Wiki Q4206 Help!!1

aburgraff

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Does anyone have any knowledge for Q4206 code. This is injectable amniotic fluid that my provider is using. According to the supplier all we had to do is submit with the CMS ruling and medical record and they should be paid. Not the case. We have used Osteophyte codes as we were assured those would pay, but again denial reverts to medical necessity. We only bill to Medicare, NGS, and according to a rep, they said there is no LCD or NDC for this code so if we follow the same guidelines as we would with 20550, 20551, 20553 and 20611 and duplicate it, it will work. I just need someone who has some personal knowledge of this code and any insights would greatly help.
 

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  • CMS Ruling Q4206.pdf
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There are some LCDs on this code. This is is listed for Q4206, even though it says skin substitute and not amniotic fluid. Here is the text of one:

Noridian has seen multiple claims where amniotic membrane derived skin substitutes are being used for indications other than the treatment of venous stasis ulcers and diabetic foot ulcers. The original coverage of these products for VSUs and DFUs only was predicated on the fact that the literature that was available only addressed the efficacy of these products in the care of refractory VSU and DFUs. To date we have not received any evidence based, peer reviewed clinical literature published in the core medical journals to support any other use. Therefore Noridian considers clinical use outside of the care of DSU and VSU as not reasonable and necessary and non-covered.

Noridian will gladly review any evidence based, peer reviewed clinical literature published in the core medical journals which may indicate that coverage may be reasonable for other wound types. Such articles should include the results of robust CMS and/or FDA approved clinical trials and/or meta-analysis that support any additional indications.

Any off-label use may be reviewed manually on redetermination. The redetermination request should include medical record documentation supporting the reason for the unique usage and include full text copies of evidence based, peer reviewed articles from core medical journals supporting such use.


And here is an article basically saying it's a billing scam: https://regenexx.com/blog/medicare-billing-amniotic-tissue/#gref

That article is actually very informative.
 
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