Reimbursement

ActiGraft Pro® system is described by the National Coverage Determination (NCD 270.3) as a blood-derived product and is eligible for reimbursement with HCPCS G0465.

Centers for Medicare & Medicaid Services (CMS) will reimburse autologous PRP for the treatment of chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by devices whose Food and Drug Administration (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).

Autologous blood derived products for chronic, non-healing wounds includes both: (1) platelet derived growth factor (PDGF) products, and (2) PRP (such as AutoloGel). The PRP is different from previous products in that it contains whole cells including white cells, red cells, plasma, platelets, fibrin, stem cells, and fibrocyte precursors.

Coverage of autologous PRP for the treatment of all other chronic non-healing wounds will be determined by local MACs.

ActiGraft Pro system is billed with HCPCS G0465

Effective July 1, 2023, Centers for Medicare & Medicaid Services has added additional language to the code descriptors for HCPCS code G0460 and HCPCS G0465.

•HCPCS G0460
Autologous platelet rich plasma or other blood-derived product for non-diabetic chronic wounds/ulcers, including as applicable phlebotomy, centrifugation or mixing, and all other preparatory procedures, administration and dressings, per treatment

•HCPCS G0465
Autologous platelet rich plasma (PRP) or other blood-derived product for diabetic chronic wounds/ulcers, using an FDA-cleared device for this indication, (includes as applicable administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment)

See the HCPCS Quarterly Update for additional details.

ActiGraft Pro system requires two diagnosis codes (ICD-10 E&L)

For claims with dates of service on or after July 1, 2023, 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.

*Disclaimer: The information provided shall not be constructed as a statement, promise, or guarantee that reimbursement will be received. Reimbursement requirements are subject to change at any time. Check with your local payer regularly.
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