Superseded Local Coverage Article Billing and Coding

Billing and Coding: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities

A56696

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Contractor Information

Article Information

General Information

Article ID
A56696
Article Title
Billing and Coding: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities
Article Type
Billing and Coding
Original Effective Date
07/11/2019
Revision Effective Date
09/09/2021
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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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.

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CMS National Coverage Policy

Relevant CMS manual instructions and policies regarding bioengineered skin substitutes are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

  • CMS Internet-Only Manual (IOM), Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40.
  • CMS Internet-Only Manual (IOM). Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 270.13.
  • CMS Change Request, CR 8213; Autologous Platelet-Rich Plasma (PRP) for Chronic Non-Healing Wounds; issued June 10, 2013

Social Security Act (XVIII) Standard References:

  • Title XVIII of the Social Security Act, 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities L36690 .

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

 

Documentation Requirements

 

  1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. Medical record documentation must support the medical necessity of the services as directed in this policy.
  5. The documentation must support that the service was performed and must be included in the patient’s medical record. This information is normally found in the history and physical, office/progress notes, hospital notes, and/or procedure report.
  6. The medical record must clearly show that the criteria listed under the “Indications and Limitations of Coverage and/or Medical Necessity” sections have been met, as well as, the appropriate diagnosis and response to treatment.
  7. The documentation must support the need for CTP application and the product used.
  8. A description of the wound(s) must be documented at baseline (prior to beginning conservative treatment) relative to size, location, stage, duration, and presence of infection, in addition to type of treatment given and response.
    1. This information must be updated in the medical record throughout treatment.
    2. Wound description must also be documented pre and post treatment with the skin substitute graft being used.
    3. If obvious signs of worsening or lack of treatment response is noted, continuing treatment with the skin substitute would not be considered medically reasonable and necessary without documentation of a reasonable rationale for doing so.
  9. Documentation of smoking history, and that the patient has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation (if applicable) as well as outcome of counselling must be in the medical record.
  10. The amount of utilized and wasted skin substitute must be clearly documented in the procedure note with the following minimum information:

    • Date, time and location of ulcer treated;
    • Name of skin substitute and how product supplied;
    • Amount of product unit used;
    • Amount of product unit discarded;
    • Reason for the wastage;
    • Manufacturer’s serial/lot/batch or other unit identification number of graft material. When manufacturer does not supply unit identification, record must document such.

    Note: CGS Administrators expects that where multiple sizes of a specific product are available, the size that best fits the wound with the least amount of wastage will be utilized. Each product material is for a single-use only and is not for use on a multiple patients.


Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

It is the expectation that a specific CTP product will be used for the episode of each documented wound, and in compliance with FDA assessments and submitted guidelines for the specific product. Greater than ten (10) applications for the treatment of a single wound within a 12-week period of time, will be considered Not Reasonable and Necessary and will be subject to review.

Separately billed repeated use of the skin substitute after 12 weeks for a single wound or episode is non-covered. Alternative or additional skin substitute products used within the 12 week initial wound episode are similarly non-covered when the sum of applications of all Skin Substitutes is greater than ten (10) for a single wound.

The utilization of a CTP non-compliant with medical necessity or designated guidelines for that specific product may necessitate review or non-coverage as not medically necessary.

Labeling for most skin substitute grafts include language suggesting multiple applications; however, Medicare does not expect that every ulcer in every patient will require the maximum number of applications listed on the product label or allowed for reimbursement.

Utilization rates that exceed peer norms, identified through data analysis may prompt prepayment or post payment medical review.

Coding Information

CPT/HCPCS Codes

Group 1

(22 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
15002 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
15003 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15004 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
15005 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15040 HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ CM OR LESS
15050 PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL ULCER, TIP OF DIGIT, OR OTHER MINIMAL OPEN AREA (EXCEPT ON FACE), UP TO DEFECT SIZE 2 CM DIAMETER
15271 APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
15272 APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15273 APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
15274 APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15275 APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
15276 APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15277 APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
15278 APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
C5271 APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
C5272 APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
C5273 APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
C5274 APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
C5275 APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
C5276 APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
C5277 APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
C5278 APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; EACH ADDITIONAL 100 SQ CM WOUND SURFACE AREA, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Group 2

(64 Codes)
Group 2 Paragraph

HCPCS codes included in this list are FDA approved/ meeting necessary regulatory requirements for CTPs for chronic ulcer treatment as of publication. Each product has specific designated approved usage. This is not an all-inclusive list of CTPs as new products and HCPCS codes will be considered for coverage if meeting the regulatory requirements and criteria. Therefore, any HCPCS code that is not included in this list will not be separately reimbursed.

