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

Social Security Act (Title XVIII) Standard References:

• 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.

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39877, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

If reporting a skin substitute product with HCPCS code A4100 or Q4100, the product name, amount injected, and amount wasted must be reported in the claim narrative/remarks or the claim will be returned to the provider/rejected.

A4100 and Q4100 are not to be used with injectable skin substitutes. If A4100 or Q4100 are reported with an injection code the claim will be returned to the provider/rejected.

When the amniotic/placental product is denied, any associated injection or application services reported on the same day for the same beneficiary will also be denied.

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.