Article for GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair and GRAFTJACKET® XPRESS Flowable Soft Tissue Scaffold – Related to LCD L26003 (A49404)


Contractor Information
 
Contractor Name 
National Government Services, Inc.
Contractor Number 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Contractor Type 
Carrier
Fiscal Intermediary
MAC – Part A
MAC- Part B


Article Information
 
Article ID Number 
A49404 
Article Type 
Article
Key Article 
Yes
Article Title 
GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair and GRAFTJACKET® XPRESS Flowable Soft Tissue Scaffold – Related to LCD L26003 
AMA CPT / ADA CDT Copyright Statement 
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
 
Primary Geographic Jurisdiction 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
 
Original Article Effective Date 
10/01/2009
Article Revision Effective Date 
07/01/2010
Article Text 
Abstract:

GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair is donated allograft human dermis, aseptically processed to remove cells and freeze-dried to remove moisture while preserving biologic components and the structure of the dermal matrix.

GRAFTJACKET® XPRESS Flowable Soft Tissue Scaffold is a micronized form of the very same product, provided as a powder and reconstituted with sterile saline solution.

For the purpose of this article, re-application refers to an additional application of skin substitutes to the same ulcer within the same treatment period. Retreatment is a new treatment period where the same ulcer is being treated again because the initial treatment was insufficient or failed.

Indications:

GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair will be considered reasonable and necessary for the following indications:
  • augmentation of repairs of large rotator cuff tears or ruptured calcaneal tendons;
  • treatment of neuropathic diabetic foot ulcers (DFU) with all the following conditions:
    1. patient has a current medical diagnosis of either Type I or Type II diabetes mellitus; and
    2. patient does not have a current HbA1C reading exceeding 12%; and
    3. full thickness ulcers of greater than three weeks duration that extend through the dermis but without tendon, muscle, capsule or bone exposure; and
    4. underlying disease process(es) contributing to the ulcer, e.g., diabetes, is adequately treated and documented; and
    5. ulcers are located on the foot or toes and are free of infection, redness, drainage, underlying osteomyelitis, surrounding cellulitis, tunnels or tracts, eschar or any necrotic material that could interfere with the adherence of GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair and the process of wound healing; and
    6. patient must have adequate arterial blood supply as evidenced by ankle-brachial index (ABI) of 0.65 or greater in the limb undergoing the procedure.

    GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair must be used in conjunction with the following standard conservative measures:
    • pressure-reducing footwear;
    • non-weight bearing regimen;
    • debridement of necrotic and callused tissue when necessary; and
    • acceptable standard methods of wound care, such as saline moistened dressings.
    The patient must be competent and/or have the support system required to participate in follow-up care associated with treatment of the wound with GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair.

    Limitations:

    The use of GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair on ulcers with any of the following conditions is considered not reasonable and necessary.
    • cellulitis
    • osteomyelitis
    • necrotic ulcer
    • draining wound
    • bone exposed wound bed
    • clinically significant wound healing impairment due to uncontrolled diabetes, poor nutrition and/or general medical condition
    • autoimmune connective tissue disease
    GRAFTJACKET® matrix is contraindicated for use in any patient who is sensitive to any of the antibiotics listed on the package or polysorbate 20.

    Use of GRAFTJACKET® XPRESS Flowable Soft Tissue Scaffold is considered investigational and is not covered.

    The scope of the practice for Podiatry is defined by state law and the individual state laws should be consulted in determining a specific podiatrist’s (or doctor of podiatric medicine) scope of practice.

    The application of GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair (CPT codes 15330, 15331, 15335 and 15336) as well as any subsequently accepted similar product is considered a physician service. As such, GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair may only be applied by a physician.

    Documentation Requirements:

    The patient's medical record must contain documentation that fully supports the medical necessity for services included within this coverage article. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

    Coding Guidelines:

    Payable places of service for the application of GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair (CPT codes 15330, 15331, 15335, 15336): office (11), urgent care facility (20), inpatient hospital (21), outpatient hospital (22), hospital emergency room (23), ambulatory surgical center (24), skilled nursing facility (31), nursing facility (32) and independent clinic (49).

    Payable places of service for GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair (HCPCS code Q4107) if billed by the facility: outpatient hospital, (22), emergency room (23), ambulatory surgical center (24) and skilled nursing facility (31).

    Payable places of service for GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair (HCPCS code Q4107) if billed by the physician or non-physician practitioner: office (11), urgent care facility (20), nursing facility (32) and independent clinic (49).

