LCD/NCD Portal
Automated World Health
L28985
SKIN SUBSTITUTES
01/01/2013
Indications and Limitations of Coverage and/or Medical Necessity
Apligraf®
• Apligraf® is supplied a living, bilayered, skin substitute.
o The epidermal layer is formed by human keratinocytes and has a well-differentiated stratum corneum.
o The dermal layer is composed of human fibroblasts in a bovine Type 1 collagen lattice.
o While matrix proteins and cytokines found in human skin are present in Apligraf®, it does not contain langerhans cells, melanocytes, macrophages, lymphocytes, blood vessels, or hair follicles.
o Apligraf® is supplied sealed in a heavy gauge polyethylene bag intended for single use as a circular disk approximately 7.5 centimeters (cm) in diameter.
• Apligraf® should be applied to a clean, debrided, thoroughly irrigated wound.
o Oozing or bleeding should be stopped through the use of gentle pressure. (See package insert for application instructions.)
• The wound should be inspected and the dressing changed at weekly intervals.
o Highly exudative wounds may require more frequent dressing changes.
o Additional applications of Apligraf® may be necessary.
o Non-adherent remnants should be gently removed, the wound bed cleansed, and additional applications applied.
o Additional applications should not be placed over adherent areas.
o Healing tissue or adherent Apligraf® should not be disrupted.
• Apligraf® will be considered medically reasonable and necessary for the following two FDA approved indications:
o When used with standard therapeutic compression for the treatment of non-infected partial and/or full-thickness skin loss ulcers due to venous insufficiency of greater than one month duration and which have not adequately responded to conventional ulcer therapy.
o When used with standard diabetic foot ulcer care for the treatment of full-thickness neuropathic diabetic foot ulcers of greater than three weeks duration which have not adequately responded to conventional diabetic foot ulcer therapy and which extend through the dermis but without tendon, muscle, capsule or bone exposure.
• Venous Leg Ulcers:
o Coverage for Apligraf® for venous insufficiency ulcers will be considered when ALL of the following conditions are met:
The venous stasis ulcer has been present for greater than one month duration.
The venous stasis ulcer must have failed to respond to documented conservative measures of at least four weeks duration.
• Conservative measures include debridement of necrotic tissue to promote healing.
• Debridement can take the form of wet-to-dry dressings, the use of enzymatic debridement (e.g., Elase, Travase), the application of dressings that enhance leukocyte migration for shallow wounds, or surgical debridement.
• A moist wound-healing environment must be provided. Excess wound exudate must be removed at each dressing change.
• Clinical infections must be eradicated. Graduated venous compression must be applied to eliminate edema.
• Possible choices for compression include elastic stockings with at least 35 mm of compression; Zinc oxide bandages changed weekly, multilayer elastic wraps, and intermittent mechanical compression.
• Prior to Apligraf® application, it is expected the medical record documentation will contain evidence that the conservative measures have failed as evidenced by an ulcer that has increased in size or depth or that there has been no change in baseline size or depth with no sign of improvement or no indication that improvement is likely (lack of granulation or progress toward closing).
The venous stasis ulcer is confirmed as being either partial or full thickness and free of infection. The ulcer must be free of cellulitis, eschar or obvious necrotic material as this will interfere with the device adherence and wound healing.
The patient must have adequate arterial blood supply to support tissue growth.
• Diabetic Foot Ulcers:
o Coverage for Apligraf® for neuropathic diabetic foot ulcers will be considered when ALL of the following conditions are met:
The type 1 or type 2 diabetic is under current medical management.
The full thickness neuropathic diabetic foot ulcer has been present for a minimum of three weeks duration.
The neuropathic diabetic foot ulcer must have failed to respond to documented conservative measures of at least four weeks duration.
• Conservative measures include aggressive sharp or surgical debridement of necrotic tissue, saline moistened dressings and a non-weight-bearing regime. Clinical infections must be eradicated.
• Prior to Apligraf® application, it is expected the medical record documentation will contain evidence that the conservative measures have failed as evidenced by an ulcer that has increased in size and depth or that there has been no change in baseline size or depth with no sign of improvement or no indication that improvement is likely (lack of granulation or progress toward closing).
The neuropathic diabetic foot ulcer is free of infection, tunnels, and tracts.
• Additionally, the ulcer must be free of cellulitis, eschar, or obvious necrotic material as this will interfere with the device adherence and wound healing.
The patient must have adequate arterial blood supply to support tissue growth.