New codes Q4237, Q4238, and Q4239 are effective 07/01/2020

Group 2 Codes
CodeDescription
Q4100 SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED
Q4101 APLIGRAF, PER SQUARE CENTIMETER
Q4102 OASIS WOUND MATRIX, PER SQUARE CENTIMETER
Q4103 OASIS BURN MATRIX, PER SQUARE CENTIMETER
Q4104 INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARE CENTIMETER
Q4105 INTEGRA DERMAL REGENERATION TEMPLATE (DRT) OR INTEGRA OMNIGRAFT DERMAL REGENERATION MATRIX, PER SQUARE CENTIMETER
Q4106 DERMAGRAFT, PER SQUARE CENTIMETER
Q4107 GRAFTJACKET, PER SQUARE CENTIMETER
Q4108 INTEGRA MATRIX, PER SQUARE CENTIMETER
Q4110 PRIMATRIX, PER SQUARE CENTIMETER
Q4111 GAMMAGRAFT, PER SQUARE CENTIMETER
Q4115 ALLOSKIN, PER SQUARE CENTIMETER
Q4117 HYALOMATRIX, PER SQUARE CENTIMETER
Q4118 MATRISTEM MICROMATRIX, 1 MG
Q4121 THERASKIN, PER SQUARE CENTIMETER
Q4122 DERMACELL, DERMACELL AWM OR DERMACELL AWM POROUS, PER SQUARE CENTIMETER
Q4123 ALLOSKIN RT, PER SQUARE CENTIMETER
Q4124 OASIS ULTRA TRI-LAYER WOUND MATRIX, PER SQUARE CENTIMETER
Q4126 MEMODERM, DERMASPAN, TRANZGRAFT OR INTEGUPLY, PER SQUARE CENTIMETER
Q4127 TALYMED, PER SQUARE CENTIMETER
Q4128 FLEX HD, ALLOPATCH HD, OR MATRIX HD, PER SQUARE CENTIMETER
Q4132 GRAFIX CORE AND GRAFIXPL CORE, PER SQUARE CENTIMETER
Q4133 GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER
Q4134 HMATRIX, PER SQUARE CENTIMETER
Q4135 MEDISKIN, PER SQUARE CENTIMETER
Q4136 EZ-DERM, PER SQUARE CENTIMETER
Q4137 AMNIOEXCEL, AMNIOEXCEL PLUS OR BIODEXCEL, PER SQUARE CENTIMETER
Q4140 BIODFENCE, PER SQUARE CENTIMETER
Q4141 ALLOSKIN AC, PER SQUARE CENTIMETER
Q4146 TENSIX, PER SQUARE CENTIMETER
Q4147 ARCHITECT, ARCHITECT PX, OR ARCHITECT FX, EXTRACELLULAR MATRIX, PER SQUARE CENTIMETER
Q4148 NEOX CORD 1K, NEOX CORD RT, OR CLARIX CORD 1K, PER SQUARE CENTIMETER
Q4151 AMNIOBAND OR GUARDIAN, PER SQUARE CENTIMETER
Q4152 DERMAPURE, PER SQUARE CENTIMETER
Q4153 DERMAVEST AND PLURIVEST, PER SQUARE CENTIMETER
Q4154 BIOVANCE, PER SQUARE CENTIMETER
Q4156 NEOX 100 OR CLARIX 100, PER SQUARE CENTIMETER
Q4157 REVITALON, PER SQUARE CENTIMETER
Q4158 KERECIS OMEGA3, PER SQUARE CENTIMETER
Q4159 AFFINITY, PER SQUARE CENTIMETER
Q4160 NUSHIELD, PER SQUARE CENTIMETER
Q4161 BIO-CONNEKT WOUND MATRIX, PER SQUARE CENTIMETER
Q4163 WOUNDEX, BIOSKIN, PER SQUARE CENTIMETER
Q4164 HELICOLL, PER SQUARE CENTIMETER
Q4165 KERAMATRIX OR KERASORB, PER SQUARE CENTIMETER
Q4166 CYTAL, PER SQUARE CENTIMETER
Q4169 ARTACENT WOUND, PER SQUARE CENTIMETER
Q4170 CYGNUS, PER SQUARE CENTIMETER
Q4173 PALINGEN OR PALINGEN XPLUS, PER SQUARE CENTIMETER
Q4174 PALINGEN OR PROMATRX, 0.36 MG PER 0.25 CC
Q4175 MIRODERM, PER SQUARE CENTIMETER
Q4176 NEOPATCH OR THERION, PER SQUARE CENTIMETER
Q4178 FLOWERAMNIOPATCH, PER SQUARE CENTIMETER
Q4180 REVITA, PER SQUARE CENTIMETER
Q4186 EPIFIX, PER SQUARE CENTIMETER
Q4187 EPICORD, PER SQUARE CENTIMETER
Q4188 AMNIOARMOR, PER SQUARE CENTIMETER
Q4195 PURAPLY, PER SQUARE CENTIMETER
Q4196 PURAPLY AM, PER SQUARE CENTIMETER
Q4197 PURAPLY XT, PER SQUARE CENTIMETER
Q4201 MATRION, PER SQUARE CENTIMETER
Q4203 DERMA-GIDE, PER SQUARE CENTIMETER
Q4231 CORPLEX P, PER CC
Q4232 CORPLEX, PER SQUARE CENTIMETER

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
09/09/2021 R9

Revision Effective: 09/09/2021

Revision Explanation: HCPCS code Q4145 and Q4177 were removed from CPT/HCPCS codes group 2 as they are not FDA approved for the indications outlined in policy L36690.

08/19/2021 R8

Revision Effective: 08/19/2021

Revision Explanation: Annual review, no changes were made.

03/25/2021 R7

Revision Effective: 03/25/2021

Revision Explanation: Added Q4180, Q4231, and Q4232 to group 2 CPT HCPCS group.  

10/08/2020 R6

Revision Effective: 10/08/2020

Revision Explanation: Added Q4201 to Group 2

10/01/2020 R5

Revision Effective: 10/01/2020

Revision Explanation: Added Q4176 and Q4170 to A56696 Group 2 

07/01/2020 R4

Revision Effective: n/a

Revision Explanation: Annual review, no changes made

07/01/2020 R3

R3
Revision Effective; 07/01/2020
Revision Explanation: Added new codes Q4237-Q4239 that were effective 07/01/2020 in the paragraph for group 2 as they have not been loaded to the database yet.

10/31/2019 R2

R2

Revision Effective; 10/31/2019

Revision Explanation: Updated the documentation requirements information and added utilization guidelines that was listed in associated information from the policy.

09/19/2019 R1

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

 

 

Associated Documents

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