    The following modifiers were effective for dates of service on or after 01/01/2009:
    • JC – Skin substitute used as a graft
    • JD – Skin substitute not used as a graft
    The JC and JD modifiers should be used when billing for skin substitutes. The difference between them is whether the skin substitute is used as a graft or as a skin covering. The definition of a skin graft for this purpose is whether the skin substitute is implanted into the wound to be incorporated in the healing of the wound. If the skin substitute is used to cover a wound, to protect it from contamination or fluid loss, then it is not a graft, but a dressing.

    Regarding application codes: These codes are not intended to be reported for simple graft application alone or application stabilized with dressings (eg, by simple gauze wrap). The skin substitute/graft is anchored using the surgeon's choice of fixation (CPT 2007). If it is not medically reasonable and necessary to anchor the GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair, (for example, due to size, depth or location of the wound), then the application is included in the appropriate E&M code and should not be submitted with the application codes.

    For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.

    Utilization Guidelines:

    A single application of Acellular Dermal Tissue Matrix for any particular ulcer is usually all that is required to achieve wound healing in those wounds that are likely to be helped by this therapy. Treatment with GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair is usually expected to last no more than twelve (12) weeks and to involve a maximum of two applications for any ulcer that initially qualifies for treatment. The use of more than two applications for the same ulcer is not considered reasonable and necessary.

    Re-application of GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair within three weeks for the same ulcer is not considered reasonable and necessary.

    Re-application of GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair where initial application has resulted in no decrease in size or depth of the wound or increase in granulation tissue, epithelialization, or progress towards closing, will be denied as not reasonable and necessary.

    Retreatment within one year following the last successful application with GRAFTJACKET® Regenerative Tissue Matrix-Ulcer is not considered reasonable and necessary.

    Retreatment of an ulcer following two failed GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair applications is not considered reasonable and necessary.

    The application code(s) (15330, 15331, 15335 and 15336) will be paid no more frequently than at 90-day intervals. Though payment for the product is allowed as appropriate to the clinical considerations, it is inappropriate to bill application codes multiple times within a 90-day period. Therefore, the use of the following modifiers is not appropriate: -58 (Staged procedure), -76 (Repeat procedure by the same physician), -78 (Return to the operating room for a related procedure during the postoperative period), and/or -79 (Unrelated procedure or service by the same physician during the postoperative period). The facility may bill for application and product at a frequency appropriate to the clinical circumstances.


    Coding Information
     
    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.

    11x Hospital-inpatient (including Part A)
    12x Hospital-inpatient or home health visits (Part B only)
    13x Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
    23x SNF-outpatient (HHA-A also)
    71x Clinic-rural health
    73x Clinic - Free-standing
    77x Clinic - Federally Qualified Health Center (FQHC)
    85x Special facility or ASC surgery-rural primary care hospital (eff 10/94)
     
    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.

    Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

    Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

    All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

    036X Operating room services-general classification
    045X Emergency room-general classification
    049X Ambulatory surgical care-general classification
    051X Clinic-general classification
    0636 Drugs requiring specific identification-detailed coding (eff 3/92)
    076X Specialty Services - General Classification (effective 08/10/09)
     
    CPT/HCPCS Codes 
    *Q4113 is considered investigational and is not covered.

    15330 ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
    15331 ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
    15335 ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
    15336 ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
    Q4107 SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER
    Q4113 ALLOGRAFT, GRAFTJACKET EXPRESS, INJECTABLE, 1CC
     
    ICD-9 Codes that are Covered 
    It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

    The ICD-9-CM codes listed below DO NOT require a secondary diagnosis.
    726.10 DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION UNSPECIFIED
    727.61 COMPLETE RUPTURE OF ROTATOR CUFF
    727.67 NONTRAUMATIC RUPTURE OF ACHILLES TENDON
    840.4 ROTATOR CUFF (CAPSULE) SPRAIN
    845.09 OTHER ANKLE SPRAIN
    ICD-9-CM codes 707.13, 707.14 or 707.15 must be billed with a diabetes mellitus ICD-9-CM code listed below as the primary diagnosis.
    707.13 ULCER OF ANKLE
    707.14 ULCER OF HEEL AND MIDFOOT
    707.15 ULCER OF OTHER PART OF FOOT
    Diabetes mellitus ICD-9-CM codes
    249.60 SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
    249.61 SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, UNCONTROLLED
    249.70 SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
    249.71 SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS, UNCONTROLLED
    249.80 SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
    249.81 SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS, UNCONTROLLED
    250.60 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
    250.61 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
    250.62 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
    250.63 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED
    250.70 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
    250.71 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
    250.72 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
    250.73 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED
    250.80 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
    250.81 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED
    250.82 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED
    250.83 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED
     


    Other Information
     
    Other Comments 
    HCPCS code Q4113 is considered investigational and is not covered.