• Apligraf® is contraindicated:
o For use on clinically infected wounds
o In patients with known allergies to bovine collagen
o In patients with known hypersensitivity to the components of the Apligraf® agarose shipping medium (See product label)
• In vitro and in vivo histology studies have shown that Apligraf® either degrades or its cell viability is reduced when the device is exposed to the following cytotoxic agents: Dakin’s solution, Mafenide acetate, Scarlet red dressing, Tincoban, Zinc sulfate, Povodine-iodine solution, Chlorhexidine, or Polymixin/Nystatin.
o The use of Apligraf® with these solutions will be considered NOT medically reasonable and necessary, and will result in denial of reimbursement.
o Additional applications of Apligraf® may be required to achieve adequate wound closure, but should be limited to no more than FIVE applications per wound.
Dermagraft®
• Dermagraft® is a cryopreserved dermal substitute composed of human fibroblasts, extracellular matrix, and a bioabsorbable scaffold.
o During the manufacturing process, the human fibroblasts are seeded into a bioabsorbable polyglactin mesh scaffold.
o The fibroblasts proliferate to fill the interstices of this scaffold and secrete human dermal collagen, matrix proteins, growth factors and cytokines to create a three-dimensional human dermal substitute containing metabolically active, living cells.
• Dermagraft® is supplied frozen in a clear bag containing one piece of approximately 2 inches x 3 inches (5 cm x 7.5 cm) intended for a single use application.
o After the thawing process, Dermagraft® is applied to clean wounds in which any necrotic or hyperkeratinized tissue has been debrided and no active bleeding is present.
o Following the initial application, the wound is covered with an appropriate non-adherent dressing.
o Dressing changes should occur initially 72 hours after the first application and then daily, or as needed thereafter.
o Additional applications of Dermagraft® may be applied weekly, or until wound closure occurs. Dermagraft® should not be applied for more than 8 applications over a 12 week period for the treatment of any given lesion. (See product label for 24-steps involved in the correct use of this product.)
• Dermagraft® will be considered medically reasonable and necessary for the following indication:
o Treatment of full thickness diabetic foot ulcers.
• Coverage for Dermagraft® used in the treatment of full thickness diabetic foot ulcers will be considered when ALL of the following conditions are met:
o The patient has documented type 1 or type 2 diabetes and is currently receiving medical management for this condition.
o The full thickness diabetic foot ulcer has been present for a minimum of six weeks duration.
o The ulcer has failed to respond to conservative measures such as non-weight bearing regimen, debridement of necrotic and callused tissue, and acceptable methods of wound care.
o The ulcer extends through the dermis, but does not involve tendon, muscle, joint capsule, or have bone exposure.
o The patient must have an adequate arterial blood supply to the foot in order to support tissue growth as evidenced by a palpable pulse on the foot (either dorsalis pedis or posterior tibial artery).
• Dermagraft® is contraindicated for use in patients with:
o Signs of clinical infection. (e.g., increased exudates, odor, redness, swelling, heat, pain, tenderness, purulent discharge).
o Ulcers with sinus tracts.
o Patients with known hypersensitivity to bovine products, as it may contain trace amounts of bovine proteins from the manufacturing medium and storage solution.
• The use of Dermagraft® in the treatment of full thickness diabetic ulcers has not been studied in patients receiving greater than 8 applications, children under the age of 18, pregnant women, patients with ulcers over a Charcot’s deformity of the midfoot or patient receiving immunosuppressive or cytotoxic agents, and is NOT indicated when these conditions are present.
• Any topical agents, cytotoxic cleansing solutions, or medications (e.g., lotions, ointments, creams, or gels) on an ulcer being treated with Dermagraft® may reduce the viability of the product.
o The use of Dermagraft® in conjunction with these solutions will be considered not reasonable and necessary and will result in denial of reimbursement.
Integra® Dermal Regeneration Template (DRT)
• Integra® DRT is a bilayer membrane system for skin replacement.
o The dermal replacement layer is made of a porous matrix of fibers of cross-linked bovine tendon collagen and glycosaminoglycan (chondroitin-6-sulfate) that is manufactured with a controlled porosity and defined degradation rate.
o The temporary epidermal substitute layer is made of synthetic polysiloxane polymer (silicone) and functions to control moisture loss from the wound.
o The collagen dermal replacement layer serves as a matrix for the infiltration of fibroblasts, macrophages, lymphocytes, and capillaries derived from the wound bed.
• Integra® DRT is used for the treatment of deep partial-thickness or full-thickness thermal injury to the skin.
• It is applied following excision of the burn wound to viable tissue.
• It serves two critical functions:
o As an "artificial skin" that provides immediate postexcisional wound homeostasis;
o As a template to generate "neodermis," a dermal-like tissue that readily accepts very thin epidermal autografts.
Formation of the neodermis typically takes 14-21 days.
After the neodermis is formed, the silicone layer is easily removed and a very thin meshed and widely spread epidermal autograft can be applied over the neodermis.
These thin epidermal autografts result in less donor site morbidity than conventional split-thickness autografts.
Since the epidermal autograft can be applied immediately after the neodermis has formed, the application of the epidermal autograft can also be scheduled at a time when sufficient donor sites are available and/or the patient's condition is suitable for the grafting procedure.
