Bioengineered Skin and Soft Tissue Substitutes

Policy ID: S-33-035

Section: Surgery

Effective Date: November 01, 2019

Revised Date: December 28, 2020

Revision Effective Date: January 01, 2021

Last Reviewed: January 19, 2021

Description

Bio-engineered skin and soft tissue substitutes may be derived from human tissue (autologous or allogeneic), non-human tissue (xenographic), synthetic materials, or a composite of these materials. Bio-engineered skin and soft tissue substitutes are utilized in the treatment for breast reconstruction, healing of lower extremity ulcers and severe burns. Acellular dermal matrix (ADM) products are utilized in the repair of a variety of soft tissues.

Criteria

Breast reconstructive surgery using ONE of the following allogeneic ADM products may be considered medically necessary for any ONE of the following indications:

Product(s):

AlloDerm®; or
AlloMax™; or
AlloMend®; or
DermaMatrix™; or
DermACELL®; or
FlexHD®; or
GraftJacket®.

Indication(s):

When there is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required; or
When there is viable but compromised or thin post-mastectomy skin flaps that are at risk of dehiscence or necrosis; or
The infra-mammary fold and lateral mammary folds have been undermined during mastectomy and re-establishment of these landmarks is needed.

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15777	19357	19361
19364	19367	19368	19369	19380	Q4100	Q4107
Q4116	Q4128	Q4122

Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary:

AlloPatch®; or
Apligraf®; or
Dermagraft®; or
Integra® Dermal Regeneration Template; or
Oasis® Ultra Tri-Layer Matrix; or
Oasis Wound Matrix

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15275	15276	15277
15278	Q4101	Q4102	Q4105	Q4106	Q4124	Q4128

Treatment of chronic, non-infected, partial- or full-thickness lower extremity skin ulcers due to venous insufficiency, which have not adequately responded following a one (1)-month period of conventional ulcer therapy, usingany ONE of the following tissue-engineered skin substitutes may be considered medically necessary:

Apligraf; or
Oasis™ Wound Matrix; or
Oasis® Ultra Tri-Layer Matrix

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15275	15276	15277
15278	Q4101	Q4102	Q4124

Treatment of dystrophic epidermolysis bullosa using the following tissue-engineered skin substitutesmay beconsidered medically necessary for ALL of the following indications:

Product(s):

OrCel™.

Indication(s):

Treatment of mitten-hand deformity when standard wound therapy has failed; and
When provided in accordance with the Humanitarian Device Exemption (HDE) specifications of theFood and Drug Administration (FDA).

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15275	15276	15277
15278	Q4100

Treatment of second- and third-degree burns using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary.

Epicel®
- Treatment of deep dermal or full-thickness burns comprising a total body surface area greater than or equal to 30% when provided in accordance with the HDE specifications of the FDA; or
Integra Dermal Regeneration Template™; or
TransCyte™.

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15150	15151	15152	15155	15156	15157	15271
15272	15273	15274	15275	15276	15277	15278
Q4100	Q4105	Q4182

TheraSkin® may be considered medically necessary for any ONE of the following indications:

In conjunction with standard therapeutic compression for the treatment of chronic, non-infected, partial or full-thickness skin ulcers due to venous insufficiency greater than one (1)-month duration and which have not adequately responded following a one (1)-month period of conventional ulcer therapy (i.e., standard dressing changes, standard therapeutic compression, etc.); or
In conjunction with standard diabetic foot ulcer care for the treatment of full-thickness neuropathic diabetic foot ulcers greater than one (1)-month duration which have not adequately responded following at least four (4) weeks of conventional ulcer therapy (i.e., surgical debridement, complete off-loading and standard dressing changes, etc.) which can extend through the dermis, including tendon, muscle, joint capsule or bone exposure; or
Other uses supported by clinical results and clinical literature include pressure sores, skin cancer excision (e.g., Mohs Surgery), large surgical wounds (i.e., club release, etc.), radiation compromised wounds and necrotizing fasciitis.

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15275	15276	15277
15278	Q4121

ALL other skin and soft tissue substitutes not listed above are considered experimental/investigational and, therefore, non-covered, because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature. This includes, but is not limited to:

ACell® UBM Hydrated Wound Dressing; and
ACell® UBM Lyophilized Wound Dressing; and
ActiveMatrix®; and
AlloSkin™; and
AlloSkin™ RT; and
Alphaplex with MariGen Omega3; and
Aongen™ Collagen Matrix; and
Architect Extracellular Matrix; and
ArthroFlex™ (FlexGraft); and
Atlas Wound Matrix; and
Avagen Wound Dressing; and
Avaulta Plus™; and
BellaCell HD or Surederm; and
Biobrane®; and
CellerateRX®; and
Collagen Sponge (Innocoll); and
Collagen Wound Dressing (Oasis Research); and
Collaguard; and
CollaSorb™; and
CollaWound™; and
Coll-E-Derm; and
Collexa®; and
Collieva®; and
Conexa™; and
Coreleader Colla-Pad; and
CorMatrix®; and
CRXa™; and
Cymetra®; and
Cytal; and
Dermadapt™ Wound Dressing; and
DermaGide; and
DermaMatrix Acellular Dermis; and
DermaPure™; and
Derm-maxx; and
DressSkin; and
Durepair Regeneration Matrix®; and
Endoform Dermal Template™; and
ENDURAgen™; and
Excellagen; and
E-Z Derm™; and
FlowerDerm; and
FlowerPatch™; and
FortaDerm™ Wound Dressing; and
GammaGraft; and
GraftJacket® Regenerative Tissue Matrix; and
GraftJacket® Xpress, injectable; and
HA Absorbent Wound Dressing; and
Helicoll; and
Hyalomatrix® (Laserskin®); and
Hyalomatrix® PA; and
hMatrix®; and
Integra™ Flowable Wound Matrix; and
Integra™ Bilayer Wound Matrix; and
Integra™ Matrix; and
Kerrox; and
MatriDerm®; and
MatriStem® Burn Matrix; and
MatriStem® Micromatrix; and
MatriStem® Wound Matrix; and
Matrix HD™; and
MediHoney®; and
Mediskin®; and
MemoDerm™; and
Miroderm; and
MyOwnSkin; and
Neox®; and
Oasis® Burn Matrix; and
Permacol™; and
PriMatrix; and
Primatrix™ Dermal Repair Scaffold; and
Progenamatix; and
Puraply; and
Puraply AM; and
Puraply XT; and
Puros® Dermis; and
Repliform®; and
SS Matrix™; and
Skin TE; and
Stimulen™ Collagen; and
StrataGraft; and
Strattice™ (xenograft); and
Suprathel®; and
SurgiMend®; and
Talymed®; and
TenoGlide™; and
Tensix™; and
TheraForm™ Standard/Sheet; and
Truskin; and
Unite® Biomatrix; and
Veritas® Collagen Matrix; and
Xcm Biologic Tissue Matrix.

