Hereditary Cancer Germline Testing: NCD and LCD, "Risk factor" vs "Clinical indication"

MolDx has released a new and very different LCD for cancer germline testing.  These are LCD L38966 and billing article A58652.

The LCD simply states that the patient must have a cancer, and a clinical indication for testing, and a risk factor for testing.

The LCD, and the article, do NOT give any specific authoritative guidelines.   This will surprise readers who are used to a list of an LCD's complex rules for cancer testing such as a headcount of first degree relatives, or a history of Ashkenazi heritage, or a dozen other rules.

What are Clinical Indication and Risk Factor?

NCD 90.2 was revised in 2020 to include hereditary NGS panels.  The decision summary of the NCD is brief: a patient must have "any cancer diagnosis, a clinical indication for testing, a risk factor for testing." This is the same brief text as the new LCD.

But, the narrative analysis for the NCD provides definitions.  In fact, CMS remarked that one of the main revisions in the "final" hereditary LCD was to define for the reader, what they meant by clinical indications and risk factors.

https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=296

There, we read, 

Clinical indications are different from risk factors.  A RISK FACTOR is a variable associated with INCREASED RISK (such as age, gender, family history) absent signs and symptoms.

A CLINICAL INDICATION, is a sign, symptom, or test result, or medical condition, that leads to a recommendation for a test.  

RISK MODELS may use both risk factors (age) and clinical indications [to estimate a risk value].  For example, the FRAX fracture calculator uses age and sex which are generic factors and not considered illnesses or medical conditions, but also measured bone density or T score which is a medical sign or test result.)

Later in the NCD, lest there be any doubt, CMS states that "clinical indications (can be) a personal history of breast cancer or ovarian cancer."   This is important because it makes, at least sometimes, the two separate bullet points redundant.  (If "personal history cancer" can checkmark the other box, "clinical indication.")

___

While the MolDx LCD and Article don't name any guidelines, that I can see, we can refer to ABSA and the newest CRC version for NCCN.   Age > 65 is a risk factor, and a "sign or symptom" is having cancer.

MACS Now Often List Webpages for Carrier-Priced Codes

 My memory is that ten or fifteen years ago, MACs never listed the prices of contractor-priced codes.   I recall one client being told, "We here at (MAC) have set your price, but if you want to know what it is, you have to submit a claim and look at the reimbursement, or else, file a FOIA request to learn what we priced you at."

Now, in 2022, it seems common that MACs have websites that show carrier-based priced.   This can have financial implications; for example, the main code used by the public comment iRhythm does not have a nationally set price, and investor analysts search around the MAC websites to find out the current price or if it has changed.

Here are some basic links.

• CGS Administrators, LLC

• Contractor Priced Codes Not Published

• https://cgsmedicare.com/partb/pubs/news/2014/1014/cope27145.html

•  

 

• First Coast Service Options, Inc.

• Contractor Priced Codes Published

• https://medicare.fcso.com/Data_files/0493233.pdf

• 2022 Medicare Part B Contractor-Priced Codes for Florida

• National Government Services, Inc.

• Contractor Priced Codes Not Published

• Noridian Healthcare Solutions, LLC

•  

• https://med.noridianmedicare.com/web/jeb/fees-news/fee-schedules/contractor-status-codes-c-status

• Contractor Status Codes (C-Status)

CMS does not establish fees for C status codes; they are priced per Contractor discretion. Each year these code prices are reviewed and revised (price increase and/or decrease varies from code to code). Normally, prices are not determined until they are billed. Our review of medical records will assist in the evaluation and pricing of these services. Updates to contractor priced fees will be posted quarterly.

• Novitas Solutions, Inc.

• Contractor Priced Codes Not Published

• https://www.novitas-solutions.com/webcenter/portal/FeeSchedules_JH

• Local contractor pricing

Novitas will establish RVUs and payment amounts for these services, generally on an individual case basis following review of documentation. At this time Novitas does not have a published list of contractor priced codes.