    Sources of Information and Basis for Decision:

    Sources of Information and Basis for Decision:

    Adams JE, Zobitz ME, Reach JS, An KN, Steinmann SP. Rotator cuff repair using an acellular dermal matrix graft: an in vivo study in a canine model. Arthroscopy. 2006;22(7):700-709.

    Barber FA, McGarry JE, Herbert MA. A biomechanical study of Achilles tendon repair augmentation using Graft-Jacket Matrix. Foot and Ankle International. 2008;23(4).

    Beniker D, McQuillan D, Livesey S, et al. The use of acellular dermal matrix as a scaffold for periosteum replacement. Orthopedics. 2003;26(5 Suppl)s:591-596.

    Bond JL, Dopirak RM, Higgins J, et al. Arthroscopic replacement of massive, irreparable rotator cuff tears using a GraftJacket Allograft: technique and preliminary results. Arthroscopy. 2008;24(4):403-409.

    Brigido S, Schwartz E, McCarroll R, Hardin-Young J. Use of an acellular flowable dermal replacement scaffold on lower extremity sinus tract wounds: a retrospective series. Foot & Ankle Specialist. 2009;2(2):67-72.

    Brigido SA. The use of an acellular dermal regenerative tissue matrix in the treatment of lower extremity wounds: a prospective 16-week pilot study. Int Wound J. 2006;3(3):181-187.

    Brigido SA, Boc SF, Lopez RC. Effective management of major lower extremity wounds using an acellular regenerative tissue matrix: a pilot study. Orthopedics. 2004;27(1 Suppl):s145-149.

    Burkhead W, Schiffern S, Krishnan S. Use of Graft Jacket as an augmentation for massive rotator cuff tears. Semin Arthro. 2007;18:11-18.

    Burns JP, Snyder SJ. Biologics patches for management of irreparable rotator cuff tears. Techniques in Shoulder & Elbow Surgery. 2009;10(1):1-21.

    Chen J, Wang A, Zheng M. Scaffolds for tendon and ligament repair: review of the efficacy of commercial products. Expert Rev. Med. Devices. 2009;6(1):61-73.

    Coons D, Barber F. Tendon Graft substitutes- rotator cuff patches. Sports Med Arthrosc Rev. 2006;14(3):185-190.

    Derwin KA, Baker AR, Spragg RK, Leigh DR, Iannotti JP. Commercial extracellular matrix scaffolds for rotator cuff tendon repair. Biomechanical, biochemical and cellular properties. J Bone Joint Surg AM. 2006;88(12):2665-2672.

    Fini M, Torricelli P, Giavaresi G, et al. In vitro study comparing two collageneous membranes in view of their clinical application for rotator cuff tendon regeneration. J Orthop Res. 2007;25(1):98-107.

    Ide J, Kikukawa K, Hirose J, et al. Reconstruction of large rotator-cuff tears with acellular dermal matrix grafts in rats. J Shoulder Elbow Surg. 2009;(18);2:288-295.

    Kokkalis ZT, Zanaros G, Sotereanos DG. Ligament reconstruction with tendon interposition using acellular dermal allograft for thumb carpometacarpal arthritis. Techniques in Hand & Upper Extremity Surgery. 2008:1-7.

    Kummer FJ, Iesaka K. The role of graft materials in suture augmentation for tendon repairs and reattachment. J Biomed Mater Res B Appl Biomater. 2005;74(2):789-791.

    Labbe MR. Arthroscopic technique for patch augmentation of rotator cuff repairs. Arthroscopy. 2006;22(10):1136 e1-6.

    Lee DK. Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures. J Foot Ankle Surg. 2007;46(6):451-455.

    Lee MS. GraftJacket augmentation of chronic Achilles tendon ruptures. Orthopedics. 2004;27(1 Suppl):151-153.

    Liden B, Simmons M. Histologic evalution of a 6-month GraftJacket Matrix biopsy used for Achilles tendon augmentation. JAPMA. 2009;99(2):104-107.

