HCPCS Level II Q4391: Amnioplast Double, Per Square Centimeter

HCPCS Level II code Q4391 describes an amnioplast double product billed per square centimeter as an add-on supply used in surgical or wound repair settings; the service type is a surgical adjunct/supply and the typical site of service is an operating room or procedure suite where the primary procedure requiring amnioplast placement is performed.

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HCPCS Level II Q4391: Amnioplast Double, Per Square Centimeter

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Get alerted when payer policies referencing Q4391 are released or updated.

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Clinical & Coding Specifications

Clinical Context

A typical patient is an adult or adolescent presenting with a full-thickness or complex amniotic membrane defect after conjunctival disease, ocular surface reconstruction, pterygium surgery complication, chemical burn, or persistent corneal epithelial defect. The procedure coded as Q4391 (amnioplast double, per square centimeter) is used when two layers of amniotic membrane are applied to the ocular surface to promote healing, provide a biologic scaffold, reduce inflammation, and restore corneal or conjunctival integrity. Clinical workflow includes preoperative assessment by an ophthalmologist (cornea or oculoplastic specialist), informed consent, sterile preparation in an operating room or procedure suite, measurement of the defect size, tailoring and securing two layers of amniotic membrane (often with fibrin glue, sutures, or a combination), postoperative topical antibiotics and corticosteroids, and scheduled follow-up visits to monitor integration and epithelialization. Typical sites of service are hospital outpatient surgical departments, ambulatory surgery centers, and certain ophthalmology procedure suites equipped for minor ocular surgery. Patient factors such as active infection, ocular surface inflammation, and prior grafting procedures influence intraoperative decisions and potential use of modifiers to reflect complexity or supplies used.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`66140`	Excision of pterygium; simple	Performed before or instead of amniotic membrane grafting when pterygium is the underlying cause of the defect; amnioplast may follow to prevent recurrence or repair conjunctival defect.
`65435`	Conjunctival advancement (fornix reconstruction), with or without graft	May be performed in the same operative session for extensive conjunctival defects together with amniotic membrane placement.
`65778`	Placement of amniotic membrane on the ocular surface for wound healing (separate procedure code for some payers)	Often performed as the primary CPT-equivalent procedure; `Q4391` is an HCPCS add-on describing double-layer amnioplast billed per square centimeter in addition to primary procedure.
`15271`	Application of skin substitute graft to face, scalp, eyelids or external genitalia; up to 75 sq cm	In some settings, comparable grafting supply codes or tissue handling codes are reported alongside amniotic membrane grafting for supply valuation and surgical staging.
`99070`	Supplies and materials (except spectacles), used by physician or other qualified health care professional	Used to report additional non-implantable supplies not included in the primary procedure when payers permit separate supply reimbursement.

Related Modifiers

5 rows

Modifier	Description	When to Use
22	Modifier –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…
52	Modifier ‑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…
53	Modifier 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…
[object Object]
90	Modifier ‑90 (Reference/Outside Laboratory) indicates that a laboratory test was performed by an entity other than the treating or reporting provider. The American Medical Association defines…	- Use CPT modifier -90 when a laboratory test is performed by an outside/reference laboratory (an entity other than the treating or reporting physician or qualified professional) and the claim needs…

Related Provider Taxonomies

8 rows

Taxonomy Code	Specialty	Notes
207W00000X	Ophthalmology Physician	An ophthalmologist has the knowledge and professional skills needed to provide comprehensive eye and vision care. Ophthalmologists are medically train…
363LP0200X	Pediatric Nurse Practitioner	Physician Assistants & Advanced Practice Nursing Providers · Nurse Practitioner
103TA0700X	Adult Development & Aging Psychologist	A psychologist who specializes in geropsychology, which applies the knowledge and methods of psychology to understanding and helping older persons and…
207WX0109X	Neuro-ophthalmology Physician	A neuro-ophthalmologist is a subspecialist of ophthalmology. This physician evaluates, treats, and studies disorders of the eye, orbit and nervous sy…
133V00000X	Registered Dietitian	A Registered Dietitian (RD)/Registered Dietitian Nutritionist (RDN) is an individual uniquely trained in the science of nutrition and practice of diet…
364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	Physician Assistants & Advanced Practice Nursing Providers · Clinical Nurse Specialist
374700000X	Technician	(1) A person with specialized training in a narrow field of expertise whose occupation requires training and is skilled in specific technical processe…
1835G0303X	Geriatric Pharmacist	A pharmacist who is certified in geriatric pharmacy practice is designated as a "Certified Geriatric Pharmacist" (CGP). To become certified, candidat…

