M0076, Prolotherapy
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Claims must include documentation that the service met the reasonable and necessary requirements and other documentation elements as required by LCD L35010.
- When billing non-covered trigger point injections, include the appropriate Medicare modifier on the claim per Medicare billing rules.
- This billing and coding guidance complements Local Coverage Determination (LCD) L38745 for Platelet Rich Plasma; refer to LCD L38745 for specific clinical indications, coverage rules, and required documentation.
- This article contains billing, coding, or guideline information that complements the LCD; specific documentation, prior authorization, or forms are not specified here and must be obtained from the LCD or payer.
- Billing, coding, and supporting documentation requirements are provided as a complement to LCD L39023; claims must include the documentation required by LCD L39023.
- Follow the Local Coverage Determination L39058 and CMS NCD 270.3 for clinical indications and supporting documentation to justify PRP use and appropriate code selection.
Key Coverage Criteria
- Trigger point injections are covered when they meet the reasonable and necessary clinical criteria specified in Local Coverage Determination L35010.
- This article does not list specific covered indications; coverage is determined by the referenced Local Coverage Determination (LCD) for Platelet Rich Plasma.
- Refer to Local Coverage Determination L39023 for covered indications for platelet-rich plasma (PRP) injections for non-wound indications.
- Platelet-rich plasma (PRP) used for treatment of chronic non-healing wounds is covered when it meets CMS National Coverage Determination (NCD) 270.3; bill using HCPCS G0460/G0465 accordingly.
- HCPCS P9020 should be billed for one or more units of PRP transfused when used to treat conditions or coagulopathies for which PRP transfusion is indicated.
- Platelet-rich plasma (PRP) is covered only when the service meets the reasonable and necessary requirements specified in Local Coverage Determination (LCD) L39068.
20 Active Policies
CGS-L39023, Platelet Rich Plasma Injections for Non-Wound Injections
J15
A58609, Billing and Coding: Platelet Rich Plasma
J6
A58810, Billing and Coding: Platelet Rich Plasma
J9
FIRST_COAST-L39071, Platelet Rich Plasma
J9
NORIDIAN-L39058, Platelet Rich Plasma Injections for Non-Wound Injections
JF
NOVITAS-L39068, Platelet Rich Plasma
JH
NOVITAS-L35010, Trigger Point Injections
JH
PALMETTO-JJ-L38745, Platelet Rich Plasma
JJ
NGS-L38937, Platelet Rich Plasma
JK
A58808, Billing and Coding: Platelet Rich Plasma
JL
A57751, Billing and Coding: Trigger Point Injections
JL
PALMETTO-JM-L38745, Platelet Rich Plasma
JM
EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-BE32DD2898C6, Health Partners Plans Interventional Pain Management Code List - Effective 01/01/2025
A58282, Billing and Coding: Platelet Rich Plasma
A58737, Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections
A58788, Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections
UHC-POL-prolotherapy-platelet-rich-plasma-therapies, Prolotherapy and Platelet Rich Plasma Therapies
AETNA-CPB-0207, Prolotherapy and Sclerotherapy
REGENCE-MED40, Prolotherapy
UMR-POL-UMR-prolotherapy-platelet-rich-plasma-therapies, Prolotherapy and Platelet Rich Plasma Therapies
Related Codes
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