A4100, Non-sheet form skin substitute, fda cleared as a device, not otherwise
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$127.26
Non-Facility
$127.26
Documentation Required
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the medical record must be legible and include appropriate patient identification information and dates of service.
- The record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
Key Coverage Criteria
- Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.
- Amniotic and placental-derived product injections/applications are covered only when they meet the reasonable and necessary clinical requirements specified in LCD L39879 (Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound).
- EpiFix or Grafix (GrafixPL, GrafixPRIME, and GrafixPL PRIME) (Non-Injectable) — Proven and medically necessary for treating a diabetic foot ulcer when ALL of the following criteria are met: adequate circulation to the affected extremity as indicated by one or more of the following: pedal pulses palpable or pulses confirmed with doppler examination; ankle-brachial index (ABI) between 0.7 and 1.2; glycated hemoglobin test (HgA1c) < 12% (within the last 90 days); ulcer has failed to demonstrate ade [...]
- Use of acellular human dermal allograft in rhinoplasty
- Healing septal perforations using acellular dermis as bioscaffold
- Artiss is approved for attachment of skin grafts onto burn patients (clinical trial basis described).
13 Active Policies
A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J9
FIRST_COAST-L39877, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J9
NOVITAS-L39879, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
JH
A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
JL
Related Codes
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