Q4171, Interfyl, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The article provides billing and coding guidance and references LCD L39116; required documentation (e.g., medical records, prior authorization, specific forms) is not specified here and must be obtained from LCD L39116.
- Billing, coding, and documentation requirements (e.g., required medical record elements, coding guidance, prior authorization if applicable) are specified in LCD L39139 and accompanying billing guidance; review LCD L39139 for the exact documentation required for claims.
- This billing and coding article provides billing and coding guidance for Local Coverage Determination (LCD) L39575 regarding amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications.
- Full coverage, limitation, and documentation criteria are defined in LCD L39575; the source policy text was not provided in this request.
Key Coverage Criteria
- No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
- Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
- 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 skin substitute grafts for treatment of diabetic foot ulcers.
16 Active Policies
CGS-L39575, Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J15
A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J5
A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J6
WPS-L39624, Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J8
Related Codes
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