Procedure Codes

Q4100	Q4103	Q4104	Q4108	Q4110	Q4111	Q4112
Q4113	Q4114	Q4115	Q4117	Q4118	Q4123	Q4125
Q4126	Q4127	Q4128	Q4130	Q4134	Q4135	Q4136
Q4141	Q4142	Q4143	Q4146	Q4147	Q4149	Q4152
Q4158	Q4164	Q4166	Q4167	Q4172	Q4175	Q4179
Q4193	Q4195	Q4196	Q4197	Q4200	Q4202	Q4203
Q4220	Q4222	Q4226	Q4238

Outpatient HCPCS (C Codes)

C1849	C5271	C5272	C5273	C5274	C5275	C5276
C5277	C5278	C9354	C9356	C9358	C9360	C9363
C9364

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code Q4100

Q81.2

Covered Diagnosis Codes for Procedure Code Q4121

L97 codes below must be billed with one of the following codes: I83.0-I83.029, I83.2-I83.229,I87.01-I87.013,I87.03-I87.033, I87.2, I87.31-I87.313, I87.33-I87.333 or E08.621, E09.621, E10.621, E11.621, E13.621

C43.0	C43.111	C43.112	C43.121	C43.122	C43.21	C43.22
C43.31	C43.39	C43.4	C43.51	C43.52	C43.59	C43.61
C43.62	C43.71	C43.72	C43.8	C44.00	C44.01	C44.02
C44.09	C44.102	C44.109	C44.112	C44.119	C44.122	C44.129
C44.192	C44.199	C44.202	C44.209	C44.212	C44.219	C44.222
C44.229	C44.292	C44.299	C44.311	C44.319	C44.321	C44.329
C44.391	C44.399	C44.40	C44.41	C44.42	C44.49	C44.500
C44.501	C44.509	C44.510	C44.511	C44.519	C44.520	C44.521
C44.529	C44.590	C44.591	C44.599	C44.602	C44.609	C44.612
C44.619	C44.622	C44.629	C44.692	C44.699	C44.702	C44.709
C44.712	C44.719	C44.722	C44.729	C44.792	C44.799	C44.80
C44.81	C44.82	C44.89	C79.2	D03.0	D03.111	D03.112
D03.122	D03.21	D03.22	D03.39	D03.4	D03.51	D03.52
D03.59	D03.61	D03.62	D03.71	D03.72	D03.8	D04.0
D04.111	D04.112	D04.121	D04.122	D04.21	D04.22	D04.39
D04.4	D04.5	D04.61	D04.62	D04.71	D04.72	D04.8
E08.621	E09.621	E10.621	E11.621	E13.621	I83.011	I83.012
I83.013	I83.014	I83.015	I83.018	I83.019	I83.021	I83.022
I83.023	I83.024	I83.025	I83.028	I83.029	I83.211	I83.212
I83.213	I83.214	I83.215	I83.218	I83.219	I83.221	I83.222
I83.223	I83.224	I83.225	I83.228	I83.229	I87.011	I87.012
I87.013	I87.031	I87.032	I87.033	I87.2	I87.311	I87.312
I87.313	I87.331	I87.332	I87.333	L89.010	L89.012	L89.013
L89.014	L89.020	L89.022	L89.023	L89.024	L89.110	L89.112
L89.113	L89.114	L89.120	L89.122	L89.123	L89.124	L89.130
L89.132	L89.133	L89.134	L89.140	L89.142	L89.143	L89.144
L89.150	L89.152	L89.153	L89.154	L89.210	L89.212	L89.213
L89.214	L89.220	L89.222	L89.223	L89.224	L89.310	L89.312
L89.313	L89.314	L89.320	L89.322	L89.323	L89.324	L89.42
L89.43	L89.44	L89.45	L89.500	L89.502	L89.503	L89.504
L89.510	L89.512	L89.513	L89.514	L89.520	L89.522	L89.523
L89.524	L89.600	L89.602	L89.603	L89.604	L89.610	L89.612
L89.613	L89.614	L89.620	L89.622	L89.623	L89.624	L89.810
L89.812	L89.813	L89.814	L89.890	L89.892	L89.893	L89.894
L97.111	L97.112	L97.113	L97.114	L97.115	L97.116	L97.118
L97.121	L97.122	L97.123	L97.124	L97.125	L97.126	L97.128
L97.211	L97.212	L97.213	L97.214	L97.215	L97.216	L97.218
L97.221	L97.222	L97.223	L97.224	L97.225	L97.226	L97.228
L97.311	L97.312	L97.313	L97.314	L97.315	L97.316	L97.318
L97.321	L97.322	L97.323	L97.324	L97.325	L97.326	L97.328
L97.411	L97.412	L97.413	L97.414	L97.415	L97.416	L97.418
L97.421	L97.422	L97.423	L97.424	L97.425	L97.426	L97.428
L97.511	L97.512	L97.513	L97.514	L97.515	L97.516	L97.518
L97.521	L97.522	L97.523	L97.524	L97.525	L97.526	L97.528
L97.811	L97.812	L97.813	L97.814	L97.815	L97.816	L97.818
L97.821	L97.822	L97.823	L97.824	L97.825	L97.826	L97.828
L97.911	L97.912	L97.913	L97.914	L97.915	L97.916	L97.918
L97.921	L97.922	L97.923	L97.924	L97.925	L97.926	L97.928
M72.6	T81.31XA	T81.31XD	T81.31XS	T81.33XA

Covered Diagnosis Codes for Procedure Code Q4116

C50.011	C50.012	C50.021	C50.022	C50.111	C50.112	C50.121
C50.122	C50.211	C50.212	C50.221	C50.222	C50.311	C50.312
C50.321	C50.322	C50.411	C50.412	C50.421	C50.422	C50.511
C50.512	C50.521	C50.522	C50.611	C50.612	C50.621	C50.622
C50.811	C50.812	C50.821	C50.822	C50.911	C50.912	C50.921
C50.922	C79.81	D05.01	D05.02	D05.11	D05.12	D05.81
D05.82	D05.91	D05.92	Z42.1	Z80.3	Z85.3	Z90.11
Z90.12	Z90.13

Covered Diagnosis Codes for Procedure Codes Q4101, Q4105, and Q4106

L97 codes below must be billed with one of the E codes from this section: E08.621-E13.622

E08.621	E08.622	E09.621	E09.622	E10.621	E10.622	E11.621
E11.622	E13.621	E13.622	L97.111	L97.112	L97.113	L97.114
L97.115	L97.116	L97.118	L97.121	L97.122	L97.123	L97.124
L97.125	L97.126	L97.128	L97.201	L97.202	L97.203	L97.204
L97.211	L97.212	L97.213	L97.214	L97.215	L97.216	L97.218
L97.221	L97.222	L97.223	L97.224	L97.225	L97.226	L97.228
L97.301	L97.302	L97.303	L97.304	L97.311	L97.312	L97.313
L97.314	L97.315	L97.316	L97.318	L97.321	L97.322	L97.323
L97.324	L97.325	L97.326	L97.328	L97.401	L97.402	L97.403
L97.404	L97.411	L97.412	L97.413	L97.414	L97.415	L97.416
L97.418	L97.421	L97.422	L97.423	L97.424	L97.425	L97.426
L97.428	L97.501	L97.502	L97.503	L97.504	L97.511	L97.512
L97.513	L97.514	L97.515	L97.516	L97.518	L97.521	L97.522
L97.523	L97.524	L97.525	L97.526	L97.528	L97.801	L97.802
L97.803	L97.804	L97.811	L97.812	L97.813	L97.814	L97.815
L97.816	L97.818	L97.821	L97.822	L97.823	L97.824	L97.825
L97.826	L97.828	L97.901	L97.902	L97.903	L97.904	L97.911
L97.912	L97.913	L97.914	L97.915	L97.916	L97.918	L97.921
L97.922	L97.923	L97.924	L97.925	L97.926	L97.928