In a multicenter clinical trial, Integra® DRT remained in place successfully for up to 73 days prior to epidermal autografting.
• Integra® DRT will be considered medically reasonable and necessary for the following indication:
o Post-excisional treatment of life-threatening full-thickness or deep partial-thickness thermal injuries where sufficient autograft is not available at the time of excision or not desirable due to the physiological condition of the patient.
• Excision of the wound must be performed thoroughly to remove all coagulation eschar and nonviable tissue. Integra® DRT will not take to nonviable tissue.
o Leaving any remaining nonviable tissue may create an environment for bacterial growth. Hemostatis must be achieved prior to applying Integra® DRT.
o Inadequate control of bleeding will interfere with the incorporation of this product.
o Integra® DRT should be applied on the day of excision.
• Integra® DRT should not be used on patients with known allergies to cow collagen or in patients with clinically diagnosed infected wounds.
OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix
• OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix are biologically derived extracellular matrix-based wound products that are compatible with human tissue.
o Unlike other collagen-based wound care materials, OASIS® is a complex scaffold that provides an optimal environment for a favorable host tissue response, a response characterized by restoration of tissue structure and function.
o OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix are comprised of porcine-derived acellular small intestine submucosal (SIS) for use in wound management.
• OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix will be considered reasonable and medically necessary for the following indications:
o Partial and full-thickness wounds (neuropathic diabetic foot or venous stasis ulcers)
o Venous ulcers
o Diabetic ulcers
• Coverage for OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix for venous stasis ulcers ((VSU) will be considered when ALL the following conditions are met:
o The venous stasis ulcer has been present for greater than one month duration; and
o The venous stasis ulcer has failed to respond to documented conservative measures of at least four weeks duration.
A “failed response” is defined as an ulcer that has increased in size or depth, or for which there has been no change in baseline size or depth and no sign of improvement or indication that improvement is likely, such as granulation, epithelialization, or progress towards closing.
Documentation of response or lack thereof requires measurement of the ulcer at baseline and at completion of at least four weeks of standard conservative management.
Documentation should also include measurement of the ulcer immediately prior to the placement of OASIS Wound Matrix.
Conservative methods of wound care include wound tissue hydration with saline, non-adherent dressings, moisture-donating or absorptive dressing (depending on amount of exudate), and compression wraps.
• Coverage for OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix for neuropathic diabetic foot ulcers (DFU) will be considered when ALL the following conditions are met:
o The patient is currently under management for either Type I or Type II diabetes mellitus.
o The non-healing diabetic foot ulcer has been present for greater than one month and has a viable wound bed with granulation tissue present.
o Standard conservative wound care measures have been tried.
Conservative measures include removal of mechanical stress, debridement of necrotic tissue if present, and saline moistened dressings; and
o The ulcer is located on the foot or toes that are free of exposed bone, tendon, or fascia.
• OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix are contraindicated for patients with known sensitivity to porcine material and for use in third degree burns.
• The use of OASIS® Wound Matrix and OASIS® Ultra Tri-Layer Matrix on infected] wounds, wounds with excessive exudates, bleeding, acute swelling, cellulitis, osteomyelitis, necrotic ulcer, bone exposed wound bed, or clinically significant lack of wound healing due to uncontrolled diabetes is NOT considered medically reasonable and necessary, and will result in denial of the claim.
• The use of OASIS® Ultra Tri-Layer Matrix should only be used on large problematic wounds requiring larger thicker applications of OASIS®.
o Minimal to no wastage would be expected when using OASIS® Ultra Tri-Layer Matrix for these type wounds.
• Coverage will not be provided under this LCD for any wound treatment that does not meet the definition of C9365 (ASC only), Q4101, Q4102, Q4105, or Q4106.
o All other such products will be considered to be, at most, “biologic wound dressings” which are included in the Evaluation and Management (E/M) service and should not be billed separately.
CPT/HCPCS Codes
Note: For graft preparation and application, see attached “Coding Guidelines”.
Q4105 INTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER SQUARE CENTIMETER
Q4106 DERMAGRAFT, PER SQUARE CENTIMETER
Q4101 APLIGRAF, PER SQUARE CENTIMETER
Q4102 OASIS WOUND MATRIX, PER SQUARE CENTIMETER
Q4124 OASIS ULTRA TRI-LAYER WOUND MATRIX, PER SQUARE CENTIMETER
The following HCPCS codes are not separately payable and are considered not medically reasonable and necessary products:
Acceptable literature supporting use of any of the below not medically reasonable and necessary products may be submitted with a formal reconsideration request to this LCD. Refer to the reconsideration process outlined on the website http://medicare.fcso.com
C9363 Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter (ASC only)
C9366 EpiFix, per square centimeter (ASC only)
C9367 Skin Substitute, Endoform Dermal Template, per square centimeter (ASC only)
C9368 Grafix core, per square centimeter (ASC only)
C9369 Grafix prime, per square centimeter (ASC only)
J3590 Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter (Provider only)
A new service or procedure that has been issued a CPT/HCPCS code or is FDA approved does not, in itself, make the procedure "medically reasonable and necessary." New services, procedures, technologies must be evaluated and approved either nationally or by the medical policy staff before they are considered Medicare covered services.