• Palmetto GBA, LLC

• Contractor Priced Codes Not Published

• Wisconsin Physician Service Government Health Administrators

• Some Contractor Priced Codes Published

• https://www.wpsgha.com/wps/portal/mac/site/fees-and-reimbursements/guides-and-resources/carrier-priced/!ut/p/z1/jVHBToQwEP0WDxxhxiUS4q0aXTQQvazWXkwXuqUbtiXTsiR-vU32ZKLI3Gby3puX90AAB2Hl2WgZjLNyiPuHKD5fq6qorkusXzYNImse3_KHsr57YgW8LwBy3OYg1vDxj2G4jr8AEMvyz_89iAlsqLlvNIhRhj419uCA68l0yqfSdikp7yZqlQfeSiKjKB3JtKqL3sSC-iWdFf704PaXKpjd52U0QuqgSFE2UTz3IYz-NsEE53nOtHN6UFnrTgn-RumdD8B_ImE87Xb8q67weDOca3b1DSskvB8!/dz/d5/L2dBISEvZ0FBIS9nQSEh/#

•  

CMS Contacts Database

 CONTACTS database seems to be lots of organizations (not persons at CMS).  For example you can get the Ombudsman for Aging Services in North Dakota.

https://www.cms.gov/contacts

Something called Coverage/InfoExchange as of May 2022 still lists an Excel "CMD" medical director directory with emails.

https://www.cms.gov/Medicare/Coverage/InfoExchange

CMS publishes an NCD REPORT TO CONGRESS.  As of May 2022, the most recent was CY2020.  Half of it is boilerplate rules.

https://www.cms.gov/Medicare/Coverage/InfoExchange/Reports

Medicare Advantage and Price-Based Appeals

Generally, Medicare Advantage plans to not have to following CMS pricing and coding or bundling rules.  For example, they can have different copays on certain services, compared to fee for service Medicare.  Sometimes a rule intervenes; for example, the Trump administration in 2018 allowed Medicare Advantage plans to use step therapy rules in Part B drugs, a particular named payment policy that had been blocked during the Obama administration in 2012.   Here, here.   

What about payment level?  CMS lets MA plans offer lower payment levels, but there's a secret weapon available to the MA out-of-network provider who feels underpaid.  They can appeal the MA price appeal up to the Original Medicare rate.  I'm told this is usually successful.  It's found at 42 CFR 422.214.  Also, if the patient is outside an area where his MA plan offers in-network rates, then the MA plan "must pay on contract provider the Original Medicare payment rate."  If the MA plan is "providing access to services by non-network means."   

https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol3/xml/CFR-2011-title42-vol3-sec422-214.xml

__

See a 4/2022 article on Medicare and drug pricing (mentioning step therapy) here.

See my 2021 note on this MA price topic, https://brucedocumentblog.blogspot.com/2021/05/regulaton-about-medicare-advantage.html

__

§ 422.214Special rules for services furnished by noncontract providers.

(a) Services furnished by non-section 1861(u) providers. 

(1) Any provider (other than a provider of services as defined in section 1861(u) of the Act) that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.

(2) Any statutory provisions (including penalty provisions) that apply to payment for services furnished to a beneficiary not enrolled in an MA plan also apply to the payment described in paragraph (a)(1) of this section.

(b) Services furnished by section 1861(u) providers of service. Any provider of services as defined in section 1861(u) of the Act that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts (less any payments under §§ 412.105(g) and 413.76 of this chapter) that it could collect if the beneficiary were enrolled in original Medicare. (Section 412.105(g) concerns indirect medical education payment to hospitals for managed care enrollees. Section 413.76 concerns calculating payment for direct medical education costs.)

(c) Deemed request for Medicare payment rate. A noncontract section 1861(u) of the Act provider of services that furnishes services to MA enrollees and submits the same information that it would submit for payment under Original Medicare is deemed to be seeking to be paid the amount it would be paid under Original Medicare unless the provider expressly notifies the MA organization in writing that it is billing an amount less than such amount.

(d) Regional PPO payments in non-network areas. An MA Regional PPO must pay non-contract providers the Original Medicare payment rate in those portions of its service area where it is providing access to services by non-network means under § 422.111(b)(3)(ii) of this part.

[63 FR 35085, June 26, 1998, as amended at 65 FR 40325, June 29, 2000; 70 FR 4724, Jan. 28, 2005; 70 FR 47490, Aug. 12, 2005; 76 FR 21564, Apr. 15, 2011]

Jama IM Disses value of incremental accuracy - CACS. Also: Diagrams re Acc Approv Rx $$

 

AMA Targets vs MOLDX "Syndromic Pathogen Panels"

 Subject: RE: [EXTERNAL] Super quick question about Infectious Disease Tech Asssmt

Good afternoon,

 

Molecular (DNA/RNA) syndromic panels (‘panel’ as defined in the policy is a test that detects > 1 pathogen) for infectious disease pathogen identification testing are the tests within scope of this policy.  A 'syndromic panel' is further defined as one that simultaneously detects multiple different pathogens associated with similar and overlapping clinical symptomatology.

