Q4104, Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on,
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
- Follow Medicare documentation requirements to demonstrate that the service/item is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
- No documentation requirements are specified in the provided excerpt.
- Full LCD/LCA documents must be consulted for required medical records, prior treatment documentation, wound measurements, photographs, debridement records, and other clinical documentation typically required to establish medical necessity.
- No explicit documentation requirements are stated in the provided text
Key Coverage Criteria
- Cohealyx Collagen Dermal Matrix: Draining wounds
- Cohealyx Collagen Dermal Matrix: Full-thickness wounds
- Cohealyx Collagen Dermal Matrix: Partial-thickness wounds
- Cohealyx Collagen Dermal Matrix: Pressure ulcers
- Cohealyx Collagen Dermal Matrix: Surgical wounds (e.g., donor sites/grafts, podiatric, post-laser surgery, post-Mohs surgery, wound dehiscence)
- Cohealyx Collagen Dermal Matrix: Trauma wounds (e.g., abrasions, lacerations, second-degree burns, skin tears)
9 Active Policies
HUMANA-SKIN-AND-TISSUE-SUBSTITUTES-MA, Skin and Tissue Substitutes
HUMANA-SKIN-AND-TISSUE-SUBSTITUTES-VA-MEDICAID, Skin and Tissue Substitutes
ANTHEM-CG-SURG-127, CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
AMBETTER-CP.MP.186, Burn Surgery
AMBETTER-CP.MP.185, Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers
Related Codes
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