Q4174 — Palingen or promatrx, 0.36 mg per 0.25 cc
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
- 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 references Local Coverage Determination LCD L39624 for coverage and documentation requirements for amniotic and placental-derived product injections/applications for musculoskeletal (non-wound) indications; the LCD text was not provided so specific documentation requirements cannot be extracted.
- 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.
Key Coverage Criteria
- 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).
- Amniotic membrane, amniotic fluid, or any other placental-derived product injections and/or applications for musculoskeletal injuries, joint conditions, or other musculoskeletal indications are not covered.
- None — This is a NON-coverage policy for all amniotic membrane, amniotic fluid or other placental-derived product injections and/or applications as a means of managing musculoskeletal injuries, joint conditions, and all other conditions not stated below.
- This guidance does NOT include discussion on burns, wounds or ophthalmic conditions (i.e., burns, wounds, and ophthalmic conditions are not addressed by this LCD).
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
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59740 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
J05
Related Codes
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