision of colostomy; with Excluded from Payment repair of paracolostomy hernia $1,240.04 -- Inpatient Only in ASCs for CY 2020 (separate procedure)

* CPT 49659 Physician status code is “C.” C = Contractor priced. Medicare Administrative Contractors will establish payment amounts for these services, generally on an individual case basis, following review of documentation, such as an operative report.

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 7

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Hiatal Hernia Repair

39540 Repair, diaphragmatic Excluded from Payment hernia (other than neonatal), $913.43 — Inpatient Only in ASCs for CY 2020 traumatic; acute

39541 Repair, diaphragmatic Excluded from Payment hernia (other than neonatal), $986.33 — Inpatient Only in ASCs for CY 2020 traumatic; chronic

43280 Laparoscopy, surgical, Excluded from Payment esophagogastric fundoplasty $1,136.10 5362 $8,413.11 in ASCs for CY 2020 (eg, Nissen, Toupet procedures)

43281 Laparoscopy, surgical, repair of paraesophageal hernia, Excluded from Payment includes fundoplasty, when $1,624.75 5362 $8,413.11 in ASCs for CY 2020 performed; without implantation of mesh

43282 Laparoscopy, surgical, repair of paraesophageal hernia, Excluded from Payment includes fundoplasty, when $1,826.86 5362 $8,413.11 in ASCs for CY 2020 performed; with implantation of mesh

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 8

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Hiatal Hernia Repair (continued)

43283 Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty Excluded From Payment $166.01 -- Inpatient Only or wedge gastroplasty) (List in ASCs for CY 2020 separately in addition to code for primary procedure)

43332 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, Excluded From Payment $1,216.58 -- Inpatient Only except neonatal; without in ASCs for CY 2020 implantation of mesh or other prosthesis

43333 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, Excluded From Payment $1,328.82 -- Inpatient Only except neonatal; with in ASCs for CY 2020 implantation of mesh or other prosthesis

43334 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, Excluded From Payment $1,307.17 -- Inpatient Only except neonatal; without in ASCs for CY 2020 implantation of mesh or other prosthesis

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 9

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Hiatal Hernia Repair (continued)

43335 Repair, paraesophageal hiatal hernia (including Excluded from Payment fundoplication), via thoracotomy, $1,398.47 — Inpatient Only in ASCs for CY 2020 except neonatal; with implantation of mesh or other prosthesis

43336 Repair, paraesophageal hiatal hernia (including fundoplication), via Excludedfrom Payment $1,516.85 — Inpatient Only thoracoabdominal incision, except in ASCs for CY 2020 neonatal; without implantation of mesh or other prosthesis

43337 Repair, paraesophageal hiatal hernia (including fundoplication), via Excluded from Payment $1,618.62 — Inpatient Only thoracoabdominal incision, except in ASCs for CY 2020 neonatal; with implantation of mesh or other prosthesis

+0437T* Implantation of non- biologic or synthetic implant Packaged Service/Item; Packaged Service/Item; (eg, polypropylene) for fascial Contractor Priced — No Separate No Separate reinforcement of the abdominal Payment Made Payment Made wall (List separately in addition to code for primary procedure)**

**As with most add-on codes, this code is approved to be used with only certain primary procedures. Please refer to your CPT manual for approved primary procedures. * CPT 0437T Physician status code is “C.” C = Contractor priced. Medicare Administrative Contractors will establish payment amounts for these services, generally on an individual case basis, following review of documentation, such as an operative report.

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 10

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Stoma Procedures

44141 Colectomy, partial; with Excluded from Payment $1,914.19 — Inpatient Only skin level cecostomy or colostomy in ASCs for CY 2020

44143 Colectomy, partial; with end colostomy and closure of Excluded from Payment $1,747.10 — Inpatient Only distal segment (Hartmann type in ASCs for CY 2020 procedure)

44144 Colectomy, partial; with resection, with colostomy Excluded from Payment $1,856.09 — Inpatient Only or ileostomy and creation of in ASCs for CY 2020 mucofistula