Covered Diagnosis Codes for Procedure Codes Q4101 and Q4102

L97 codes below must be billed with one of the following codes: I83.0-I83.029, I83.2-I83.229, I87.01-I87.013, I87.03-I87.033, I87.2, I87.31-I87.313, I87.33-I87.333

I83.011	I83.012	I83.013	I83.014	I83.015	I83.018	I83.019
I83.021	I83.022	I83.023	I83.024	I83.025	I83.028	I83.029
I83.211	I83.212	I83.213	I83.214	I83.215	I83.218	I83.219
I83.221	I83.222	I83.223	I83.224	I83.225	I83.228	I83.229
I87.011	I87.012	I87.013	I87.031	I87.032	I87.033	I87.2
I87.311	I87.312	I87.313	I87.331	I87.332	I87.333	L97.111
L97.112	L97.113	L97.114	L97.115	L97.116	L97.118	L97.121
L97.122	L97.123	L97.124	L97.125	L97.126	L97.128	L97.211
L97.212	L97.213	L97.214	L97.215	L97.216	L97.218	L97.221
L97.222	L97.223	L97.224	L97.225	L97.226	L97.228	L97.311
L97.312	L97.313	L97.314	L97.315	L97.316	L97.318	L97.321
L97.322	L97.323	L97.324	L97.325	L97.326	L97.328	L97.411
L97.412	L97.413	L97.414	L97.415	L97.416	L97.418	L97.421
L97.422	L97.423	L97.424	L97.425	L97.426	L97.428	L97.511
L97.512	L97.513	L97.514	L97.515	L97.516	L97.518	L97.521
L97.522	L97.523	L97.524	L97.525	L97.526	L97.528	L97.811
L97.812	L97.813	L97.814	L97.815	L97.816	L97.818	L97.821
L97.822	L97.823	L97.824	L97.825	L97.826	L97.828	L97.911
L97.912	L97.913	L97.914	L97.915	L97.916	L97.918	L97.919
L97.921	L97.922	L97.923	L97.924	L97.925	L97.926	L97.928
L97.929

