For Dates of Service Before January 1, 2018

Cellular/Tissue-Based Products

The following table lists allowable procedure codes, corresponding application codes, and related ICD diagnosis codes for CTPs. Providers are required to follow CPT and HCPCS coding guidelines for reporting application procedure codes and product codes when submitting claims to ForwardHealth. Application procedure codes will not be covered when associated with noncovered CTPs.

No PA is required for CTP products. All non-indicated conditions are considered noncovered. More information regarding ForwardHealth's coverage policy for CTPs is available.

HCPCS Code	Description	Covered Conditions	CPT Application Code	Allowable ICD Diagnosis Code(s)	Description
Q4101	Apligraf, per square centimeter	Venous leg ulcers	15271–15278	I83.001–I83.029	Varicose veins of lower extremity with ulcer
				I83.201–I83.229	Varicose veins of lower extremity with ulcer and inflammation
				I87.2	Venous insufficiency (chronic) (peripheral)
				I70.231^–I70.25^	Atherosclerosis of native arteries of leg with ulceration
				I70.331^–I70.749^	Atherosclerosis of bypass graft(s) of leg with ulceration
				L97.201^–L97.529^	Non-pressure chronic ulcer
		Full-thickness neuropathic diabetic foot ulcers	15275–15278	E08.621, E09.621, E10.621, E11.621, E13.621	Diabetes mellitus with foot ulcer
				E08.622, E09.622, E10.622, E11.622, E13.622	Diabetes mellitus with other skin ulcer
				L97.301^–L97.529^	Non-pressure chronic ulcer of ankle, heel, or foot
Q4106	Dermagraft, per square centimeter	Full-thickness neuropathic diabetic foot ulcers	15275–15278	E08.621, E09.621, E10.621, E11.621, E13.621	Diabetes mellitus with foot ulcer
				E08.622, E09.622, E10.622, E11.622, E13.622	Diabetes mellitus with other skin ulcer
				L97.301^–L97.529^	Non-pressure chronic ulcer of ankle, heel, or foot
Q4116	Alloderm, per square centimeter	Breast reconstructive surgery	15271–15274, 15777	C50.011–C50.019	Malignant neoplasm of nipple and areola, female
				C50.111–C50.119	Malignant neoplasm of central portion of breast, female
				C50.211–C50.219	Malignant neoplasm of upper-inner quadrant of breast, female
				C50.311–C50.319	Malignant neoplasm of lower-inner quadrant of breast, female
				C50.411–C50.419	Malignant neoplasm of upper-outer quadrant of breast, female
				C50.511–C50.519	Malignant neoplasm of lower-outer quadrant of breast, female
				C50.611–C50.619	Malignant neoplasm of axillary tail of breast, female
				C50.811–C50.819	Malignant neoplasm of overlapping sites of breast, female
				C50.911–C50.919	Malignant neoplasm of breast of unspecified site, female
				C50.021–C50.029	Malignant neoplasm of nipple and areola, male
				C50.121–C50.129	Malignant neoplasm of central portion of breast, male
				C50.221–C50.229	Malignant neoplasm of upper-inner quadrant of breast, male
				C50.321–C50.329	Malignant neoplasm of lower-inner quadrant of breast, male
				C50.421–C50.429	Malignant neoplasm of upper-outer quadrant of breast, male
				C50.521–C50.529	Malignant neoplasm of lower-outer quadrant of breast, male
				C50.621–C50.629	Malignant neoplasm of axillary tail of breast, male
				C50.821–C50.829	Malignant neoplasm of overlapping sites of breast, male
				C50.921–C50.929	Malignant neoplasm of breast of unspecified site, male
				D05.00–D05.02	Lobular carcinoma in situ of breast
				D05.10–D05.12	Intraductal carcinoma in situ of breast
				D05.80–D05.82	Other specified type of carcinoma in situ of breast
				D05.90–D05.92	Unspecified type of carcinoma in situ of breast
				Z85.3	Personal history of malignant neoplasm of breast
				Z90.10–Z90.13	Acquired absence of breast and nipple
Q4131	Epifix or epicord, per square centimeter	Venous leg ulcers	15271–15278	I83.001–I83.029	Varicose veins of lower extremity with ulcer
				I83.201–I83.229	Varicose veins of lower extremity with ulcer and inflammation
				I87.2	Venous insufficiency (chronic) (peripheral)
				I70.231^–I70.25^	Atherosclerosis of native arteries of leg with ulceration
				I70.331^–I70.749^	Atherosclerosis of bypass graft(s) of leg with ulceration
				L97.201^–L97.529^	Non-pressure chronic ulcer
		Full-thickness neuropathic diabetic foot ulcers	15275–15278	E08.621, E09.621, E10.621, E11.621, E13.621	Diabetes mellitus with foot ulcer
				E08.622, E09.622, E10.622, E11.622, E13.622	Diabetes mellitus with other skin ulcer
				L97.301^–L97.529^	Non-pressure chronic ulcer of ankle, heel, or foot

^*	The ICD diagnosis code must be billed with ICD code I87.2 (Venous insufficiency [chronic] [peripheral]) as the primary diagnosis.

^**

The ICD code must be billed with an ICD diagnosis code for diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.622, E13.621, E13.622). Note that categories E08 and E09 have a code first rule which states the underlying condition precipitating the diabetes must be coded first.