Healthcare Common Procedure Coding System (HCPCS) Codes and Diagnosis Coding

11.3.2 – Healthcare Common Procedure Coding System (HCPCS) Codes and Diagnosis Coding (Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02- 14-22 MACs) Healthcare Common Procedure Coding System (HCPCS) Code Effective for claims with dates of service on or after April 13, 2021, Medicare providers shall report HCPCS code G0460 for PRP services for the treatment of chronic non-healing non-diabetic wounds. Effective for claims with dates of service on or after April 13, 2021, Medicare providers shall report HCPCS code G0465 for PRP services for the treatment of chronic non-healing diabetic wounds under the conditions and criteria outlined in NCD Manual Section 270.3. If ICD-10 Diagnosis coding is applicable For claims with dates of service on or after April 13, 2021, PRP, for the treatment of chronic non-healing diabetic wounds must be billed reporting both an ICD-10 diagnosis code for diabetes mellitus and an ICD-10 diagnosis code for chronic ulcers. - Two diagnosis codes are required- Diabetic Mellitus plus Chronic Ulcer Diabetes Mellitus E08.621 Diabetes mellitus due to underlying condition with foot ulcer E08.622 Diabetes mellitus due to underlying condition with other skin ulcer E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E13.621 Other specified diabetes mellitus with foot ulcer E13.622 Other specified diabetes mellitus with other skin ulcer Chronic Ulcer L97.111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin L97.112 Non-pressure chronic ulcer of right thigh with fat layer exposed L97.113 Non-pressure chronic ulcer of right thigh with necrosis of muscle L97.115 Non-pressure chronic ulcer of right thigh with muscle involvement without evidence of necrosis L97.116 Non-pressure chronic ulcer of right thigh with bone involvement without evidence of necrosis L97.118 Non-pressure chronic ulcer of right thigh with other specified severity L97.114 Non-pressure chronic ulcer of right thigh with necrosis of bone L97.121 Non-pressure chronic ulcer of left thigh limited to breakdown of skin L97.122 Non-pressure chronic ulcer of left thigh with fat layer exposed L97.123 Non-pressure chronic ulcer of left thigh with necrosis of muscle L97.124 Non-pressure chronic ulcer of left thigh with necrosis of bone L97.125 Non-pressure chronic ulcer of left thigh with muscle involvement without evidence of necrosis L97.126 Non-pressure chronic ulcer of left thigh with bone involvement without evidence of necrosis L97.128 Non-pressure chronic ulcer of left thigh with other specified severity L97.211 Non-pressure chronic ulcer of right calf limited to breakdown of skin L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed L97.213 Non-pressure chronic ulcer of right calf with necrosis of muscle L97.214 Non-pressure chronic ulcer of right calf with necrosis of bone L97.215 Non-pressure chronic ulcer of right calf with muscle involvement without evidence of necrosis L97.216 Non-pressure chronic ulcer of right calf with bone involvement without evidence of necrosis L97.218 Non-pressure chronic ulcer of right calf with other specified severity L97.221 Non-pressure chronic ulcer of left calf limited to breakdown of skin L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed L97.223 Non-pressure chronic ulcer of left calf with necrosis of muscle L97.224 Non-pressure chronic ulcer of left calf with necrosis of bone L97.225 Non-pressure chronic ulcer of left calf with muscle involvement without evidence of necrosis L97.226 Non-pressure chronic ulcer of left calf with bone involvement without evidence of necrosis L97.228 Non-pressure chronic ulcer of left calf with other specified severity L97.315 Non-pressure chronic ulcer of right ankle with muscle involvement without evidence of necrosis L97.316 Non-pressure chronic ulcer of right ankle with bone involvement without evidence of necrosis L97.318 Non-pressure chronic ulcer of right ankle with other specified severity L97.321 Non-pressure chronic ulcer of left ankle limited to breakdown of skin L97.322 Non-pressure chronic ulcer of left ankle with fat layer exposed L97.323 Non-pressure chronic ulcer of left ankle with necrosis of muscle L97.324 Non-pressure chronic ulcer of left ankle with necrosis of bone L97.325 Non-pressure chronic ulcer of left ankle with muscle involvement without evidence of necrosis L97.326 Non-pressure chronic ulcer of left ankle with bone involvement without evidence of necrosis L97.328 Non-pressure chronic ulcer of left ankle with other specified severity L97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin L97.412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed L97.413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle L97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone L97.415 Non-pressure chronic ulcer of right heel and midfoot with muscle involvement without evidence of necrosis L97.416 Non-pressure chronic ulcer of right heel and midfoot with bone involvement without evidence of necrosis L97.418 Non-pressure chronic ulcer of right heel and midfoot with other specified severity L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin L97.422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed L97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle L97.424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone L97.425 Non-pressure chronic ulcer of left heel and midfoot with muscle involvement without evidence of necrosis L97.426 Non-pressure chronic ulcer of left heel and midfoot with bone involvement without evidence of necrosis L97.428 Non-pressure chronic ulcer of left heel and midfoot with other specified severity L98.411 Non-pressure chronic ulcer of buttock limited to breakdown of skin L98.412 Non-pressure chronic ulcer of buttock with fat layer exposed L98.413 Non-pressure chronic ulcer of buttock with necrosis of muscle L98.414 Non-pressure chronic ulcer of buttock with necrosis of bone L98.415 Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necrosis L98.416 Non-pressure chronic ulcer of buttock with bone involvement without evidence of necrosis L98.418 Non-pressure chronic ulcer of buttock with other specified severity L98.421 Non-pressure chronic ulcer of back limited to breakdown of skin L98.422 Non-pressure chronic ulcer of back with fat layer exposed L98.423 Non-pressure chronic ulcer of back with necrosis of muscle L98.424 Non-pressure chronic ulcer of back with necrosis of bone L98.425 Non-pressure chronic ulcer of back with muscle involvement without evidence of necrosis L98.426 Non-pressure chronic ulcer of back with bone involvement without evidence of necrosis L98.428 Non-pressure chronic ulcer of back with other specified severity L98.491 Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin L98.492 Non-pressure chronic ulcer of skin of other sites with fat layer exposed L98.493 Non-pressure chronic ulcer of skin of other sites with necrosis of muscle L98.494 Non-pressure chronic ulcer of skin of other sites with necrosis of bone Frequency Requirements: Effective for claims with dates of service on and after April 13, 2021, contractors shall cover PRP services for chronic non-healing diabetic wounds, G0465, for a maximum of 20 weeks beginning with the first week of treatment. Effective for claims with dates of services on or after April 13, 2021, the local MACs shall have discretion to pay PRP services for chronic non-healing diabetic wounds, G0465, that are performed more than 20 weeks after the date of the first PRP service when the -KX modifier is reported on the claim. Effective for claims with dates of service on and after April 13, 2021, contractors shall have discretion to cover, and determine frequency for, PRP services for chronic non-healing non-diabetic wounds, G0460.