NOTE: An Advance Beneficiary Notice (ABN) is required for items and services not covered by Medicare due to being considered not medically reasonable and necessary. The beneficiary should be thoroughly educated about the benefits and risks of this item or service. If such notice is not given, providers may not shift financial liability for such items or services to beneficiaries should a claim for such items or services be denied by Medicare.
Q4125 ARTHROFLEX, PER SQUARE CENTIMETER
Q4126 MEMODERM, DERMASPAN, TRANZGRAFT OR INTEGUPLY, PER SQUARE CENTIMETER
Q4127 TALYMED, PER SQUARE CENTIMETER
Q4128 FLEX HD, ALLOPATCH HD, OR MATRIX HD, PER SQUARE CENTIMETER
Q4129 UNITE BIOMATRIX, PER SQUARE CENTIMETER
Q4130 STRATTICE TM, PER SQUARE CENTIMETER
Q4131 EPIFIX, PER SQUARE CENTIMETER
Q4132 GRAFIX CORE, PER SQUARE CENTIMETER
Q4133 GRAFIX PRIME, PER SQUARE CENTIMETER
Q4134 HMATRIX, PER SQUARE CENTIMETER
Q4135 MEDISKIN, PER SQUARE CENTIMETER
Q4136 EZ-DERM, PER SQUARE CENTIMETER
Q4103 OASIS BURN MATRIX, PER SQUARE CENTIMETER
Q4104 INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARE CENTIMETER
C9363 SKIN SUBSTITUTE, INTEGRA MESHED BILAYER WOUND MATRIX, PER SQUARE CENTIMETER
C9367 SKIN SUBSTITUTE, ENDOFORM DERMAL TEMPLATE, PER SQUARE CENTIMETER
J3590 UNCLASSIFIED BIOLOGICS
Q4100 SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED
Q4107 GRAFTJACKET, PER SQUARE CENTIMETER
Q4108 INTEGRA MATRIX, PER SQUARE CENTIMETER
Q4110 PRIMATRIX, PER SQUARE CENTIMETER
Q4111 GAMMAGRAFT, PER SQUARE CENTIMETER
Q4112 CYMETRA, INJECTABLE, 1CC
Q4113 GRAFTJACKET XPRESS, INJECTABLE, 1CC
Q4114 INTEGRA FLOWABLE WOUND MATRIX, INJECTABLE, 1CC
Q4115 ALLOSKIN, PER SQUARE CENTIMETER
Q4117 HYALOMATRIX, PER SQUARE CENTIMETER
Q4118 MATRISTEM MICROMATRIX, 1 MG
Q4119 MATRISTEM WOUND MATRIX, PSMX, RS, OR PSM, PER SQUARE CENTIMETER
Q4120 MATRISTEM BURN MATRIX, PER SQUARE CENTIMETER
Q4121 THERASKIN, PER SQUARE CENTIMETER
Q4122 DERMACELL, PER SQUARE CENTIMETER
Q4123 ALLOSKIN RT, PER SQUARE CENTIMETER
ICD-9 Codes that Support Medical Necessity
Apligraf® (Q4101)
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
454.0 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER
454.2 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION
459.31 CHRONIC VENOUS HYPERTENSION WITH ULCER
459.33 CHRONIC VENOUS HYPERTENSION WITH ULCER AND INFLAMMATION
707.10 UNSPECIFIED ULCER OF LOWER LIMB
707.11 ULCER OF THIGH
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
707.19 ULCER OF OTHER PART OF LOWER LIMB
707.8 CHRONIC ULCER OF OTHER SPECIFIED SITES
OASIS® Wound Matrix (Q4102)and OASIS® Ultra Tri-layer Matrix (Q4124)
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
454.0 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER
454.2 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION
459.31 CHRONIC VENOUS HYPERTENSION WITH ULCER
459.33 CHRONIC VENOUS HYPERTENSION WITH ULCER AND INFLAMMATION
707.10 UNSPECIFIED ULCER OF LOWER LIMB
707.11 ULCER OF THIGH
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
707.19 ULCER OF OTHER PART OF LOWER LIMB
707.8 CHRONIC ULCER OF OTHER SPECIFIED SITES
[Integra® DRT (Q4105)
941.30 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF FACE AND HEAD
941.31 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF EAR (ANY PART)
941.34 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF CHIN
941.35 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF NOSE (SEPTUM)
941.36 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF SCALP (ANY PART)
941.37 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOREHEAD AND CHEEK
941.38 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF NECK
941.39 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK
941.40 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF FACE AND HEAD WITHOUT LOSS OF BODY PART
941.41 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF EAR (ANY PART) WITHOUT LOSS OF EAR
941.44 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF CHIN WITHOUT LOSS OF CHIN
941.45 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF NOSE (SEPTUM) WITHOUT LOSS OF NOSE
941.46 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF SCALP (ANY PART) WITHOUT LOSS OF SCALP
941.47 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOREHEAD AND CHEEK WITHOUT LOSS OF FOREHEAD AND CHEEK
941.48 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF NECK WITHOUT LOSS OF NECK
941.49 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK WITHOUT LOSS OF A BODY PART
941.50 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FACE AND HEAD UNSPECIFIED SITE WITH LOSS OF BODY PART
941.51 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF EAR (ANY PART) WITH LOSS OF EAR
941.54 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF CHIN WITH LOSS OF CHIN
941.55 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF NOSE (SEPTUM) WITH LOSS OF NOSE
941.56 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF SCALP (ANY PART) WITH LOSS OF SCALP
941.57 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOREHEAD AND CHEEK WITH LOSS OF FOREHEAD AND CHEEK
941.58 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF NECK WITH LOSS OF NECK
941.59 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES (EXCEPT EYE) OF FACE HEAD AND NECK WITH LOSS OF A BODY PART
942.20 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF UNSPECIFIED SITE OF TRUNK
942.21 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF BREAST
942.22 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF CHEST WALL EXCLUDING BREAST AND NIPPLE
942.23 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF ABDOMINAL WALL
942.24 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF BACK (ANY PART)
942.25 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF GENITALIA