Covered Diagnosis Codes for Procedure Codes Q4105 and Q4182

T20.20XA	T20.20XD	T20.20XS	T20.211A	T20.211D	T20.211S	T20.212A
T20.212D	T20.212S	T20.22XA	T20.22XD	T20.22XS	T20.23XA	T20.23XD
T20.23XS	T20.24XA	T20.24XD	T20.24XS	T20.25XA	T20.25XD	T20.25XS
T20.26XA	T20.26XD	T20.26XS	T20.27XA	T20.27XD	T20.27XS	T20.29XA
T20.29XD	T20.29XS	T20.30XA	T20.30XD	T20.30XS	T20.311A	T20.311D
T20.311S	T20.312A	T20.312D	T20.312S	T20.32XA	T20.32XD	T20.32XS
T20.33XA	T20.33XD	T20.33XS	T20.34XA	T20.34XD	T20.34XS	T20.35XA
T20.35XD	T20.35XS	T20.36XA	T20.36XD	T20.36XS	T20.37XA	T20.37XD
T20.37XS	T20.39XA	T20.39XD	T20.39XS	T20.60XA	T20.60XD	T20.60XS
T20.611A	T20.611D	T20.611S	T20.612A	T20.612D	T20.612S	T20.62XA
T20.62XD	T20.62XS	T20.63XA	T20.63XD	T20.63XS	T20.64XA	T20.64XD
T20.64XS	T20.65XA	T20.65XD	T20.65XS	T20.66XA	T20.66XD	T20.66XS
T20.67XA	T20.67XD	T20.67XS	T20.69XA	T20.69XD	T20.69XS	T20.70XA
T20.70XD	T20.70XS	T20.711A	T20.711D	T20.711S	T20.712A	T20.712D
T20.712S	T20.72XA	T20.72XD	T20.72XS	T20.73XA	T20.73XD	T20.73XS
T20.74XA	T20.74XD	T20.74XS	T20.75XA	T20.75XD	T20.75XS	T20.76XA
T20.76XD	T20.76XS	T20.77XA	T20.77XD	T20.77XS	T20.79XA	T20.79XD
T20.79XS	T21.21XA	T21.21XD	T21.21XS	T21.22XA	T21.22XD	T21.22XS
T21.23XA	T21.23XD	T21.23XS	T21.24XA	T21.24XD	T21.24XS	T21.25XA
T21.25XD	T21.25XS	T21.26XA	T21.26XD	T21.26XS	T21.27XA	T21.27XD
T21.27XS	T21.29XA	T21.29XD	T21.29XS	T21.31XA	T21.31XD	T21.31XS
T21.32XA	T21.32XD	T21.32XS	T21.33XA	T21.33XD	T21.33XS	T21.34XA
T21.34XD	T21.34XS	T21.35XA	T21.35XD	T21.35XS	T21.36XA	T21.36XD
T21.36XS	T21.37XA	T21.37XD	T21.37XS	T21.39XA	T21.39XD	T21.39XS
T21.61XA	T21.61XD	T21.61XS	T21.62XA	T21.62XD	T21.62XS	T21.63XA
T21.63XD	T21.63XS	T21.64XA	T21.64XD	T21.64XS	T21.65XA	T21.65XD
T21.65XS	T21.66XA	T21.66XD	T21.66XS	T21.67XA	T21.67XD	T21.67XS
T21.69XA	T21.69XD	T21.69XS	T21.71XA	T21.71XD	T21.71XS	T21.72XA
T21.72XD	T21.72XS	T21.73XA	T21.73XD	T21.73XS	T21.74XA	T21.74XD
T21.74XS	T21.75XA	T21.75XD	T21.75XS	T21.76XA	T21.76XD	T21.76XS
T21.77XA	T21.77XD	T21.77XS	T21.79XA	T21.79XD	T21.79XS	T22.20XA
T22.20XD	T22.20XS	T22.211A	T22.211D	T22.211S	T22.212A	T22.212D
T22.212S	T22.221A	T22.221D	T22.221S	T22.222A	T22.222D	T22.222S
T22.231A	T22.231D	T22.231S	T22.232A	T22.232D	T22.232S	T22.241A
T22.241D	T22.241S	T22.242A	T22.242D	T22.242S	T22.251A	T22.251D
T22.251S	T22.252A	T22.252D	T22.252S	T22.261A	T22.261D	T22.261S
T22.262A	T22.262D	T22.262S	T22.291A	T22.291D	T22.291S	T22.292A
T22.292D	T22.292S	T22.30XA	T22.30XD	T22.30XS	T22.311A	T22.311D
T22.311S	T22.312A	T22.312D	T22.312S	T22.321A	T22.321D	T22.321S
T22.322A	T22.322D	T22.322S	T22.331A	T22.331D	T22.331S	T22.332A
T22.332D	T22.332S	T22.341A	T22.341D	T22.341S	T22.342A	T22.342D
T22.342S	T22.351A	T22.351D	T22.351S	T22.352A	T22.352D	T22.352S
T22.361A	T22.361D	T22.361S	T22.362A	T22.362D	T22.362S	T22.391A
T22.391D	T22.391S	T22.392A	T22.392D	T22.392S	T22.60XA	T22.60XD
T22.60XS	T22.611A	T22.611D	T22.611S	T22.612A	T22.612D	T22.612S
T22.621A	T22.621D	T22.621S	T22.622A	T22.622D	T22.622S	T22.631A
T22.631D	T22.631S	T22.632A	T22.632D	T22.632S	T22.641A	T22.641D
T22.641S	T22.642A	T22.642D	T22.642S	T22.651A	T22.651D	T22.651S
T22.652A	T22.652D	T22.652S	T22.661A	T22.661D	T22.661S	T22.662A
T22.662D	T22.662S	T22.691A	T22.691D	T22.691S	T22.692A	T22.692D
T22.692S	T22.70XA	T22.70XD	T22.70XS	T22.711A	T22.711D	T22.711S
T22.712A	T22.712D	T22.712S	T22.721A	T22.721D	T22.721S	T22.722A
T22.722D	T22.722S	T22.731A	T22.731D	T22.731S	T22.732A	T22.732D
T22.732S	T22.741A	T22.741D	T22.741S	T22.742A	T22.742D	T22.742S
T22.751A	T22.751D	T22.751S	T22.752A	T22.752D	T22.752S	T22.761A
T22.761D	T22.761S	T22.762A	T22.762D	T22.762S	T22.791A	T22.791D
T22.791S	T22.792A	T22.792D	T22.792S	T23.201A	T23.201D	T23.201S
T23.202A	T23.202D	T23.202S	T23.211A	T23.211D	T23.211S	T23.212A
T23.212D	T23.212S	T23.221A	T23.221D	T23.221S	T23.222A	T23.222D
T23.222S	T23.231A	T23.231D	T23.231S	T23.232A	T23.232D	T23.232S
T23.241A	T23.241D	T23.241S	T23.242A	T23.242D	T23.242S	T23.251A
T23.251D	T23.251S	T23.252A	T23.252D	T23.252S	T23.261A	T23.261D
T23.261S	T23.262A	T23.262D	T23.262S	T23.271A	T23.271D	T23.271S
T23.272A	T23.272D	T23.272S	T23.291A	T23.291D	T23.291S	T23.292A
T23.292D	T23.292S	T23.301A	T23.301D	T23.301S	T23.302A	T23.302D
T23.302S	T23.311A	T23.311D	T23.311S	T23.312A	T23.312D	T23.312S
T23.321A	T23.321D	T23.321S	T23.322A	T23.322D	T23.322S	T23.331A
T23.331D	T23.331S	T23.332A	T23.332D	T23.332S	T23.341A	T23.341D
T23.341S	T23.342A	T23.342D	T23.342S	T23.351A	T23.351D	T23.351S
T23.352A	T23.352D	T23.352S	T23.361A	T23.361D	T23.361S	T23.362A
T23.362D	T23.362S	T23.371A	T23.371D	T23.371S	T23.372A	T23.372D
T23.372S	T23.391A	T23.391D	T23.391S	T23.392A	T23.392D	T23.392S
T23.601A	T23.601D	T23.601S	T23.602A	T23.602D	T23.602S	T23.611A
T23.611D	T23.611S	T23.612A	T23.612D	T23.612S	T23.621A	T23.621D
T23.621S	T23.622A	T23.622D	T23.622S	T23.631A	T23.631D	T23.631S
T23.632A	T23.632D	T23.632S	T23.641A	T23.641D	T23.641S	T23.642A
T23.642D	T23.642S	T23.651A	T23.651D	T23.651S	T23.652A	T23.652D
T23.652S	T23.661A	T23.661D	T23.661S	T23.662A	T23.662D	T23.662S
T23.671A	T23.671D	T23.671S	T23.672A	T23.672D	T23.672S	T23.691A
T23.691D	T23.691S	T23.692A	T23.692D	T23.692S	T23.701A	T23.701D
T23.701S	T23.702A	T23.702D	T23.702S	T23.711A	T23.711D	T23.711S
T23.712A	T23.712D	T23.712S	T23.721A	T23.721D	T23.721S	T23.722A
T23.722D	T23.722S	T23.731A	T23.731D	T23.731S	T23.732A	T23.732D
T23.732S	T23.741A	T23.741D	T23.741S	T23.742A	T23.742D	T23.742S
T23.751A	T23.751D	T23.751S	T23.752A	T23.752D	T23.752S	T23.761A
T23.761D	T23.761S	T23.762A	T23.762D	T23.762S	T23.771A	T23.771D
T23.771S	T23.772A	T23.772D	T23.772S	T23.791A	T23.791D	T23.791S
T23.792A	T23.792D	T23.792S	T24.201A	T24.201D	T24.201S	T24.202A
T24.202D	T24.202S	T24.211A	T24.211D	T24.211S	T24.212A	T24.212D
T24.212S	T24.221A	T24.221D	T24.221S	T24.222A	T24.222D	T24.222S
T24.231A	T24.231D	T24.231S	T24.232A	T24.232D	T24.232S	T24.291A
T24.291D	T24.291S	T24.292A	T24.292D	T24.292S	T24.301A	T24.301D
T24.301S	T24.302A	T24.302D	T24.302S	T24.311A	T24.311D	T24.311S
T24.312A	T24.312D	T24.312S	T24.321A	T24.321D	T24.321S	T24.322A
T24.322D	T24.322S	T24.331A	T24.331D	T24.331S	T24.332A	T24.332D
T24.332S	T24.391A	T24.391D	T24.391S	T24.392A	T24.392D	T24.392S
T24.601A	T24.601D	T24.601S	T24.602A	T24.602D	T24.602S	T24.611A
T24.611D	T24.611S	T24.612A	T24.612D	T24.612S	T24.621A	T24.621D
T24.621S	T24.622A	T24.622D	T24.622S	T24.631A	T24.631D	T24.631S
T24.632A	T24.632D	T24.632S	T24.691A	T24.691D	T24.691S	T24.692A
T24.692D	T24.692S	T24.701A	T24.701D	T24.701S	T24.702A	T24.702D
T24.702S	T24.711A	T24.711D	T24.711S	T24.712A	T24.712D	T24.712S
T24.721A	T24.721D	T24.721S	T24.722A	T24.722D	T24.722S	T24.731A
T24.731D	T24.731S	T24.732A	T24.732D	T24.732S	T24.791A	T24.791D
T24.791S	T24.792A	T24.792D	T24.792S	T25.211A	T25.211D	T25.211S
T25.212A	T25.212D	T25.212S	T25.221A	T25.221D	T25.221S	T25.222A
T25.222D	T25.222S	T25.231A	T25.231D	T25.231S	T25.232A	T25.232D
T25.232S	T25.291A	T25.291D	T25.291S	T25.292A	T25.292D	T25.292S
T25.311A	T25.311D	T25.311S	T25.312A	T25.312D	T25.312S	T25.321A
T25.321D	T25.321S	T25.322A	T25.322D	T25.322S	T25.331A	T25.331D
T25.331S	T25.332A	T25.332D	T25.332S	T25.391A	T25.391D	T25.391S
T25.392A	T25.392D	T25.392S	T25.611A	T25.611D	T25.611S	T25.612A
T25.612D	T25.612S	T25.621A	T25.621D	T25.621S	T25.622A	T25.622D
T25.622S	T25.631A	T25.631D	T25.631S	T25.632A	T25.632D	T25.632S
T25.691A	T25.691D	T25.691S	T25.692A	T25.692D	T25.692S	T25.711A
T25.711D	T25.711S	T25.712A	T25.712D	T25.712S	T25.721A	T25.721D
T25.721S	T25.722A	T25.722D	T25.722S	T25.731A	T25.731D	T25.731S
T25.732A	T25.732D	T25.732S	T25.791A	T25.791D	T25.791S	T25.792A
T25.792D	T25.792S