Therefore, if a molecular test detects multiple types or strains of one common pathogen – ie the test detects 

• only Influenza (even if it detects both Influenza A and B), 
• only Herpes Simplex Virus (even if it detects both HSV-1 and -2), or 
• only Human Immunodeficiency Virus (even if it detects both HIV-1 and HIV-2) - 

then the test is not within scope of the policy, as it is not a syndromic panel.

Note that the syndromic test panel is a single test with multiple components and is characterized by a single unit of service.  A syndromic panel cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.

 

Thank you,

 

MolDX

When do you have to submit a TA, rather than just submit the CPT code?

Does this TA apply to panels of 2-5 as well as panels of 6 or more?

Novitas Article on Bioengineered Coverage Q4206

 https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=54117

Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds

A54117

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Novitas Solutions, Inc.	A and B MAC	04111 - MAC A	J - H	Colorado
Novitas Solutions, Inc.	A and B MAC	04112 - MAC B	J - H	Colorado
Novitas Solutions, Inc.	A and B MAC	04211 - MAC A	J - H	New Mexico
Novitas Solutions, Inc.	A and B MAC	04212 - MAC B	J - H	New Mexico
Novitas Solutions, Inc.	A and B MAC	04311 - MAC A	J - H	Oklahoma
Novitas Solutions, Inc.	A and B MAC	04312 - MAC B	J - H	Oklahoma
Novitas Solutions, Inc.	A and B MAC	04411 - MAC A	J - H	Texas
Novitas Solutions, Inc.	A and B MAC	04412 - MAC B	J - H	Texas
Novitas Solutions, Inc.	A and B MAC	04911 - MAC A	J - H	Colorado New Mexico Oklahoma Texas
Novitas Solutions, Inc.	A and B MAC	07101 - MAC A	J - H	Arkansas
Novitas Solutions, Inc.	A and B MAC	07102 - MAC B	J - H	Arkansas
Novitas Solutions, Inc.	A and B MAC	07201 - MAC A	J - H	Louisiana
Novitas Solutions, Inc.	A and B MAC	07202 - MAC B	J - H	Louisiana
Novitas Solutions, Inc.	A and B MAC	07301 - MAC A	J - H	Mississippi
Novitas Solutions, Inc.	A and B MAC	07302 - MAC B	J - H	Mississippi
Novitas Solutions, Inc.	A and B MAC	12101 - MAC A	J - L	Delaware
Novitas Solutions, Inc.	A and B MAC	12102 - MAC B	J - L	Delaware
Novitas Solutions, Inc.	A and B MAC	12201 - MAC A	J - L	District of Columbia
Novitas Solutions, Inc.	A and B MAC	12202 - MAC B	J - L	District of Columbia
Novitas Solutions, Inc.	A and B MAC	12301 - MAC A	J - L	Maryland
Novitas Solutions, Inc.	A and B MAC	12302 - MAC B	J - L	Maryland
Novitas Solutions, Inc.	A and B MAC	12401 - MAC A	J - L	New Jersey
Novitas Solutions, Inc.	A and B MAC	12402 - MAC B	J - L	New Jersey
Novitas Solutions, Inc.	A and B MAC	12501 - MAC A	J - L	Pennsylvania
Novitas Solutions, Inc.	A and B MAC	12502 - MAC B	J - L	Pennsylvania
Novitas Solutions, Inc.	A and B MAC	12901 - MAC A	J - L	Delaware District of Columbia Maryland New Jersey Pennsylvania

Article Information

General Information

Article ID
A54117

Article Title
Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds

Article Type
Billing and Coding

Original Effective Date
10/01/2015

Revision Effective Date
08/13/2020

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 2021 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 © 2021 American Dental Association. All rights reserved.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS 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. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

CMS National Coverage Policy

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.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35041, Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds. Please refer to the LCD for reasonable and necessary requirements.

The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing.

The individual products will continue to be identified with a Level II Healthcare Common Procedure Coding System (HCPCS) supply code from the section of the manual entitled “Skin Substitutes”.

The Current Procedural Terminology (CPT) application CPT codes 15271-15278 intended for the use of skin substitutes is entitled “Skin Substitute Grafts”. The skin replacement surgery Skin Substitute Grafts application guidelines in the current CPT codebook provide an overview of the types of procedures performed, measurement of the wound surface area, and reporting of skin closure, biological dressing, and supply of the skin substitute graft material.