942.29 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK
942.30 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF TRUNK
942.31 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF BREAST
942.32 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF CHEST WALL EXCLUDING BREAST AND NIPPLE
942.33 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF ABDOMINAL WALL
942.34 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF BACK (ANY PART)
942.35 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF GENITALIA
942.39 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF OTHER AND MULTIPLE SITES OF TRUNK
942.40 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TRUNK UNSPECIFIED SITE WITHOUT LOSS OF BODY PART
942.41 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF BREAST WITHOUT LOSS OF BREAST
942.42 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF CHEST WALL EXCLUDING BREAST AND NIPPLE WITHOUT LOSS OF CHEST WALL
942.43 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF ABDOMINAL WALL WITHOUT LOSS OF ABDOMINAL WALL
942.44 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF BACK (ANY PART) WITHOUT LOSS OF BACK
942.45 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF GENITALIA WITHOUT LOSS OF GENITALIA
942.49 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK WITHOUT LOSS OF BODY PART
942.50 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF TRUNK WITH LOSS OF BODY PART
942.51 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF BREAST WITH LOSS OF BREAST
942.52 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF CHEST WALL EXCLUDING BREAST AND NIPPLE WITH LOSS OF CHEST WALL
942.53 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF ABDOMINAL WALL WITH LOSS OF ABDOMINAL WALL
942.54 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF BACK (ANY PART) WITH LOSS OF BACK
942.55 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF GENITALIA WITH LOSS OF GENITALIA
942.59 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK WITH LOSS OF A BODY PART
943.30 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF UPPER LIMB
943.31 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOREARM
943.32 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF ELBOW
943.33 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UPPER ARM
943.34 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF AXILLA
943.35 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF SHOULDER
943.36 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF SCAPULAR REGION
943.39 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND
943.40 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF UPPER LIMB WITHOUT LOSS OF A BODY PART
943.41 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOREARM WITHOUT LOSS OF FOREARM
943.42 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF ELBOW WITHOUT LOSS OF ELBOW
943.43 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UPPER ARM WITHOUT LOSS OF UPPER ARM
943.44 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN OF AXILLA WITHOUT LOSS OF AXILLA
943.45 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF SHOULDER WITHOUT LOSS OF SHOULDER
943.46 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF SCAPULAR REGION WITHOUT LOSS OF SCAPULA
943.49 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND WITHOUT LOSS OF UPPER LIMB
943.50 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF UPPER LIMB WITH LOSS OF A BODY PART
943.51 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOREARM WITH LOSS OF FOREARM
943.52 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF ELBOW WITH LOSS OF ELBOW
943.53 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UPPER ARM WITH LOSS OF UPPER ARM
943.54 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF AXILLA WITH LOSS OF AXILLA
943.55 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF SHOULDER WITH LOSS OF SHOULDER
943.56 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF SCAPULAR REGION WITH LOSS OF SCAPULA
943.59 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND WITH LOSS OF UPPER LIMB
944.30 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF HAND
944.31 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB
944.32 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF THUMB (NAIL)
944.33 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF TWO OR MORE DIGITS OF HAND NOT INCLUDING THUMB
944.34 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF TWO OR MORE DIGITS OF HAND INCLUDING THUMB
944.35 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF PALM OF HAND
944.36 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF BACK OF HAND
944.37 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF WRIST
944.38 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF WRIST(S) AND HAND(S)
944.40 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF HAND WITHOUT LOSS OF HAND
944.41 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB WITHOUT LOSS OF FINGER
944.42 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF THUMB (NAIL) WITHOUT LOSS OF THUMB
944.43 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TWO OR MORE DIGITS OF HAND NOT INCLUDING THUMB WITHOUT FINGERS
944.44 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TWO OR MORE DIGITS OF HAND INCLUDING THUMB WITHOUT LOSS OF FINGERS
944.45 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF PALM OF HAND WITHOUT LOSS OF PALM
944.46 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF BACK OF HAND WITHOUT LOSS OF BACK OF HAND
944.47 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF WRIST WITHOUT LOSS OF WRIST
944.48 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) WITHOUT LOSS OF A BODY PART