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Coding HCPCS Updates effective July 1, 2020
Internal Medical Policy Committee 9-22-2020 Coding update:
- added procedure codes Q4102 and Q4124 under section involving "Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers"
- added procedure code Q4124 under section regarding "Treatment of chronic, non-infected, partial- or full-thickness lower extremity skin ulcers due to venous insufficiency"
- Removed procedure code Q4124 from section regarding: ALL other skin and soft tissue substitutes
Internal Medical Policy Committee 1-19-2021 Coding update- Removed Procedure code 19366

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-33-034

Section: Surgery

Effective Date: November 01, 2019

Revised Date: September 21, 2020

Revision Effective Date: November 02, 2020

Last Reviewed: September 21, 2020

Archived Date: December 31, 2020

Description

Criteria

Breast reconstructive surgery using ONE of the following allogeneic ADM products may be considered medically necessary for any ONE of the following indications:

Product(s):

AlloDerm®; or
AlloMax™; or
AlloMend®; or
DermaMatrix™; or
DermACELL®; or
FlexHD®; or
GraftJacket®.

Indication(s):

When there is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required; or
When there is viable but compromised or thin post-mastectomy skin flaps that are at risk of dehiscence or necrosis; or
The infra-mammary fold and lateral mammary folds have been undermined during mastectomy and re-establishment of these landmarks is needed.

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15777	19357	19361
19364	19366	19367	19368	19369	19380	Q4100
Q4107	Q4116	Q4128	Q4122

Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary:

AlloPatch®; or
Apligraf®; or
Dermagraft®; or
Integra® Dermal Regeneration Template; or
Oasis® Ultra Tri-Layer Matrix; or
Oasis Wound Matrix

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15275	15276	15277
15278	Q4101	Q4102	Q4105	Q4106	Q4124	Q4128

Apligraf; or
Oasis™ Wound Matrix; or
Oasis® Ultra Tri-Layer Matrix

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15275	15276	15277
15278	Q4101	Q4102	Q4124

Treatment of dystrophic epidermolysis bullosa using the following tissue-engineered skin substitutesmay beconsidered medically necessary for ALL of the following indications:

Product(s):

OrCel™.

Indication(s):

Treatment of mitten-hand deformity when standard wound therapy has failed; and
When provided in accordance with the Humanitarian Device Exemption (HDE) specifications of theFood and Drug Administration (FDA).

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15275	15276	15277
15278	Q4100

Treatment of second- and third-degree burns using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary.

Epicel®
- Treatment of deep dermal or full-thickness burns comprising a total body surface area greater than or equal to 30% when provided in accordance with the HDE specifications of the FDA; or
Integra Dermal Regeneration Template™; or
TransCyte™.

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15150	15151	15152	15155	15156	15157	15271
15272	15273	15274	15275	15276	15277	15278
Q4100	Q4105	Q4182

TheraSkin® may be considered medically necessary for any ONE of the following indications:

In conjunction with standard therapeutic compression for the treatment of chronic, non-infected, partial or full-thickness skin ulcers due to venous insufficiency greater than one (1)-month duration and which have not adequately responded following a one (1)-month period of conventional ulcer therapy (i.e., standard dressing changes, standard therapeutic compression, etc.); or
In conjunction with standard diabetic foot ulcer care for the treatment of full-thickness neuropathic diabetic foot ulcers greater than one (1)-month duration which have not adequately responded following at least four (4) weeks of conventional ulcer therapy (i.e., surgical debridement, complete off-loading and standard dressing changes, etc.) which can extend through the dermis, including tendon, muscle, joint capsule or bone exposure; or
Other uses supported by clinical results and clinical literature include pressure sores, skin cancer excision (e.g., Mohs Surgery), large surgical wounds (i.e., club release, etc.), radiation compromised wounds and necrotizing fasciitis.

Services that do not meet the above criteria will be considered not medically necessary.

Procedure Codes

15271	15272	15273	15274	15275	15276	15277
15278	Q4121

ACell® UBM Hydrated Wound Dressing; and
ACell® UBM Lyophilized Wound Dressing; and
ActiveMatrix®; and
AlloSkin™; and
AlloSkin™ RT; and
Alphaplex with MariGen Omega3; and
Aongen™ Collagen Matrix; and
Architect Extracellular Matrix; and
ArthroFlex™ (FlexGraft); and
Atlas Wound Matrix; and
Avagen Wound Dressing; and
Avaulta Plus™; and
BellaCell HD or Surederm; and
Biobrane®; and
CellerateRX®; and
Collagen Sponge (Innocoll); and
Collagen Wound Dressing (Oasis Research); and
Collaguard; and
CollaSorb™; and
CollaWound™; and
Coll-E-Derm; and
Collexa®; and
Collieva®; and
Conexa™; and
Coreleader Colla-Pad; and
CorMatrix®; and
CRXa™; and
Cymetra®; and
Cytal; and
Dermadapt™ Wound Dressing; and
DermaGide; and
DermaMatrix Acellular Dermis; and
DermaPure™; and
Derm-maxx; and
DressSkin; and
Durepair Regeneration Matrix®; and
Endoform Dermal Template™; and
ENDURAgen™; and
Excellagen; and
E-Z Derm™; and
FlowerDerm; and
FlowerPatch™; and
FortaDerm™ Wound Dressing; and
GammaGraft; and
GraftJacket® Regenerative Tissue Matrix; and
GraftJacket® Xpress, injectable; and
HA Absorbent Wound Dressing; and
Helicoll; and
Hyalomatrix® (Laserskin®); and
Hyalomatrix® PA; and
hMatrix®; and
Integra™ Flowable Wound Matrix; and
Integra™ Bilayer Wound Matrix; and
Integra™ Matrix; and
Kerrox; and
MatriDerm®; and
MatriStem® Burn Matrix; and
MatriStem® Micromatrix; and
MatriStem® Wound Matrix; and
Matrix HD™; and
MediHoney®; and
Mediskin®; and
MemoDerm™; and
Miroderm; and
MyOwnSkin; and
Neox®; and
Oasis® Burn Matrix; and
Permacol™; and
PriMatrix; and
Primatrix™ Dermal Repair Scaffold; and
Progenamatix; and
Puraply; and
Puraply AM; and
Puraply XT; and
Puros® Dermis; and
Repliform®; and
SS Matrix™; and
Skin TE; and
Stimulen™ Collagen; and
StrataGraft; and
Strattice™ (xenograft); and
Suprathel®; and
SurgiMend®; and
Talymed®; and
TenoGlide™; and
Tensix™; and
TheraForm™ Standard/Sheet; and
Truskin; and
Unite® Biomatrix; and
Veritas® Collagen Matrix; and
Xcm Biologic Tissue Matrix.