These procedures are not to be reported for application of non-graft wound dressings or for a biologic implant for soft tissue reinforcement.

Coding Guidance:

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.

Per the Current Procedural Terminology (CPT) definition, skin substitute grafts include non-autologous skin (dermal or epidermal, cellular and acellular) grafts (e.g., homograft, allograft), non-human skin substitute grafts (i.e., xenograft), and biological products that form a sheet scaffolding for skin growth. Skin substitute graft codes are not to be reported for application of non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid) or injected skin substitutes.

Non-graft wound dressings or injected skin substitue codes are not used with skin replacement surgery application codes and are considered incorrect coding. Such products are bundled into other standard management procedures if medically necessary and not separately payable.

Claims reporting skin substitute grafts must contain the presence of an appropriate application CPT code.

If the service for the application code is denied, the service for the skin substitute will also be denied.

Effective 01/01/2017, per CR 9603, when billing for Part B drugs and biologicals (except those provided under Competitive Acquisition Program [CAP] for Part B drugs and biologicals), the use of the JW modifier to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patient’s medical record.

Novitas expects that where multiple sizes of a specific product are available, the size that best fits the wound with the least amount of wastage will be utilized.

When a portion of a drug/biological is discarded, the medical record must clearly document the amount administered and the amount wasted. The documentation must include the date, time, amount of medication wasted, and the reason for the wastage.

In situations where a portion of a single use package must be discarded, payment will be made for the portion discarded along with the amount applied up to the amount of the product on the package label. Medical record documentation must clearly indicate the information noted above.

Note: The unused portion must actually be discarded and may not be used for another patient.

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.

Coding Information

CPT/HCPCS Codes

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Group 1

 (22 Codes)

Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

The following CPT/HCPCS codes outlined in this Billing and Coding Article will not have diagnosis code limitations applied at this time.

Group 1 Codes

Code	Description
15002	Wound prep trk/arm/leg
15003	Wound prep addl 100 cm
15004	Wound prep f/n/hf/g
15005	Wnd prep f/n/hf/g addl cm
15040	Harvest cultured skin graft
15050	Skin pinch graft
15271	Skin sub graft trnk/arm/leg
15272	Skin sub graft t/a/l add-on
15273	Skin sub grft t/arm/lg child
15274	Skn sub grft t/a/l child add
15275	Skin sub graft face/nk/hf/g
15276	Skin sub graft f/n/hf/g addl
15277	Skn sub grft f/n/hf/g child
15278	Skn sub grft f/n/hf/g ch add
C5271	Low cost skin substitute app
C5272	Low cost skin substitute app
C5273	Low cost skin substitute app
C5274	Low cost skin substitute app
C5275	Low cost skin substitute app
C5276	Low cost skin substitute app
C5277	Low cost skin substitute app
C5278	Low cost skin substitute app

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

 (1 Code)

Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Group 1 Codes

Code	Description
XX000	Not Applicable

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

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Group 1

 (1 Code)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
XX000	Not Applicable