44312 Revision of ileostomy; simple (release of superficial scar) $621.46 5055 $2,977.29 $1,504.38 (Separate procedure)

44206 Laparoscopy, surgical; colectomy, partial, with end Excluded from Payment colostomy and closure of distal $1,832.99 — Inpatient Only in ASCs for CY 2020 segment (Hartmann type procedure)

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 11

CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures

Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv

Stoma Procedures (continued)

44314 Revision of ileostomy; Excluded from Payment complicated (reconstruction $1,053.09 — Inpatient Only in ASCs for CY 2020 in-depth) (Separate procedure)

44320 Colostomy or skin level Excluded from Payment $1,259.89 — Inpatient Only cecostomy in ASCs for CY 2020

44340 Revision of colostomy; simple (release of superficial scar) $651.78 5055 $2,977.29 $1,504.38 (Separate procedure)

44345 Revision of colostomy; Excluded from Payment complicated [reconstruction $1,100.01 — Inpatient Only in ASCs for CY 2020 in-depth] (Separate procedure)

44346 Revision of colostomy; Excluded From Payment with repair of paracolostomy $1,240.04 — Inpatient Only in ASCs for CY 2020 hernia (Separate procedure)

44605 Suture of large intestine; (colorrhaphy) for perforated ulcer, Excluded from Payment diverticulum, wound, injury, $1,368.88 — Inpatient Only in ASCs for CY 2020 or rupture (single or multiple perforations); with colostomy

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 12

HCPCS Level II Codesv The following is the HCPCS Level II code that relates to hernia repair procedures using OviTex:

Codes Description

Mesh (Implantable) – (ie, Davol Synthetic Mesh, AlloMax™ Surgical Graft, Phasix™ Mesh, Phasix™ ST Mesh, C1781 XenMatrix™ Surgical Graft and XenMatrix™ AB Surgical Graft)

Modifiers Modifiers explain that a procedure or service was changed without changing the definition of the CPT code set. Here are some common modifiers related to hernia repair procedures.

Modifier Description

50 Bilateral Procedure

51 Multiple Procedures

59 Distinct Procedural Service

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 13

ICD-10-PCS Codesvi ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes were implemented October 1, 2015. It is the physician’s responsibility to select the codes that appropriately represent the service performed, as well as to report the ICD-10-CM code based on the findings or the pre- service signs, symptoms, or conditions of the individual patient. The following are examples of series descriptors of ICD-10-PCS procedure codes that relate to hernia repair procedures (not an all inclusive list).

ICD-10-PCS Codes Series Descriptors

0D8 Division/Gastrointestinal System

0DB Excision/Gastrointestinal System

0DJ Inspection/Gastrointestinal System

0DN Release/Gastrointestinal System

0DQ Repair/Gastrointestinal System

0DT Resection/Gastrointestinal System

0DU Supplement/Gastrointestinal System

0DV Restriction/Gastrointestinal System

0F5 Destruction/Hepatobiliary System and Pancreas

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 14

ICD-10-PCS Codes Series Descriptors

0FB Excision/Hepatobiliary System and Pancreas

0FJ Inspection/Hepatobiliary System and Pancreas

0FN Release/Hepatobiliary System and Pancreas

0FT Resection/Hepatobiliary System and Pancreas

0W2 Change/Anatomical Regions, General

0WJ Inspection/Anatomical Regions, General

0WQ Repair/Anatomical Regions, General

0WU Supplement/Anatomical Regions, General

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 15

Medicare Hospital Inpatient Payment (MS-DRG) Payment for inpatient hospital services is based on a classification system determined by patient diagnosis known as Medicare Severity – Diagnosis Related Groups (MS-DRGs). The MS-DRG assignment is based on the combination of ICD-10-CM and ICD-10-PCS codes reported. Only one MS-DRG is assigned to a patient for a particular hospital admission. Therefore, one payment is made per patient and that payment is based upon the MS-DRG assignment. The following MS-DRGs may be appropriate for hernia repair procedures (not an all-inclusive list).