Procedure Codes

Q4100	Q4103	Q4104	Q4108	Q4110	Q4111	Q4112
Q4113	Q4114	Q4115	Q4117	Q4118	Q4123	Q4125
Q4126	Q4127	Q4128	Q4130	Q4134	Q4135	Q4136
Q4141	Q4142	Q4143	Q4146	Q4147	Q4149	Q4152
Q4158	Q4164	Q4166	Q4167	Q4172	Q4175	Q4179
Q4193	Q4195	Q4196	Q4197	Q4200	Q4202	Q4203
Q4220	Q4222	Q4226	Q4238

Outpatient HCPCS (C Codes)

C1849	C5271	C5272	C5273	C5274	C5275	C5276
C5277	C5278	C9354	C9356	C9358	C9360	C9363
C9364

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code Q4100

Q81.2

Covered Diagnosis Codes for Procedure Code Q4121

C43.0	C43.111	C43.112	C43.121	C43.122	C43.21	C43.22
C43.31	C43.39	C43.4	C43.51	C43.52	C43.59	C43.61
C43.62	C43.71	C43.72	C43.8	C44.00	C44.01	C44.02
C44.09	C44.102	C44.109	C44.112	C44.119	C44.122	C44.129
C44.192	C44.199	C44.202	C44.209	C44.212	C44.219	C44.222
C44.229	C44.292	C44.299	C44.311	C44.319	C44.321	C44.329
C44.391	C44.399	C44.40	C44.41	C44.42	C44.49	C44.500
C44.501	C44.509	C44.510	C44.511	C44.519	C44.520	C44.521
C44.529	C44.590	C44.591	C44.599	C44.602	C44.609	C44.612
C44.619	C44.622	C44.629	C44.692	C44.699	C44.702	C44.709
C44.712	C44.719	C44.722	C44.729	C44.792	C44.799	C44.80
C44.81	C44.82	C44.89	C79.2	D03.0	D03.111	D03.112
D03.122	D03.21	D03.22	D03.39	D03.4	D03.51	D03.52
D03.59	D03.61	D03.62	D03.71	D03.72	D03.8	D04.0
D04.111	D04.112	D04.121	D04.122	D04.21	D04.22	D04.39
D04.4	D04.5	D04.61	D04.62	D04.71	D04.72	D04.8
E08.621	E09.621	E10.621	E11.621	E13.621	I83.011	I83.012
I83.013	I83.014	I83.015	I83.018	I83.019	I83.021	I83.022
I83.023	I83.024	I83.025	I83.028	I83.029	I83.211	I83.212
I83.213	I83.214	I83.215	I83.218	I83.219	I83.221	I83.222
I83.223	I83.224	I83.225	I83.228	I83.229	I87.011	I87.012
I87.013	I87.031	I87.032	I87.033	I87.2	I87.311	I87.312
I87.313	I87.331	I87.332	I87.333	L89.010	L89.012	L89.013
L89.014	L89.020	L89.022	L89.023	L89.024	L89.110	L89.112
L89.113	L89.114	L89.120	L89.122	L89.123	L89.124	L89.130
L89.132	L89.133	L89.134	L89.140	L89.142	L89.143	L89.144
L89.150	L89.152	L89.153	L89.154	L89.210	L89.212	L89.213
L89.214	L89.220	L89.222	L89.223	L89.224	L89.310	L89.312
L89.313	L89.314	L89.320	L89.322	L89.323	L89.324	L89.42
L89.43	L89.44	L89.45	L89.500	L89.502	L89.503	L89.504
L89.510	L89.512	L89.513	L89.514	L89.520	L89.522	L89.523
L89.524	L89.600	L89.602	L89.603	L89.604	L89.610	L89.612
L89.613	L89.614	L89.620	L89.622	L89.623	L89.624	L89.810
L89.812	L89.813	L89.814	L89.890	L89.892	L89.893	L89.894
L97.111	L97.112	L97.113	L97.114	L97.115	L97.116	L97.118
L97.121	L97.122	L97.123	L97.124	L97.125	L97.126	L97.128
L97.211	L97.212	L97.213	L97.214	L97.215	L97.216	L97.218
L97.221	L97.222	L97.223	L97.224	L97.225	L97.226	L97.228
L97.311	L97.312	L97.313	L97.314	L97.315	L97.316	L97.318
L97.321	L97.322	L97.323	L97.324	L97.325	L97.326	L97.328
L97.411	L97.412	L97.413	L97.414	L97.415	L97.416	L97.418
L97.421	L97.422	L97.423	L97.424	L97.425	L97.426	L97.428
L97.511	L97.512	L97.513	L97.514	L97.515	L97.516	L97.518
L97.521	L97.522	L97.523	L97.524	L97.525	L97.526	L97.528
L97.811	L97.812	L97.813	L97.814	L97.815	L97.816	L97.818
L97.821	L97.822	L97.823	L97.824	L97.825	L97.826	L97.828
L97.911	L97.912	L97.913	L97.914	L97.915	L97.916	L97.918
L97.921	L97.922	L97.923	L97.924	L97.925	L97.926	L97.928
M72.6	T81.31XA	T81.31XD	T81.31XS	T81.33XA

Covered Diagnosis Codes for Procedure Code Q4116

C50.011	C50.012	C50.021	C50.022	C50.111	C50.112	C50.121
C50.122	C50.211	C50.212	C50.221	C50.222	C50.311	C50.312
C50.321	C50.322	C50.411	C50.412	C50.421	C50.422	C50.511
C50.512	C50.521	C50.522	C50.611	C50.612	C50.621	C50.622
C50.811	C50.812	C50.821	C50.822	C50.911	C50.912	C50.921
C50.922	C79.81	D05.01	D05.02	D05.11	D05.12	D05.81
D05.82	D05.91	D05.92	Z42.1	Z80.3	Z85.3	Z90.11
Z90.12	Z90.13

Covered Diagnosis Codes for Procedure Codes Q4101, Q4105, and Q4106

L97 codes below must be billed with one of the E codes from this section: E08.621-E13.622

E08.621	E08.622	E09.621	E09.622	E10.621	E10.622	E11.621
E11.622	E13.621	E13.622	L97.111	L97.112	L97.113	L97.114
L97.115	L97.116	L97.118	L97.121	L97.122	L97.123	L97.124
L97.125	L97.126	L97.128	L97.201	L97.202	L97.203	L97.204
L97.211	L97.212	L97.213	L97.214	L97.215	L97.216	L97.218
L97.221	L97.222	L97.223	L97.224	L97.225	L97.226	L97.228
L97.301	L97.302	L97.303	L97.304	L97.311	L97.312	L97.313
L97.314	L97.315	L97.316	L97.318	L97.321	L97.322	L97.323
L97.324	L97.325	L97.326	L97.328	L97.401	L97.402	L97.403
L97.404	L97.411	L97.412	L97.413	L97.414	L97.415	L97.416
L97.418	L97.421	L97.422	L97.423	L97.424	L97.425	L97.426
L97.428	L97.501	L97.502	L97.503	L97.504	L97.511	L97.512
L97.513	L97.514	L97.515	L97.516	L97.518	L97.521	L97.522
L97.523	L97.524	L97.525	L97.526	L97.528	L97.801	L97.802
L97.803	L97.804	L97.811	L97.812	L97.813	L97.814	L97.815
L97.816	L97.818	L97.821	L97.822	L97.823	L97.824	L97.825
L97.826	L97.828	L97.901	L97.902	L97.903	L97.904	L97.911
L97.912	L97.913	L97.914	L97.915	L97.916	L97.918	L97.921
L97.922	L97.923	L97.924	L97.925	L97.926	L97.928

Covered Diagnosis Codes for Procedure Codes Q4101 and Q4102

L97 codes below must be billed with one of the following codes: I83.0-I83.029, I83.2-I83.229, I87.01-I87.013, I87.03-I87.033, I87.2, I87.31-I87.313, I87.33-I87.333

