Q4100 — Skin substitute, not otherwise specified
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical records must be legible, include complete patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner.
- The submitted medical record must support the selected ICD-10-CM diagnosis code(s), the CPT/HCPCS code(s) billed, that the service was performed, and the medical necessity of the services.
- Baseline wound description (prior to conservative treatment) must be documented including size, location, stage, duration, presence of infection, type of treatment given, and response, with ongoing updates during treatment.
- Pre- and post-treatment wound descriptions specific to the skin substitute graft used must be documented in the medical record.
Key Coverage Criteria
- 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.
- 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).
- CTP application is covered for chronic non-healing lower extremity wounds (including diabetic foot ulcers and venous leg ulcers) that have failed to respond to documented appropriate conservative wound care for greater than 4 weeks.
- CTPs are covered for partial- or full-thickness ulcers with a clean granular base that do not involve exposed tendon, muscle, joint capsule, or bone unless the specific CTP package label explicitly permits use in such deeper wounds.
20 Active Policies
A59739 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
J05
A59711 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
J06
A59763 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J09
A59764 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J09
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