944.50 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF HAND WITH LOSS OF HAND
944.51 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB WITH LOSS OF FINGER
944.52 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF THUMB (NAIL) WITH LOSS OF THUMB
944.53 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TWO OR MORE DIGITS OF HAND NOT INCLUDING THUMB WITH LOSS OF FINGERS
944.54 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TWO OR MORE DIGITS OF HAND INCLUDING THUMB WITH LOSS OF FINGERS
944.55 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF PALM OF HAND WITH LOSS OF PALM OF HAND
944.56 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF BACK OF HAND WITH LOSS OF BACK OF HAND
944.57 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF WRIST WITH LOSS OF WRIST
944.58 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S) WITH LOSS OF A BODY PART
945.20 BLISTERS EPIDERMAL LOSS (SECOND DEGREE) OF UNSPECIFIED SITE OF LOWER LIMB (LEG)
945.21 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF TOE(S) (NAIL)
945.22 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FOOT
945.23 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF ANKLE
945.24 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF LOWER LEG
945.25 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF KNEE
945.26 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF THIGH (ANY PART)
945.29 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S)
945.30 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF LOWER LIMB
945.31 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF TOE(S) (NAIL)
945.32 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOOT
945.33 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF ANKLE
945.34 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF LOWER LEG
945.35 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF KNEE
945.36 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF THIGH (ANY PART)
945.39 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF LOWER LIMB(S)
945.40 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE OF LOWER LIMB (LEG) WITHOUT LOSS OF A BODY PART
945.41 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TOE(S) (NAIL) WITHOUT LOSS OF TOE(S)
945.42 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOOT WITHOUT LOSS OF FOOT
945.43 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF ANKLE WITHOUT LOSS OF ANKLE
945.44 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF LOWER LEG WITHOUT LOSS OF LOWER LEG
945.45 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF KNEE WITHOUT LOSS OF KNEE
945.46 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF THIGH (ANY PART) WITHOUT LOSS OF THIGH
945.49 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S) WITHOUT LOSS OF A BODY PART
945.50 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF UNSPECIFIED SITE LOWER LIMB (LEG) WITH LOSS OF A BODY PART
945.51 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF TOE(S) (NAIL) WITH LOSS OF TOE(S)
945.52 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF FOOT WITH LOSS OF FOOT
945.53 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF ANKLE WITH LOSS OF ANKLE
945.54 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF LOWER LEG WITH LOSS OF LOWER LEG
945.55 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF KNEE WITH LOSS OF KNEE
945.56 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF THIGH (ANY PART) WITH LOSS OF THIGH
945.59 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S) WITH LOSS OF A BODY PART
946.0 BURNS OF MULTIPLE SPECIFIED SITES UNSPECIFIED DEGREE
946.1 ERYTHEMA DUE TO BURN (FIRST DEGREE) OF MULTIPLE SPECIFIED SITES
946.2 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SPECIFIED SITES
946.3 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SPECIFIED SITES
946.4 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITHOUT LOSS OF A BODY PART
946.5 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITH LOSS OF A BODY PART
948.00 BURN (ANY DEGREE) INVOLVING LESS THAN 10 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.10 BURN (ANY DEGREE) INVOLVING 10-19 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.11 BURN (ANY DEGREE) INVOLVING 10-19 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.20 BURN (ANY DEGREE) INVOLVING 20-29 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.21 BURN (ANY DEGREE) INVOLVING 20-29 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.22 BURN (ANY DEGREE) INVOLVING 20-29 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 20-29%
948.30 BURN (ANY DEGREE) INVOLVING 30-39 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.31 BURN (ANY DEGREE) INVOLVING 30-39 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.32 BURN (ANY DEGREE) INVOLVING 30-39 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 20-29%
948.33 BURN (ANY DEGREE) INVOLVING 30-39 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 30-39%
948.40 BURN (ANY DEGREE) INVOLVING 40-49 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.41 BURN (ANY DEGREE) INVOLVING 40-49 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.42 BURN (ANY DEGREE) INVOLVING 40-49 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 20-29%
948.43 BURN (ANY DEGREE) INVOLVING 40-49 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 30-39%
948.44 BURN (ANY DEGREE) INVOLVING 40-49 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 40-49%
948.50 BURN (ANY DEGREE) INVOLVING 50-59 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.51 BURN (ANY DEGREE) INVOLVING 50-59 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.52 BURN (ANY DEGREE) INVOLVING 50-59 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 20-29%
948.53 BURN (ANY DEGREE) INVOLVING 50-59 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 30-39%