I83.011	I83.012	I83.013	I83.014	I83.015	I83.018	I83.019
I83.021	I83.022	I83.023	I83.024	I83.025	I83.028	I83.029
I83.211	I83.212	I83.213	I83.214	I83.215	I83.218	I83.219
I83.221	I83.222	I83.223	I83.224	I83.225	I83.228	I83.229
I87.011	I87.012	I87.013	I87.031	I87.032	I87.033	I87.2
I87.311	I87.312	I87.313	I87.331	I87.332	I87.333	L97.111
L97.112	L97.113	L97.114	L97.115	L97.116	L97.118	L97.121
L97.122	L97.123	L97.124	L97.125	L97.126	L97.128	L97.211
L97.212	L97.213	L97.214	L97.215	L97.216	L97.218	L97.221
L97.222	L97.223	L97.224	L97.225	L97.226	L97.228	L97.311
L97.312	L97.313	L97.314	L97.315	L97.316	L97.318	L97.321
L97.322	L97.323	L97.324	L97.325	L97.326	L97.328	L97.411
L97.412	L97.413	L97.414	L97.415	L97.416	L97.418	L97.421
L97.422	L97.423	L97.424	L97.425	L97.426	L97.428	L97.511
L97.512	L97.513	L97.514	L97.515	L97.516	L97.518	L97.521
L97.522	L97.523	L97.524	L97.525	L97.526	L97.528	L97.811
L97.812	L97.813	L97.814	L97.815	L97.816	L97.818	L97.821
L97.822	L97.823	L97.824	L97.825	L97.826	L97.828	L97.911
L97.912	L97.913	L97.914	L97.915	L97.916	L97.918	L97.919
L97.921	L97.922	L97.923	L97.924	L97.925	L97.926	L97.928
L97.929

