Medicare reimbursement for cellular and/or tissue-based products (CTPs) — billed with Q-codes — and their associated CPT application codes (15271–15278) can be complex. For wound care physicians, understanding which products are covered, how to document appropriately, and how to code claims correctly is critical to avoiding denials and ensuring compliance.

Understanding Q-Codes and CPT Application Codes in Wound Care

What Are Q-Codes in Wound Care Billing?

Q-codes identify specific skin substitute products used in advanced wound care. Each Q-code corresponds to a distinct product, billed per square centimeter applied. Covered Q-codes appear in Appendix A of the applicable Medicare LCD, while Appendix B lists non-covered products, such as Q4303 (Complete aa).

Before application, always verify the product’s coverage status in your MAC’s LCD to avoid non-payable claims.

Overview of CPT 15271–15278 Application Codes

These CPT codes represent the professional service of applying the skin substitute to the wound:

• 15271–15274: Trunk, arms, legs
• 15275–15278: Face, scalp, mouth, hands, feet, genitalia
  Add-on codes (15272, 15274, 15276, 15278) apply for each additional 25 sq cm.

Medicare Coverage Rules for Q-Codes in Wound Care

Covered vs. Non-Covered Q-Codes Under Medicare LCDs

Only Q-codes in the LCD’s Appendix A are reimbursable when paired with CPT 15271–15278. Products in Appendix B, like Q4303, are deemed not reasonable and necessary for DFU (diabetic foot ulcer) or VLU (venous leg ulcer) treatment and will be denied.
DFU (diabetic foot ulcer) and VLU (venous leg ulcer) treatments involve standard wound care like debridement, compression, and infection management, along with specialized therapies for chronic or slow-healing wounds.

Why Q4303 Is Not Covered for DFU/VLU Treatment

Under LCD MP371, Q4303 is non-covered regardless of diagnosis, ulcer severity, or prior care. Even with complete documentation, Medicare will not pay for Q4303.

Using ABNs and Modifiers for Non-Covered Products

If a non-covered product is clinically appropriate, issue an Advance Beneficiary Notice (ABN) and bill with the GY modifier. This makes the patient or secondary payer responsible for payment.

Documentation Requirements for Q-Codes with CPT 15271–15278

ICD-10 Diagnosis Code Precision

Select an ICD-10-CM code that specifies:

• Anatomical site (e.g., right hip, left heel)
• Ulcer type (pressure ulcer, diabetic ulcer, venous ulcer)
• Stage (Stage 3, Stage 4, full-thickness loss)

Example: L89.213 – Pressure ulcer of right hip, stage 3

Wound Measurements and Clinical Descriptions

Document:

• Length × width × depth in cm
• Stage and description (tissue loss, drainage, appearance)
• Onset date and Present on Admission (POA) status

Proof of Failed Conservative Care

Medicare requires ≥4 weeks of unsuccessful standard care, including:

• Dressings
• Off-loading or compression
• Infection control
• Debridement

Recording Product Application and Wastage

• Pre-application measurements
• Exact sq cm applied
• Wastage with invoice documentation
• Modifiers:
  • JW for discarded amount
  • JZ if no wastage

Compliance Risks and Audit Red Flags in Wound Care Billing

Common Documentation Gaps

• Missing ulcer stage
• No evidence of prior conservative care
• Missing wound measurements

Improper Use of CPT and Q-Code Pairings

• Billing a non-covered Q-code with application CPTs
• Billing debridement and graft application same day without justification

Best Practices for Medicare-Compliant Wound Care Billing

Step-by-Step Billing Workflow

1. Verify Q-code coverage in LCD Appendix A

2. Confirm ≥4 weeks failed conservative care

3. Document ulcer details and measurements

4. Bill CPT application code based on site and size

5. Bill Q-code per sq cm applied

6. Use correct modifiers for wastage or non-coverage

Choosing Covered Q-Codes for Maximum Reimbursement

Examples of covered Q-codes:

• Q4101 – Apligraf
• Q4151 – Amnioband Guardian
• Q4186 – Epifix
• Q4187 – Amnioexcel Plus

Key Takeaways for Wound Care Physicians

Avoiding Denials with Accurate Q-Code and CPT Billing

• Always check LCD coverage lists before application
• Pair Q-codes with correct CPT application codes
• Document every required clinical detail