MS-DRGs and 2020 National Average Medicare Rates for Hernia and Abdominal Wall Repair Procedures

National Average MS-DRGvii Description MS-DRG Ratevii

Hernia Repair

350 Inguinal and Femoral Hernia Procedures With MCC* $15,267

351 Inguinal and Femoral Hernia Procedures With CC** $9,127

352 Inguinal and Femoral Hernia Procedures Without CC/MCC $6,740

353 Hernia Procedures Except Inguinal and Femoral With MCC $18,570

354 Hernia Procedures Except Inguinal and Femoral With CC $10,779

355 Hernia Procedures Except Inguinal and Femoral Without CC/MCC $8,590

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 16

National Average MS-DRGvii Description MS-DRG Ratevii

Parastomal

347 Anal and Stomal Procedures With MCC $16,501

348 Anal and Stomal Procedures With CC $8,821

349 Anal and Stomal Procedures Without CC/MCC $6,139

Hiatal

326 Stomach, Esophageal, and Duodenal Procedures With MCC $32,988

327 Stomach, Esophageal, and Duodenal Procedures With CC $16,104

328 Stomach, Esophageal, and Duodenal Procedures Without CC/MCC $9,858

Abdominal Wall

335 Peritoneal Adhesiolysis With MCC $25,318

336 Peritoneal Adhesiolysis With CC $14,184

337 Peritoneal Adhesiolysis Without CC/MCC $10,263

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 17

National Average MS-DRGvii Description MS-DRG Ratevii

Small Bowel and Large Bowel/Intestinal Procedures

329 Major Small & Large Bowel Procedures With MCC $30,714

330 Major Small & Large Bowel Procedures With CC $15,815

331 Major Small & Large Bowel Procedures Without CC/MCC $10,573

332 Rectal Resection With MCC $21,856

333 Rectal Resection With CC $14,165

334 Rectal Resection Without CC/MCC $9,641

347 Anal & Stomal Procedures With MCC $16,501

348 Anal & Stomal Procedures With CC $8,821

349 Anal & Stomal Procedures Without CC/MCC $6,139

MCC – Major complications and/or comorbidity CC – Complications and/or comorbidity

ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 18

Disclaimer Information presented in this document is current as of February 2020. Any subsequent changes which may occur in coding, coverage and payment are not reflected herein. TELA Bio does not guarantee that use of the codes noted above will ensure coverage and/or payment. It is always the provider’s responsibility to determine and submit appropriate codes, charges, modifiers and bills for the services that were rendered. This information is provided as of the date listed above, and all coding and reimbursement information is subject to change without notice. Payers or their local branches may have their own coding and reimbursement requirements and policies. Before filing any claims, providers should verify current requirements and policies with the payer. Do not use OviTex in patients known to be sensitive to materials of ovine (sheep) origin. For additional important safety information, please see the OviTex Reinforced BioScaffold Instructions for Use. For Prescription Use Only. TELA Bio, Inc. owns or has applied for the following trademarks or service marks: TELA Bio, OviTex. All other trademarks are trademarks of their respective owners or holders. MK-EM-0031 rev01 (May 2020)

References i. 2020 AMA CPT Professional ii. Medicare Program; revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2020; Final Rule with Comment, Federal Register (84 Fed Reg. No. 221) November 15, 2019, 42 CFR Parts 403, 409, 410, 411, 414, 415, 425, 489 and 498; Addenda B iii. Medicare Program; Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction Notice Federal Register (85 Fed Reg. No. 2) January 3, 2020 42 CFR Parts 405, 410, 412,414, 416, 419 and 486 [CMS-1717-CN Addenda B] iv. Medicare Program; Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Correction Notice Federal Register (85 Fed Reg. No. 2) January 3, 2020 42 CFR Parts 405, 410, 412,414, 416, 419 and 486 [CMS-1717-CN Addenda AA, EE] v 2020 HCPCS Level II Professional Edition AMA vi. 2020 ICD-10-PCS Professional The complete official code set Optum 360 2019 vii. 2020 DRG Expert Volume 1 Optum 360, LLC Medicare Program; Hospital inpatient Prospective Payment System for Acute Care Hospitals and the Long-Term Care Hospitals Prospective Payment System and Policy Changes and Fiscal Year 2020 Rates; Final Rule Correction Notice 2, October 8, 2019, 42 CFR Parts 412, 413 and 495; Table 1A-1E, Table 5

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