Covered Diagnosis Codes for Procedure Codes Q4105 and Q4182

T20.20XA	T20.20XD	T20.20XS	T20.211A	T20.211D	T20.211S	T20.212A
T20.212D	T20.212S	T20.22XA	T20.22XD	T20.22XS	T20.23XA	T20.23XD
T20.23XS	T20.24XA	T20.24XD	T20.24XS	T20.25XA	T20.25XD	T20.25XS
T20.26XA	T20.26XD	T20.26XS	T20.27XA	T20.27XD	T20.27XS	T20.29XA
T20.29XD	T20.29XS	T20.30XA	T20.30XD	T20.30XS	T20.311A	T20.311D
T20.311S	T20.312A	T20.312D	T20.312S	T20.32XA	T20.32XD	T20.32XS
T20.33XA	T20.33XD	T20.33XS	T20.34XA	T20.34XD	T20.34XS	T20.35XA
T20.35XD	T20.35XS	T20.36XA	T20.36XD	T20.36XS	T20.37XA	T20.37XD
T20.37XS	T20.39XA	T20.39XD	T20.39XS	T20.60XA	T20.60XD	T20.60XS
T20.611A	T20.611D	T20.611S	T20.612A	T20.612D	T20.612S	T20.62XA
T20.62XD	T20.62XS	T20.63XA	T20.63XD	T20.63XS	T20.64XA	T20.64XD
T20.64XS	T20.65XA	T20.65XD	T20.65XS	T20.66XA	T20.66XD	T20.66XS
T20.67XA	T20.67XD	T20.67XS	T20.69XA	T20.69XD	T20.69XS	T20.70XA
T20.70XD	T20.70XS	T20.711A	T20.711D	T20.711S	T20.712A	T20.712D
T20.712S	T20.72XA	T20.72XD	T20.72XS	T20.73XA	T20.73XD	T20.73XS
T20.74XA	T20.74XD	T20.74XS	T20.75XA	T20.75XD	T20.75XS	T20.76XA
T20.76XD	T20.76XS	T20.77XA	T20.77XD	T20.77XS	T20.79XA	T20.79XD
T20.79XS	T21.21XA	T21.21XD	T21.21XS	T21.22XA	T21.22XD	T21.22XS
T21.23XA	T21.23XD	T21.23XS	T21.24XA	T21.24XD	T21.24XS	T21.25XA
T21.25XD	T21.25XS	T21.26XA	T21.26XD	T21.26XS	T21.27XA	T21.27XD
T21.27XS	T21.29XA	T21.29XD	T21.29XS	T21.31XA	T21.31XD	T21.31XS
T21.32XA	T21.32XD	T21.32XS	T21.33XA	T21.33XD	T21.33XS	T21.34XA
T21.34XD	T21.34XS	T21.35XA	T21.35XD	T21.35XS	T21.36XA	T21.36XD
T21.36XS	T21.37XA	T21.37XD	T21.37XS	T21.39XA	T21.39XD	T21.39XS
T21.61XA	T21.61XD	T21.61XS	T21.62XA	T21.62XD	T21.62XS	T21.63XA
T21.63XD	T21.63XS	T21.64XA	T21.64XD	T21.64XS	T21.65XA	T21.65XD
T21.65XS	T21.66XA	T21.66XD	T21.66XS	T21.67XA	T21.67XD	T21.67XS
T21.69XA	T21.69XD	T21.69XS	T21.71XA	T21.71XD	T21.71XS	T21.72XA
T21.72XD	T21.72XS	T21.73XA	T21.73XD	T21.73XS	T21.74XA	T21.74XD
T21.74XS	T21.75XA	T21.75XD	T21.75XS	T21.76XA	T21.76XD	T21.76XS
T21.77XA	T21.77XD	T21.77XS	T21.79XA	T21.79XD	T21.79XS	T22.20XA
T22.20XD	T22.20XS	T22.211A	T22.211D	T22.211S	T22.212A	T22.212D
T22.212S	T22.221A	T22.221D	T22.221S	T22.222A	T22.222D	T22.222S
T22.231A	T22.231D	T22.231S	T22.232A	T22.232D	T22.232S	T22.241A
T22.241D	T22.241S	T22.242A	T22.242D	T22.242S	T22.251A	T22.251D
T22.251S	T22.252A	T22.252D	T22.252S	T22.261A	T22.261D	T22.261S
T22.262A	T22.262D	T22.262S	T22.291A	T22.291D	T22.291S	T22.292A
T22.292D	T22.292S	T22.30XA	T22.30XD	T22.30XS	T22.311A	T22.311D
T22.311S	T22.312A	T22.312D	T22.312S	T22.321A	T22.321D	T22.321S
T22.322A	T22.322D	T22.322S	T22.331A	T22.331D	T22.331S	T22.332A
T22.332D	T22.332S	T22.341A	T22.341D	T22.341S	T22.342A	T22.342D
T22.342S	T22.351A	T22.351D	T22.351S	T22.352A	T22.352D	T22.352S
T22.361A	T22.361D	T22.361S	T22.362A	T22.362D	T22.362S	T22.391A
T22.391D	T22.391S	T22.392A	T22.392D	T22.392S	T22.60XA	T22.60XD
T22.60XS	T22.611A	T22.611D	T22.611S	T22.612A	T22.612D	T22.612S
T22.621A	T22.621D	T22.621S	T22.622A	T22.622D	T22.622S	T22.631A
T22.631D	T22.631S	T22.632A	T22.632D	T22.632S	T22.641A	T22.641D
T22.641S	T22.642A	T22.642D	T22.642S	T22.651A	T22.651D	T22.651S
T22.652A	T22.652D	T22.652S	T22.661A	T22.661D	T22.661S	T22.662A
T22.662D	T22.662S	T22.691A	T22.691D	T22.691S	T22.692A	T22.692D
T22.692S	T22.70XA	T22.70XD	T22.70XS	T22.711A	T22.711D	T22.711S
T22.712A	T22.712D	T22.712S	T22.721A	T22.721D	T22.721S	T22.722A
T22.722D	T22.722S	T22.731A	T22.731D	T22.731S	T22.732A	T22.732D
T22.732S	T22.741A	T22.741D	T22.741S	T22.742A	T22.742D	T22.742S
T22.751A	T22.751D	T22.751S	T22.752A	T22.752D	T22.752S	T22.761A
T22.761D	T22.761S	T22.762A	T22.762D	T22.762S	T22.791A	T22.791D
T22.791S	T22.792A	T22.792D	T22.792S	T23.201A	T23.201D	T23.201S
T23.202A	T23.202D	T23.202S	T23.211A	T23.211D	T23.211S	T23.212A
T23.212D	T23.212S	T23.221A	T23.221D	T23.221S	T23.222A	T23.222D
T23.222S	T23.231A	T23.231D	T23.231S	T23.232A	T23.232D	T23.232S
T23.241A	T23.241D	T23.241S	T23.242A	T23.242D	T23.242S	T23.251A
T23.251D	T23.251S	T23.252A	T23.252D	T23.252S	T23.261A	T23.261D
T23.261S	T23.262A	T23.262D	T23.262S	T23.271A	T23.271D	T23.271S
T23.272A	T23.272D	T23.272S	T23.291A	T23.291D	T23.291S	T23.292A
T23.292D	T23.292S	T23.301A	T23.301D	T23.301S	T23.302A	T23.302D
T23.302S	T23.311A	T23.311D	T23.311S	T23.312A	T23.312D	T23.312S
T23.321A	T23.321D	T23.321S	T23.322A	T23.322D	T23.322S	T23.331A
T23.331D	T23.331S	T23.332A	T23.332D	T23.332S	T23.341A	T23.341D
T23.341S	T23.342A	T23.342D	T23.342S	T23.351A	T23.351D	T23.351S
T23.352A	T23.352D	T23.352S	T23.361A	T23.361D	T23.361S	T23.362A
T23.362D	T23.362S	T23.371A	T23.371D	T23.371S	T23.372A	T23.372D
T23.372S	T23.391A	T23.391D	T23.391S	T23.392A	T23.392D	T23.392S
T23.601A	T23.601D	T23.601S	T23.602A	T23.602D	T23.602S	T23.611A
T23.611D	T23.611S	T23.612A	T23.612D	T23.612S	T23.621A	T23.621D
T23.621S	T23.622A	T23.622D	T23.622S	T23.631A	T23.631D	T23.631S
T23.632A	T23.632D	T23.632S	T23.641A	T23.641D	T23.641S	T23.642A
T23.642D	T23.642S	T23.651A	T23.651D	T23.651S	T23.652A	T23.652D
T23.652S	T23.661A	T23.661D	T23.661S	T23.662A	T23.662D	T23.662S
T23.671A	T23.671D	T23.671S	T23.672A	T23.672D	T23.672S	T23.691A
T23.691D	T23.691S	T23.692A	T23.692D	T23.692S	T23.701A	T23.701D
T23.701S	T23.702A	T23.702D	T23.702S	T23.711A	T23.711D	T23.711S
T23.712A	T23.712D	T23.712S	T23.721A	T23.721D	T23.721S	T23.722A
T23.722D	T23.722S	T23.731A	T23.731D	T23.731S	T23.732A	T23.732D
T23.732S	T23.741A	T23.741D	T23.741S	T23.742A	T23.742D	T23.742S
T23.751A	T23.751D	T23.751S	T23.752A	T23.752D	T23.752S	T23.761A
T23.761D	T23.761S	T23.762A	T23.762D	T23.762S	T23.771A	T23.771D
T23.771S	T23.772A	T23.772D	T23.772S	T23.791A	T23.791D	T23.791S
T23.792A	T23.792D	T23.792S	T24.201A	T24.201D	T24.201S	T24.202A
T24.202D	T24.202S	T24.211A	T24.211D	T24.211S	T24.212A	T24.212D
T24.212S	T24.221A	T24.221D	T24.221S	T24.222A	T24.222D	T24.222S
T24.231A	T24.231D	T24.231S	T24.232A	T24.232D	T24.232S	T24.291A
T24.291D	T24.291S	T24.292A	T24.292D	T24.292S	T24.301A	T24.301D
T24.301S	T24.302A	T24.302D	T24.302S	T24.311A	T24.311D	T24.311S
T24.312A	T24.312D	T24.312S	T24.321A	T24.321D	T24.321S	T24.322A
T24.322D	T24.322S	T24.331A	T24.331D	T24.331S	T24.332A	T24.332D
T24.332S	T24.391A	T24.391D	T24.391S	T24.392A	T24.392D	T24.392S
T24.601A	T24.601D	T24.601S	T24.602A	T24.602D	T24.602S	T24.611A
T24.611D	T24.611S	T24.612A	T24.612D	T24.612S	T24.621A	T24.621D
T24.621S	T24.622A	T24.622D	T24.622S	T24.631A	T24.631D	T24.631S
T24.632A	T24.632D	T24.632S	T24.691A	T24.691D	T24.691S	T24.692A
T24.692D	T24.692S	T24.701A	T24.701D	T24.701S	T24.702A	T24.702D
T24.702S	T24.711A	T24.711D	T24.711S	T24.712A	T24.712D	T24.712S
T24.721A	T24.721D	T24.721S	T24.722A	T24.722D	T24.722S	T24.731A
T24.731D	T24.731S	T24.732A	T24.732D	T24.732S	T24.791A	T24.791D
T24.791S	T24.792A	T24.792D	T24.792S	T25.211A	T25.211D	T25.211S
T25.212A	T25.212D	T25.212S	T25.221A	T25.221D	T25.221S	T25.222A
T25.222D	T25.222S	T25.231A	T25.231D	T25.231S	T25.232A	T25.232D
T25.232S	T25.291A	T25.291D	T25.291S	T25.292A	T25.292D	T25.292S
T25.311A	T25.311D	T25.311S	T25.312A	T25.312D	T25.312S	T25.321A
T25.321D	T25.321S	T25.322A	T25.322D	T25.322S	T25.331A	T25.331D
T25.331S	T25.332A	T25.332D	T25.332S	T25.391A	T25.391D	T25.391S
T25.392A	T25.392D	T25.392S	T25.611A	T25.611D	T25.611S	T25.612A
T25.612D	T25.612S	T25.621A	T25.621D	T25.621S	T25.622A	T25.622D
T25.622S	T25.631A	T25.631D	T25.631S	T25.632A	T25.632D	T25.632S
T25.691A	T25.691D	T25.691S	T25.692A	T25.692D	T25.692S	T25.711A
T25.711D	T25.711S	T25.712A	T25.712D	T25.712S	T25.721A	T25.721D
T25.721S	T25.722A	T25.722D	T25.722S	T25.731A	T25.731D	T25.731S
T25.732A	T25.732D	T25.732S	T25.791A	T25.791D	T25.791S	T25.792A
T25.792D	T25.792S

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Coding HCPCS Updates effective July 1, 2020

Internal Medical Policy Committee 9-22-2020 Coding update

Links

References (PDF)

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