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    v1.0.28
    OpenPayerBilling CodesTemporary CodesHCPCS hcpcs-q4204-xwrap-per-sq-cm-add-on
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    HCPCS Q4204: Xwrap Per Square Centimeter (Add-on)

    Medicare pays $133 on average nationally for this procedure.

    HCPCS Level II code Q4204 describes billing for Xwrap material billed per square centimeter as an add-on supply used in surgical wound management; the service type is surgical implantable/biologic supply and the typical site of service is an operating room or procedure suite where the primary procedure requiring the adjunctive wound coverage or reinforcement is performed.

    For related coverage guidance, see recent payer policy updates: B-Hemolytic Streptococcus Testing, Human Immunodeficiency Virus (HIV) — Coverage Criteria for Testing and Resistance Assays, Hepatitis Testing (A, B, C, D) Coverage Criteria.

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    Clinical & Coding Specifications

    Clinical Context

    A 62-year-old patient with a chronic, non-healing lower extremity wound following vascular surgery presents to an outpatient wound care clinic for advanced biologic dressing placement. The clinician measures the prepared wound bed and applies a dermal regenerative matrix product billed with Q4204 billed per square centimeter as an add-on item to the primary wound debridement or closure procedure. The workflow includes wound assessment and measurement, sharp or surgical debridement as indicated, hemostasis, placement and fixation of the Q4204 material sized to the wound area, and documentation of square centimeters used. The procedure is most commonly performed in outpatient wound care centers, ambulatory surgery centers, hospital outpatient departments, or physician offices during the same encounter as the primary surgical or procedural code. Typical documentation includes wound dimensions, percentage of graft/dressing used in square centimeters, the primary procedure CPT code (for example debridement or closure), indication for the biologic dressing, and any applicable modifier to denote bilateral, increased procedural services, or multiple procedures.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    11042Debridement, subcutaneous tissue (first 20 sq cm or less)Common primary procedure when Q4204 is applied after debridement to cover and promote healing of the wound bed.
    11043Debridement, muscle and/or fascia (first 20 sq cm or less)Used when deeper debridement is performed prior to application of the per-square-centimeter biologic product.
    15271Application of skin substitute graft to trunk, arms, legs; first 100 sq cm or lessOften performed in conjunction with Q4204 when an autologous or biosynthetic substitute is placed — Q4204 may represent an additional adjunctive material billed per cm2.
    97597Debridement (eg, high pressure irrigation) with topical application, first woundUsed in wound care settings for debridement and topical therapy prior to placement of the add-on product.
    15275Application of skin substitute graft to hand; first 100 sq cm or lessRelevant when biologic dressings are used on smaller surface areas and Q4204 quantifies additional product usage by square centimeter.

    Related Modifiers

    6 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    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…
    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…
    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…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    363A00000XPhysician AssistantA physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and…
    207P00000XEmergency Medicine PhysicianAn emergency physician focuses on the immediate decision making and action necessary to prevent death or any further disability both in the pre-hospit…
    208800000XUrology PhysicianA urologist manages benign and malignant medical and surgical disorders of the genitourinary system and the adrenal gland. This specialist has compreh…
    367A00000XAdvanced Practice MidwifeAdvanced practice midwifery encompasses the independent provision of care during pregnancy, childbirth, and the postpartum period; sexual and reproduc…
    207ZC0500XCytopathology PhysicianA cytopathologist is an anatomic pathologist trained in the diagnosis of human disease by means of the study of cells obtained from body secretions an…
    202C00000XIndependent Medical Examiner PhysicianA special evaluator not involved with the medical care of the individual examinee that impartially evaluates the care being provided by other practiti…
    163WC2100XContinence Care Registered NurseNursing Service Providers · Registered Nurse
    2088P0231XPediatric Urology PhysicianSurgeons who can diagnose, treat, and manage children's urinary and genital problems. A pediatric urologist devotes a minimum of 50% of his or her pra…

    Related ICD-10-CM Codes

    22 rows

    ICD-10-CM CodeDescription
    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
    I83.019Varicose veins of right lower extremity with ulcer of unspecified site
    I87.312Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
    I87.329Chronic venous hypertension (idiopathic) with inflammation of unspecified lower extremity
    L03.116Cellulitis of left lower limb
    L08.9Local infection of the skin and subcutaneous tissue, unspecified
    L89.309Pressure ulcer of unspecified buttock, unspecified stage

    Showing 1–10 of 22

    Related Payer Policy Updates

    Specialty: Infectious Disease1 / 3

    10 rows

    PolicyPayerEffective Date
    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
    Testing for Diagnosis of Active or Latent TuberculosisOscar Health2026-10-01
    Testing for Vector-Borne InfectionsOscar Health2026-10-01
    Coronavirus Testing in the Outpatient SettingOscar Health2026-10-01
    Human Immunodeficiency Virus (HIV)blue cross blue shield - louisiana2026-09-15

    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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