948.54 BURN (ANY DEGREE) INVOLVING 50-59 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 40-49%
948.55 BURN (ANY DEGREE) INVOLVING 50-59 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 50-59%
948.60 BURN (ANY DEGREE) INVOLVING 60-69 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.61 BURN (ANY DEGREE) INVOLVING 60-69 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.62 BURN (ANY DEGREE) INVOLVING 60-69 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 20-29%
948.63 BURN (ANY DEGREE) INVOLVING 60-69 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 30-39%
948.64 BURN (ANY DEGREE) INVOLVING 60-69 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 40-49%
948.65 BURN (ANY DEGREE) INVOLVING 60-69 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 50-59%
948.66 BURN (ANY DEGREE) INVOLVING 60-69 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 60-69%
948.70 BURN (ANY DEGREE) INVOLVING 70-79 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.71 BURN (ANY DEGREE) INVOLVING 70-79 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.72 BURN (ANY DEGREE) INVOLVING 70-79 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 20-29%
948.73 BURN (ANY DEGREE) INVOLVING 70-79 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 30-39%
948.74 BURN (ANY DEGREE) INVOLVING 70-79 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 40-49%
948.75 BURN (ANY DEGREE) INVOLVING 70-79 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 50-59%
948.76 BURN (ANY DEGREE) INVOLVING 70-79 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 60-69%
948.77 BURN (ANY DEGREE) INVOLVING 70-79 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 70-79%
948.80 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.81 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.82 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 20-29%
948.83 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 30-39%
948.84 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 40-49%
948.85 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 50-59%
948.86 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 60-69%
948.87 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 70-79%
948.88 BURN (ANY DEGREE) INVOLVING 80-89 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF 80-89%
948.90 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT
948.91 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 10-19%
948.92 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 20-29%
948.93 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 30-39%
948.94 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 40-49%
948.95 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 50-59%
948.96 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 60-69%
948.97 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 70-79%
948.98 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 80-89%
948.99 BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 90% OR MORE OF BODY SURFACE
949.3 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) UNSPECIFIED SITE
949.4 DEEP NECROSIS OF UNDERLYING TISSUE DUE TO BURN (DEEP THIRD DEGREE) UNSPECIFIED SITE WITHOUT LOSS OF A BODY PART
949.5 DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART
Dermagraft® (Q4106)
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
707.14 ULCER OF HEEL AND MIDFOOT
707.15 ULCER OF OTHER PART OF FOOT
Diagnoses that Support Medical Necessity
See ICD-9 Codes that Support Medical Necessity.
Documentation Requirements
• Medical record documentation maintained by the treating provider must substantiate the medical necessity of the services being billed.
o In addition, documentation that the service was performed must be included in the patient’s medical record.
o This information is normally found in the history and physical, office/progress notes, hospital notes, and/or procedure report.
• The medical record must clearly show that the criteria listed under the “Indications and Limitations of Coverage and/or Medical Necessity” sections have been met, as well as, the appropriate diagnosis and response to treatment.
o Description of the wound must be documented at baseline (prior to beginning conservative treatment) relative to size, location, stage, duration, and presence of infection, in addition to type of treatment given and response.
o This information must be updated throughout treatment.
o Wound description must also be documented pre and post treatment with the skin substitute being used.
o If obvious signs of worsening or lack of treatment response is noted, continuing treatment with the skin substitute would not be considered medically reasonable and necessary without documentation of a reasonable rational for doing so.
• Documentation must support FDA labeling (where applicable), including the criteria, frequency, and acceptable duration of treatment for any skin substitute product billed.
• Since application of Apligraf, OASIS® Wound Matrix and Ultra Tri-Layer Matrix, Integra DRT, and Dermagraft, as well as any subsequently-accepted similar product is considered a physician service, it must be applied by either a physician or a non-physician provider (NPP), and NOT by non-advance practice nurses, therapists or medical assistants.
Utilization Guidelines
• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.
o When services are performed in excess of established parameters, they may be subject to medical review.
• The safety and effectiveness of Apligraf® have not been established for patients receiving more than five device applications.
• The use of Dermagraft® is limited to no more than 8 applications per treatment site over a 12 week period.