    Liden B, Hartman J, Wright M. Management protocol heals complex ulcers. Biomechanics. 2007;8:1-39.

    Martin BR, Sangalang M, Wu S, Armstrong DG. Outcomes of allogenic acellular matrix therapy in treatment of diabetic foot wounds: an initial experience. Int Wound J. 2005;2(2):161-165.

    Reyzelman A, Crews R, Moore J, et al. Clinical effectiveness of an acellular dermal regenerative tissue matrix compared to standard wound management in healing diabetic foot ulcers: a prospective, randomised, multicentre study. Int Wound J. Jun;6(3):196-208.

    Snyder SJ, Arnoczky SP, Bond JL, Dopirak R. Histologic evaluation of a biopsy specimen obtained 3 months after rotator cuff augmentation with GraftJacket matrix. Arthroscopy. 2009;25(3):329-333.

    Stephen A, Brigido SA, Schwartz E, Barnett L, McCarroll RE. Reconstruction of the diseased Achilles tendon using an acellular human dermal graft followed by early mobilization a preliminary series. Techniques in Foot & Ankle Surgery. 2007;6(4):249-253.

    Valentin JE, Badylak JS, McCabe GP, Badylak SF. Extracellular matrix bioscaffolds for orthopaedic applications. A comparative histologic study. J Bone Joint Surg AM. 2006;88(12):2673-2686.

    Winters CL, Bridigo SA, Liden BA, et al. A multi-center study involving the use of a human acellular dermal regenerative tissue matrix for the treatment of diabetic lower extremity wounds. Adv Skin Wound Care. 2008;(21)8:375-381.
    Revision History Explanation 
    Article published July 2010: The following paragraph was added to the “Utilization Guidelines” section:

    The application code(s) (15330, 15331, 15335 and 15336) will be paid no more frequently than at 90-day intervals. Though payment for the product is allowed as appropriate to the clinical considerations, it is inappropriate to bill application codes multiple times within a 90-day period. Therefore, the use of the following modifiers is not appropriate: -58 (Staged procedure), -76 (Repeat procedure by the same physician), -78 (Return to the operating room for a related procedure during the postoperative period), and/or -79 (Unrelated procedure or service by the same physician during the postoperative period). The facility may bill for application and product at a frequency appropriate to the clinical circumstances.

    Article published May 2010: Based on CMS instructions, non-physician practitioners may be paid for minor surgical procedures. Since CPT codes 15330, 15331, 15335 and 15336 are not considered minor surgical procedures, the following limitation regarding non-physician practitioners was added to the article:

    The application of GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair (CPT codes 15330, 15331, 15335 and 15336) as well as any subsequently accepted similar product is considered a physician service. As such, GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair may only be applied by a physician.

    Article published December 2009: In an effort to further clarify the payable places of service for the application and the biologic product, the following three coding guidelines were revised/added:

    Payable places of service for the application of GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair (CPT codes 15330, 15331, 15335, 15336): office (11), urgent care facility (20), inpatient hospital (21), outpatient hospital (22), hospital emergency room (23), ambulatory surgical center (24), skilled nursing facility (31), nursing facility (32) and independent clinic (49).

    Payable places of service for GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair (HCPCS code Q4107) if billed by the facility: outpatient hospital, (22), emergency room (23), ambulatory surgical center (24) and skilled nursing facility (31).

    Payable places of service for GRAFTJACKET® Regenerative Tissue Matrix-Ulcer Repair (HCPCS code Q4107) if billed by the physician or non-physician practitioner: office (11), urgent care facility (20), nursing facility (32) and independent clinic (49).

    Removed Change Request 6315 reference from the following coding guideline since modifiers JC and JD are applicable to physicians, non-physician practitioners and facilities:

    The following modifiers were effective for dates of service on or after 01/01/2009:
    • JC - Skin substitute used as a graft
    • JD - Skin substitute not used as a graft
    Removed ICD-9-CM codes 707.12 and 707.19 as secondary diagnoses. It is not appropriate to report these ICD-9-CM codes as a secondary diagnosis for neuropathic diabetic foot ulcers (DFUs).

    Reformatted several sources in the “Sources of Information and Basis for Decision” section.

    3/7/2010 - The description for Bill Type Code 73 was changed
    3/7/2010 - The description for Bill Type Code 77 was changed
     
    Related Documents 
    LCD(s)
    L26003 - Biologic Products for Wound Treatment and Surgical Interventions