The following table lists allowable procedure codes, corresponding application codes, and related 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 |
Diagnosis Code(s) |
Description |
|
Q4101 |
Apligraf, per square centimeter |
Venous leg ulcers |
15271-15278 |
454.0 |
Varicose veins of Lower Extremities with ulcer |
|
454.2 |
Varicose veins of lower extremities with ulcer and inflammation |
||||
|
459.81 |
Venous (peripheral) insufficiency, unspecified |
||||
|
707.12* |
Ulcer of calf |
||||
|
707.13* |
Ulcer of ankle |
||||
|
707.14* |
Ulcer of heel and midfoot |
||||
|
707.15* |
Ulcer of other part of foot (toe) |
||||
|
707.19* |
Ulcer of other part of lower limb |
||||
|
Full-thickness neuropathic diabetic foot ulcers |
15275-15278 |
249.60-249.71 |
Secondary diabetes mellitus with neurologic manifestations or peripheral disorders |
||
|
250.60-250.83 |
Diabetes with neurologic, peripheral or other specified disorders |
||||
|
707.13 |
Ulcer of ankle |
||||
|
707.14 |
Ulcer of heel and midfoot |
||||
|
707.15 |
Ulcer of other part of foot (toe) |
||||
|
Q4106 |
Dermagraft, per square centimeter |
Full-thickness neuropathic diabetic foot ulcers |
15275-15278 |
249.60-249.83 |
Secondary diabetes mellitus with neurologic manifestations or peripheral disorders |
|
250.60-250.83 |
Diabetes with neurologic, peripheral, or other specified disorders |
||||
|
707.13** |
Ulcer of ankle |
||||
|
707.14** |
Ulcer of heel and midfoot |
||||
|
707.15** |
Ulcer of other part of foot (toe) |
||||
|
Q4116 |
Alloderm, per square centimeter |
Breast reconstructive surgery |
15271-15274, 15777 |
174.0-174.9 |
Malignant neoplasm of female breast |
|
175.0-175.9 |
Malignant neoplasm of male breast |
||||
|
233.0 |
Carcinoma in situ of breast |
||||
|
V10.3 |
Personal history of malignant neoplasm; breast |
||||
|
V45.71 |
Acquired absence of breast and nipple |
||||
|
Q4131 |
Epifix, per square centimeter |
Venous leg ulcers |
15271-15278 |
454.0 |
Varicose veins of Lower Extremities with ulcer |
|
454.2 |
Varicose veins of lower extremities with ulcer and inflammation |
||||
|
459.81 |
Venous (peripheral) insufficiency, unspecified |
||||
|
707.12* |
Ulcer of calf |
||||
|
707.13* |
Ulcer of ankle |
||||
|
707.14* |
Ulcer of heel and midfoot |
||||
|
707.15* |
Ulcer of other part of foot (toe) |
||||
|
707.19* |
Ulcer of other part of lower limb |
||||
|
Full-thickness neuropathic diabetic foot ulcers |
15275-15278 |
249.60-249.71 |
Secondary diabetes mellitus with neurologic manifestations or peripheral disorders |
||
|
250.60-250.83 |
Diabetes with neurologic, peripheral or other specified disorders |
||||
|
707.13 |
Ulcer of ankle |
||||
|
707.14 |
Ulcer of heel and midfoot |
||||
|
707.15 |
Ulcer of other part of foot (toe) |