Does 15004 require prior authorization?

No, 15004 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 15004?

Medicare facility rate: $228.80. Non-facility rate: $404.48. Work RVU: 4.47.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

4.47

Facility

$228.80

Non-Facility

$404.48

Entire medical record must be maintained and available on request, with each page legible, containing complete patient identification and dates of service, and the legible signature of the responsible physician or non-physician practitioner.
Submitted medical records must support the selected ICD-10-CM diagnosis code(s) and the CPT/HCPCS code must accurately describe the service performed.
When a portion of a Part B drug/biological from a single-use vial/package is discarded, bill the discarded amount on a separate claim line using modifier JW and document in the medical record the date, time, amount administered, amount wasted, and reason for wastage.
Providers are expected to use the product size that best fits the wound to minimize wastage and must document the amount applied and the amount wasted when partial discard occurs.

Application of bioengineered skin substitute grafts is covered for lower-extremity chronic non-healing wounds when dressings and conservative treatments appear insufficient to achieve complete healing.
Skin substitute graft CPT codes (15271-15278) apply to non-autologous skin grafts (homograft/allograft), non-human/xenograft grafts, and biological sheet scaffolding products used as skin substitutes.
Application of a cellular and/or tissue-based product (CTP) to a documented lower-extremity wound is covered when the medical record supports medical necessity for the specific wound and treatment.
A specific CTP product may be used for the episode of care for each documented wound when use is consistent with the product's FDA labeling and submitted product-specific guidelines.
Application of bioengineered skin substitutes is covered for chronic non-healing lower extremity wounds (including diabetic foot ulcers and venous leg ulcers) that have failed to respond to organized comprehensive conservative wound care for at least 4 weeks.
Covered for partial- or full-thickness ulcers with a clean granular base that do not involve tendon, muscle, joint capsule and have no exposed bone or sinus tracts.

A54117 — Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds

J12

L35041 — Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds

J12

A56696 — Billing and Coding: Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities

L36690 — Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities

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