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Coverage

The Centers for Medicare & Medicaid Services (CMS) will reimburse for autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds, using an FDA-cleared device, under section 1862(a)(1)(A) of the Social Security Act (the Act) for a duration of 20 weeks, when prepared by devices whose FDA-cleared indications include the management of exuding cutaneous wounds, such as diabetic ulcers.

Coverage of autologous PRP for the treatment of chronic non-healing diabetic wounds beyond 20 weeks will be determined by local Medicare Administrative Contractors (MACs).

Coverage of autologous PRP for the treatment of all other chronic non-healing wounds will be determined by local Medicare Administrative Contractors (MACs) under section 1862(a)(1)(A) of the Act.

Coverage under private insurance is currently determined on a case-by-case basis.

Healthcare Diagnosis Codes (ICD-10) for CMS Coverage

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

E08.621Diabetes mellitus due to underlying condition with foot ulcer
E08.622Diabetes mellitus due to underlying condition with other skin ulcer
E09.621Drug or chemical induced diabetes mellitus with foot ulcer
E09.622Drug or chemical induced diabetes mellitus with other skin ulcer
E10.621Type 1 diabetes mellitus with foot ulcer
E10.622Type 1 diabetes mellitus with other skin ulcer
E11.621Type 2 diabetes mellitus with foot ulcer
E11.622Type 2 diabetes mellitus with other skin ulcer
E13.621Other specified diabetes mellitus with foot ulcer
E13.622Other specified diabetes mellitus with other skin ulcer

Chronic Ulcer

L97.111Non-pressure chronic ulcer of right thigh limited to breakdown of skin
L97.112Non-pressure chronic ulcer of right thigh with fat layer exposed
L97.113Non-pressure chronic ulcer of right thigh with necrosis of muscle
L97.115Non-pressure chronic ulcer of right thigh with muscle involvement without evidence of necrosis
L97.116Non-pressure chronic ulcer of right thigh with bone involvement without evidence of necrosis
L97.118Non-pressure chronic ulcer of right thigh with other specified severity
L97.114Non-pressure chronic ulcer of right thigh with necrosis of bone
L97.121Non-pressure chronic ulcer of left thigh limited to breakdown of skin
L97.122Non-pressure chronic ulcer of left thigh with fat layer exposed
L97.123Non-pressure chronic ulcer of left thigh with necrosis of muscle
L97.124Non-pressure chronic ulcer of left thigh with necrosis of bone
L97.125Non-pressure chronic ulcer of left thigh with muscle involvement without evidence of necrosis
L97.126Non-pressure chronic ulcer of left thigh with bone involvement without evidence of necrosis
L97.128Non-pressure chronic ulcer of left thigh with other specified severity
L97.211Non-pressure chronic ulcer of right calf limited to breakdown of skin
L97.212Non-pressure chronic ulcer of right calf with fat layer exposed
L97.213Non-pressure chronic ulcer of right calf with necrosis of muscle
L97.214Non-pressure chronic ulcer of right calf with necrosis of bone
L97.215Non-pressure chronic ulcer of right calf with muscle involvement without evidence of necrosis
L97.216Non-pressure chronic ulcer of right calf with bone involvement without evidence of necrosis
L97.218Non-pressure chronic ulcer of right calf with other specified severity
L97.221Non-pressure chronic ulcer of left calf limited to breakdown of skin
L97.222Non-pressure chronic ulcer of left calf with fat layer exposed
L97.223Non-pressure chronic ulcer of left calf with necrosis of muscle
L97.224Non-pressure chronic ulcer of left calf with necrosis of bone
L97.225Non-pressure chronic ulcer of left calf with muscle involvement without evidence of necrosis
L97.226Non-pressure chronic ulcer of left calf with bone involvement without evidence of necrosis
L97.228Non-pressure chronic ulcer of left calf with other specified severity
L97.315Non-pressure chronic ulcer of right ankle with muscle involvement without evidence of necrosis
L97.316Non-pressure chronic ulcer of right ankle with bone involvement without evidence of necrosis
L97.318Non-pressure chronic ulcer of right ankle with other specified severity
L97.321Non-pressure chronic ulcer of left ankle limited to breakdown of skin
L97.322Non-pressure chronic ulcer of left ankle with fat layer exposed
L97.323Non-pressure chronic ulcer of left ankle with necrosis of muscle
L97.324Non-pressure chronic ulcer of left ankle with necrosis of bone
L97.325Non-pressure chronic ulcer of left ankle with muscle involvement without evidence of necrosis
L97.326Non-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
L97.411Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin
L97.412Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed
L97.413Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle
L97.414Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone

Additional right ankle chronic ulcer codes under review for coverage by CMS

L97.311Non-pressure chronic ulcer of right ankle limited to breakdown of skin
L97.312Non-pressure chronic ulcer of right ankle with fat layer exposed
L97.313Non-pressure chronic ulcer of right ankle with necrosis of muscle
L97.314Non-pressure chronic ulcer of right ankle with necrosis of bone

Place of Service (POS) for Professional Claims

For claims with dates of service on or after April 13, 2021, use POS codes 11, 19, 22, and 49 for PRP services.

Aurix^® Treatments Are Billed Using HCPCS Code G0465

G0465 Code Descriptor: Autologous platelet rich plasma (PRP) for diabetic chronic wounds/ulcers, using an FDA-cleared device (includes administration, dressings, phlebotomy, centrifugation, and all other preparatory procedures, per treatment)

The AURIX Reimbursement Assistant (AURA) program which includes Benefits Verification services and all claims support is administered by PRIA Healthcare. Email: aurix@priahealthcare.com Phone: 833-602-8749
Coverage under private insurance and Medicaid is currently determined on a case-by-case basis. Please contact aurix@priahealthcare.com, phone 833-602-8749 for more information on submitting a claim for Aurix to one of these payers.