LCD Reference Article Billing and Coding Article

Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374

Expand All | Collapse All
Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A59374
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
Article Type
Billing and Coding
Original Effective Date
12/10/2023
Revision Effective Date
04/01/2024
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39575 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(24 Codes)
Group 1 Paragraph

All amniotic and placental-derived products injected and/or applied for musculoskeletal indications, non-wound are considered NON-Covered, including but not limited to the codes listed below.

Group 1 Codes
Code Description
Q4139 Amnio or biodmatrix, inj 1cc
Q4145 Epifix, inj, 1mg
Q4155 Neoxflo or clarixflo 1 mg
Q4162 Wndex flw, bioskn flw, 0.5cc
Q4168 Amnioband, 1 mg
Q4171 Interfyl, 1 mg
Q4174 Palingen or promatrx
Q4177 Floweramnioflo, 0.1 cc
Q4185 Cellesta flowab amnion 0.5cc
Q4189 Artacent ac, 1 mg
Q4192 Restorigin, 1 cc
Q4206 Fluid flow or fluid gf 1 cc
Q4212 Allogen, per cc
Q4213 Ascent, 0.5 mg
Q4215 Axolotl ambient, cryo 0.1 mg
Q4230 Cogenex flow amnion 0.5 cc
Q4231 Corplex p, per cc
Q4233 Surfactor /nudyn per 0.5 cc
Q4240 Corecyte topical only 0.5 cc
Q4241 Polycyte, topical only 0.5cc
Q4242 Amniocyte plus, per 0.5 cc
Q4245 Amniotext, per cc
Q4246 Coretext or protext, per cc
Q4310 Procenta, per 100 mg
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(6,634 Codes)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
M00.00 - M99.9 Staphylococcal arthritis, unspecified joint - Biomechanical lesion, unspecified
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/01/2024 R3

Revision Effective: 04/01/2024

Revision Explanation: Added new code Q4310 to CPT/HCPCS group 1.

12/28/2023 R2

Revision Effective: 11/16/2023

Revision Explanation: HCPCS codes Q4112 and Q4149 removed as they are not amniotic or placenta derived products. 

12/10/2023 R1

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
05/03/2024 04/01/2024 - N/A Currently in Effect You are here
12/18/2023 12/28/2023 - 03/31/2024 Superseded View
11/07/2023 12/10/2023 - 12/27/2023 Superseded View
10/16/2023 12/10/2023 - N/A Superseded View

Keywords

N/A