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
999x	Not Applicable

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
99999	Not Applicable

Other Coding Information

N/A

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
08/13/2020	R21	Article revised and published on 08/13/2020. Based on review of this billing and coding article, the “Coding Guidance” section was updated to include proper coding information in regards to skin replacement surgery application codes and non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid) or injected skin substitutes.
07/01/2020	R20	Article revised and published on 06/25/2020 effective for dates of service on and after 07/01/2020 to remove the parenthetical note related to examples of procedures not to be reported for application of non-graft wound dressings. Group 2 paragraph and codes have been deleted as Q codes representing skin substitutes, are covered when administered and consistent with the related LCD and billed with application codes. A note was added to the text to indicate HCPCS codes Q4177 and Q4206 are exceptions and do not require an application code. HCPCS codes Q4177 and Q4206 are retroactively covered for all dates of service when not billed with application codes 15271-15278.
04/30/2020	R19	Article revised and published on 04/30/2020 effective for dates of service on and after 01/01/2020. The following CPT/HCPCS code has been added to group 2: Q4170.
03/12/2020	R18	Article revised and published on 03/12/2020 effective for dates of service on and after 10/01/2019. The following HCPCS code has been added to group 2: Q4226. Standard language and format changes have been made throughout the article.
02/13/2020	R17	Article revised and published in response to provider inquiries. Healthcare Common Procedure Coding System (HCPCS) code Q4197 and Q4184 were added to the article on 02/13/2020 effective for dates of services on and after 10/21/2019.
01/01/2020	R16	Article revised and published on 01/16/2020 effective for dates of service on and after 01/01/2020 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS code(s) have been added to the CPT/HCPCS code Group 2 in the article: Q4208, Q4209, Q4210, Q4211, Q4214, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221 and Q4222. For the following CPT/HCPCS code(s) either the short description and/or the long description has been changed. Depending on which description is used in this article, there may not be any change in how the code displays in the document: Q4122 and Q4165.
10/01/2019	R15	Article revised and published on 10/31/2019 in response to the October 2019 Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes. The following HCPCS have undergone a code descriptor change: Q4165 and Q4122.
09/26/2019	R14	Article revised and published on 09/26/2019. In addition to the changes made in Revision History Number 13 below, due to system changes, the order of the Coding Section has been revised and new sections for CPT/HCPCS Modifiers and Other Coding Information have been made.
09/26/2019	R13	Article revised and published on 09/26/2019 efective for dates of service on and after 02/04/2019 to add codes Q4183, Q4187, Q4188 and Q4203 to Group 2 CPT/HCPCS codes.
03/21/2019	R12	Article revised and published on 03/21/2019 All codes from L35041, Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds, have been placed in this article per CMS Change Request 10901. Billing instruction for HCPCS code Q4172 has been removed due to code deleted with 2019 HCPCS Update. Article title has been changed to clarify that the Article is providing billing and coding information.
01/01/2019	R11	Article revised and published on 02/14/2019 effective for dates of service on and after 01/01/2019 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS code(s) have been deleted and therefore removed from the Article: Q4131 and Q4172. The following CPT/HCPCS code(s) have been added to Group 2 Codes: Q4186, Q4190, Q4195 and Q4196. For the following CPT/HCPCS code(s) either the short description and/or the long description was changed. Depending on which description is used in this Article, there may not be any change in how the code displays in the document: Q4133 and Q4137.
09/17/2018	R10	Article revised and published on 11/08/2018 effective for dates of service on and after 09/17/2018 to add the following HCPCS code to CPT/HCPCS Code Group 2: Q4180.
07/26/2018	R9	Article revised and published on 07/26/2018 to add HCPCS code Q4178 to CPT/HCPCS Code Group 2 effective for dates of service on and after 04/09/2018.
04/12/2018	R8	Article revised and published on 04/12/2018 to revise statement that an appropriate application CPT code is necessary when billing a skin substitute Q code.
01/01/2018	R7	Article revised and published on 01/25/2018 effective for dates of service on and after 01/01/2018 to reflect the annual CPT/HCPCS code updates. For the following CPT/HCPCS codes either the short description and/or the long description was changed: Q4132, Q4133, Q4148, Q4156, Q4158, Q4163. Depending on which description is used in this article there may not be any change in how the codes display in the document.
05/05/2017	R6	Article revised and published 07/13/2017 effective for dates of service on and after 05/05/2017 to add the following CPT/HCPCS code to Group 2: Q4169. Revision history from 05/11/2017 should reflect that the article (not LCD) was revised.
01/01/2017	R5	LCD revised and published on 05/11/2017 effective for dates of service on and after 01/01/2017 to add the following CPT/HCPCS codes to Group 2: Q4173 and Q4175.
01/01/2017	R4	Article revised and published on 01/12/2017 effective for dates of service on and after 01/01/2017 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS codes: C9349, Q4119, Q4120, and Q4129 have been deleted and therefore removed from group 2 of the Article. The following CPT/HCPCS codes: Q4166 and Q4172 have been added to group 2 of the Article. References to HCPCS code C9349 in the Coding Guidance section have been revised to HCPCS code Q4172. For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: Q4105 and Q4131. Coding Guidance added regarding use of JW modifier.
04/18/2016	R3	Article revised and published on 07/14/2016 effective for dates of service on and after 04/18/2016 to add HCPCS code Q4128 to the Group 2 codes.
01/01/2016	R2	Article revised and published on 01/28/2016 effective for dates of service on and after 01/01/2016 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS codes have been added to Group 2: Q4161, Q4163, Q4164, and Q4165. For the following CPT/HCPCS code, either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: Q4153.
10/01/2015	R1	Article revised and published on 08/13/2015 to add HCPCS codes Q4146 and Q4147. The HCPCS code descriptor for C9349 has changed in response to the 2015 HCPCS Quarter 3 update.

Associated Documents

Related Local Coverage Documents
LCDs
L35041 - Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds 

Related National Coverage Documents
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
08/06/2020	08/13/2020 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site  to retrieve them.