• The safety and effectiveness of re-treatment of a single wound using Apligraf® or Dermagraft® has not been established and is not covered.
Treatment Logic
• Tissue-engineered skin substitutes (i.e. human skin equivalents, dermal substitute tissues) are products that use living cells (e.g., fibroblasts and keratinocytes) or other collagen-derived or biologically-derived extracellular matrix in a scaffold of natural, biodegradable or synthetic matrices to foster wound healing.
• The scaffold provides a stable framework that guides tissue integration and development.
• The scaffold is also able to bind autologous proteins which influence cell migration and adherence.
• Skin substitutes are indicated in the treatment of wounds that have not responded to aggressive, conventional wound therapy, or as outlined in the indications given below.
Sources of Information and Basis for Decision
Advanced BioHealing, Inc. (2007). Product information on Dermagraft: directions for use. LaJolla, CA
Angirasa, A., Willrich, A., Cooper, B., Stuck, R. (2006). Combining bioengineered human dermal replacement and multilayered compression dressings to manage ulcers in a person with diabetes. Ostomy Wound Management, 52: 5.
FCSO LCD 29279, Skin Substitutes, 01/01/2013. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/
Fryberg, R. G., Armstrong, D. G., Giurini, J., Edwards, A., Karvette, M., Kravitz, S., Ross, C., Stovosky, J., Stuck, R. & Vanore, J. (2000). Diabetic foot disorders, a clinical practice guideline. The American College of Foot and Ankle Surgeons, and The American College of Foot and Ankle Orthopedic and Medicine. Park Ridge, IL. This source was used to provide a device description and clinical indications for the use of the product.
Food and Drug Administration, Medical Device Reporting. (2001). Summary of Safety and Effectiveness Data: Dermagraft®. Author. Rockville, MD. This source was used to provide indications and contraindications for use.
Food and Drug Administration, Medicare Device Reporting. (2008). Premarket Approval Database, Integra® Dermal Regeneration Template.
Food and Drug Administration, 510(k) Premarket notification summary. (2008). Integra™ Meshed Bilayer Wound Matrix.
Food and Drug Administration, Tissue and tissue products, 2011
Hanft, J. R., & Surprenant, M. S. (2002). Healing of chronic foot ulcers in diabetic patients treated with a human fibroblast-derived dermis. Journal of Foot and Ankle Surgery, 41, (5) 291-299. This source was used as a reference for indications and contraindicated conditions.
Healthpoint, Ltd. (2011). Product information on OASIS® Ultra Tri-Layer Matrix. Cook BioTech, Inc.
Integra Life Sciences Corp. (2004). Integra® prescribing information [Brochure]. Plainsboro, New Jersey: Author. This source was used to provide a description of and indications for use of the product.
Medicare Coverage Database
Mostow, E.N., Haraway, G.D., Dalsing, M., Hodde, J.P., King, D. (2005). Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial. Journal of Vascular Surgery, 41 (5): 837-43.
National Guideline Clearinghouse. (2004). Guideline for management of wounds in patients with lower-extremity neuropathic disease. Available: http://www.guideline.gov
Niezgoda, J.A., Van Gils, C.C., Frykberg, R.G., & Hodde, J.P. (2005). Randomized Clinical Trial Comparing OASIS Wound Matrix to Regranex Gel for Diabetic Ulcers. Advances in Skin & Wound Care, 18 (5):258-66.
Novartis Pharmaceuticals Corp. (2002). Apligraf® prescribing information. [Brochure]. East Hanover, New Jersey: Author. This source was used to provide a description of and indications for use of the product.
Organogenesis, Inc. (2006). Apligraf product lael. Received from Apligraf medical information center, Canton, MA on January 6, 2009.
Rakel, R.E. (Eds.). (2000). Saunders manual of medical practice (2nd ed.). Philadelphia, PA: W.B. Saunders Company. Used to determine diagnosis and conservative treatment.
Smith & Nephew, Inc. Wound Management Division. (2001). Dermagraft® human fibroblast-derived dermal substitute; directions for use. [Brochure]. Largo, FL: Author. This source was used to provide a description for the use of the product.
Smith & Nephew, Inc. Wound Management (2002). TranCyte Human Fibroblast-Derived Temporary Skin Substitute; Direction for use [Brochure] LaJolla, CA: Author.
Towsend, C. M. (Ed.). (2001). Sabiston textbook of surgery: the biological basis of modern surgical practice (16th ed.). (pp. 355-356). St. Louis, MO. W.B. Sanders. This source was used to provide indications for treatment of burn patients.
University of Pennsylvania School of Medicine. (2000) Venous leg ulcer guideline. [On-line]. Available: http://www.guideline.gov/VIEWS/summary.a…rief_summary&sSearch_string=venous+ulcer. Used to determine conservative treatment.
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