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    v1.0.31
    OpenPayerBilling CodesTemporary CodesHCPCS hcpcs-q4133-placental-allograft-grafix-prime-stravix-per-cm
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    HCPCS Level II Q4133: Placental Membrane Graft, per cm2

    Medicare pays $133 on average nationally for this procedure.

    HCPCS Level II code Q4133 describes application billing for placental-derived living membrane products marketed as Grafix Prime, GrafixPL Prime, Stravix, and StravixPL, billed per square centimeter as an add-on supply used to support wound and soft tissue repair; typical service type is implantable biologic/advanced wound care supply and the typical site of service is hospital outpatient or ambulatory wound care clinic where the primary procedure is performed.

    For related coverage guidance, see recent payer policy updates: Truvada (Emtricitabine and Tenofovir Disoproxil Fumarate) for HIV Prevention and Treatment, HIV/AIDS Pharmacologic Prevention and Treatment, Long-Acting Injectable Antiretroviral Agents for HIV.

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    Clinical & Coding Specifications

    Clinical Context

    A typical patient is an adult with a chronic nonhealing lower extremity ulcer (for example, a diabetic foot ulcer or venous stasis ulcer) who has failed standard wound care including debridement, offloading, and topical therapies. The wound care specialist or podiatrist evaluates the wound in an outpatient clinic or ambulatory wound center. After sharp debridement and preparation of the wound bed to remove nonviable tissue and reduce bioburden, the clinician measures the wound and selects a single-layer placental membrane allograft product such as Q4133 (Grafix Prime, GrafixPL Prime, Stravix, StravixPL) to be applied per square centimeter as an adjunctive biologic graft.

    The clinical workflow includes wound assessment and staging, informed consent, wound bed preparation (sharp debridement and hemostasis), application of the allograft sized to the wound, securement with appropriate dressings (and possibly negative pressure wound therapy), and scheduling of follow-up visits for graft take assessment and repeat applications if needed. This code is billed as an add-on, separately from primary surgical or debridement procedure codes, and charged per square centimeter of graft used. Typical sites of service are outpatient wound care clinics, ambulatory surgical centers, and hospital outpatient departments.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    97597Debridement, open wound, selective debridement; first 20 sq cm or lessOften performed immediately before application of a placental membrane graft to prepare the wound bed.
    97598Debridement, open wound, selective debridement; each additional 20 sq cmBilled for additional debridement area when needed prior to graft placement.
    15271Application of skin substitute graft to trunk, arms, legs; first 100 sq cm or less, or per graftUsed in conjunction when a skin substitute is applied to larger wounds; documents primary grafting procedure while Q4133 is an add-on per sq cm.
    11042Debridement including skin, subcutaneous tissue, first 20 sq cmSurgical debridement code that may be billed when debridement is performed in the operating room prior to grafting.
    97607Negative pressure wound therapy (NPWT), application of dressing with pump, longer than 1 dayMay be used adjunctively after graft placement to bolster graft adherence and manage exudate.

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    59Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…
    76Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
    77Modifier 77 indicates that a previously performed procedure or service was legitimately repeated by a different physician or other qualified health care professional. The AMA’s CPT definition…- Use modifier 77 when a basic procedure or service already performed is repeated by a different physician or other qualified health care professional (for example, a second provider independently…
    78CPT modifier -78 indicates an unplanned, related return to the operating or procedure room by the same provider during the global postoperative period. It is appended when treatment for a…- Use modifier -78 when an unplanned, related complication during the original procedure’s global postoperative period requires the patient to return to a formal operating or procedure room and the…
    79Modifier 79 indicates a surgical procedure performed during the postoperative global period of a prior surgery that is unrelated to the original procedure. Per AMA/CPT and CMS guidance, it is…- Use modifier 79 when the same physician (or same‑specialty physician in the same group) performs a surgical procedure during the postoperative global period of a prior surgery and the new procedure…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207P00000X
    207L00000X
    208D00000X
    207RS0010X
    2085R0205X
    2080S0012X
    207XP3100X
    163WE0900X

    Related Payer Policy Updates

    Specialty: Infectious Disease1 / 3

    10 rows

    PolicyPayerEffective Date
    Truvada (Emtricitabine and Tenofovir Disoproxil Fumarate) for HIV Prevention and Treatmentpremerabluecrossofwashington2026-10-01
    HIV/AIDS Pharmacologic Prevention and Treatmentpremerabluecrossofwashington2026-10-01
    Long-Acting Injectable Antiretroviral Agents for HIVColorado Rocky Mountain Health Plans2026-10-01
    B-Hemolytic Streptococcus TestingOscar Health2026-10-01
    Human Immunodeficiency Virus (HIV) — Coverage Criteria for Testing and Resistance AssaysOscar Health2026-10-01
    Hepatitis Testing (A, B, C, D) Coverage CriteriaOscar Health2026-10-01
    Lyme Disease Testing Coverage CriteriaOscar Health2026-10-01
    Pathogen Panel TestingOscar Health2026-10-01
    Diagnostic Testing of Common Sexually Transmitted InfectionsOscar Health2026-10-01
    Coronavirus Testing in the Outpatient SettingOscar Health2026-10-01

    Related Codes

    HCPCS-LEVEL-II-Q4139-INJECTABLE-AMNIOMATRIX-BIODMATRIX-1-CC

    HCPCS Q4139: Amniomatrix or Biodmatrix, Injectable, 1 cc

    HCPCS-LEVEL-II-Q4256-AREA-BASED-PROCEDURAL-ADD-ON-PER-SQ-CM

    HCPCS Q4256: MLG-complete Skin Graft Material, Per Sq Cm

    HCPCS-LEVEL-II-Q5132-ADALIMUMAB-AFZB-ABRILADA-10MG-INJECTION

    HCPCS Level II Q5132: Injection, adalimumab-afzb (Abrilada), 10 mg

    HCPCS-Q0035-CARDIOKYMOGRAPHY-CARDIAC-MOTION-RECORDING

    HCPCS Level II Q0035: Cardiokymography

    HCPCS-Q0081-INFUSION-THERAPY-NON-CHEMOTHERAPEUTIC-PER-VISIT

    HCPCS Level II Q0081: Infusion Therapy, Non‑Chemotherapeutic, Per Visit

    HCPCS-Q0083-CHEMOTHERAPY-NON-INFUSION-ADMINISTRATION

    HCPCS Q0083: Chemotherapy Administration, Non-Infusion Methods

    HCPCS-Q0084-CHEMOTHERAPY-INFUSION-ADMINISTRATION-PER-VISIT

    HCPCS Q0084: Chemotherapy Infusion Administration, Per Visit

    HCPCS-Q0085-CHEMOTHERAPY-INFUSION-PLUS-OTHER-TECHNIQUES-PER-VISIT

    HCPCS Q0085: Chemotherapy Infusion Plus Other Technique(s), Per Visit

    HCPCS-Q0091-PAP-SMEAR-SPECIMEN-COLLECTION-TRANSPORT

    HCPCS Q0091: Screening Papanicolaou Smear Collection and Transport

    HCPCS-Q0092-PORTABLE-XRAY-EQUIPMENT-SETUP

    HCPCS Q0092: Set-up Portable X-ray Equipment

    Showing 1–10 of 629

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    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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