Related Payer Policy Updates

Specialty: Infectious Disease1 / 3

10 rows

Policy	Payer	Effective Date
B-Hemolytic Streptococcus Testing	Oscar Health	2026-10-01
Human Immunodeficiency Virus (HIV) — Coverage Criteria for Testing and Resistance Assays	Oscar Health	2026-10-01
Hepatitis Testing (A, B, C, D) Coverage Criteria	Oscar Health	2026-10-01
Lyme Disease Testing Coverage Criteria	Oscar Health	2026-10-01
Pathogen Panel Testing	Oscar Health	2026-10-01
Diagnostic Testing of Common Sexually Transmitted Infections	Oscar Health	2026-10-01
Coronavirus Testing in the Outpatient Setting	Oscar Health	2026-10-01
Testing for Vector-Borne Infections	Oscar Health	2026-10-01
Testing for Diagnosis of Active or Latent Tuberculosis	Oscar Health	2026-10-01
Human Immunodeficiency Virus (HIV)	blue cross blue shield - louisiana	2026-09-15

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

Frequently Asked Questions

References

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.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.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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Clinical & Coding Specifications

Clinical Context

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`66140`	Excision of pterygium; simple	Performed before or instead of amniotic membrane grafting when pterygium is the underlying cause of the defect; amnioplast may follow to prevent recurrence or repair conjunctival defect.
`65435`	Conjunctival advancement (fornix reconstruction), with or without graft	May be performed in the same operative session for extensive conjunctival defects together with amniotic membrane placement.
`65778`	Placement of amniotic membrane on the ocular surface for wound healing (separate procedure code for some payers)	Often performed as the primary CPT-equivalent procedure; `Q4391` is an HCPCS add-on describing double-layer amnioplast billed per square centimeter in addition to primary procedure.
`15271`	Application of skin substitute graft to face, scalp, eyelids or external genitalia; up to 75 sq cm	In some settings, comparable grafting supply codes or tissue handling codes are reported alongside amniotic membrane grafting for supply valuation and surgical staging.
`99070`	Supplies and materials (except spectacles), used by physician or other qualified health care professional	Used to report additional non-implantable supplies not included in the primary procedure when payers permit separate supply reimbursement.

Related Modifiers

5 rows

Modifier	Description	When to Use
22	Modifier –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…
52	Modifier ‑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…
53	Modifier 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…
[object Object]
90	Modifier ‑90 (Reference/Outside Laboratory) indicates that a laboratory test was performed by an entity other than the treating or reporting provider. The American Medical Association defines…	- Use CPT modifier -90 when a laboratory test is performed by an outside/reference laboratory (an entity other than the treating or reporting physician or qualified professional) and the claim needs…

Related Provider Taxonomies

8 rows

Taxonomy Code	Specialty	Notes
207W00000X	Ophthalmology Physician	An ophthalmologist has the knowledge and professional skills needed to provide comprehensive eye and vision care. Ophthalmologists are medically train…
363LP0200X	Pediatric Nurse Practitioner	Physician Assistants & Advanced Practice Nursing Providers · Nurse Practitioner
103TA0700X	Adult Development & Aging Psychologist	A psychologist who specializes in geropsychology, which applies the knowledge and methods of psychology to understanding and helping older persons and…
207WX0109X	Neuro-ophthalmology Physician	A neuro-ophthalmologist is a subspecialist of ophthalmology. This physician evaluates, treats, and studies disorders of the eye, orbit and nervous sy…
133V00000X	Registered Dietitian	A Registered Dietitian (RD)/Registered Dietitian Nutritionist (RDN) is an individual uniquely trained in the science of nutrition and practice of diet…
364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	Physician Assistants & Advanced Practice Nursing Providers · Clinical Nurse Specialist
374700000X	Technician	(1) A person with specialized training in a narrow field of expertise whose occupation requires training and is skilled in specific technical processe…
1835G0303X	Geriatric Pharmacist	A pharmacist who is certified in geriatric pharmacy practice is designated as a "Certified Geriatric Pharmacist" (CGP). To become certified, candidat…

Related Payer Policy Updates

Specialty: Infectious Disease1 / 3

10 rows

Policy	Payer	Effective Date
B-Hemolytic Streptococcus Testing	Oscar Health	2026-10-01
Human Immunodeficiency Virus (HIV) — Coverage Criteria for Testing and Resistance Assays	Oscar Health	2026-10-01
Hepatitis Testing (A, B, C, D) Coverage Criteria	Oscar Health	2026-10-01
Lyme Disease Testing Coverage Criteria	Oscar Health	2026-10-01
Pathogen Panel Testing	Oscar Health	2026-10-01
Diagnostic Testing of Common Sexually Transmitted Infections	Oscar Health	2026-10-01
Coronavirus Testing in the Outpatient Setting	Oscar Health	2026-10-01
Testing for Vector-Borne Infections	Oscar Health	2026-10-01
Testing for Diagnosis of Active or Latent Tuberculosis	Oscar Health	2026-10-01
Human Immunodeficiency Virus (HIV)	blue cross blue shield - louisiana	2026-09-15

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

Frequently Asked Questions

References

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.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.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.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

OpenPayer

HCPCS Level II Q4391: Amnioplast Double, Per Square Centimeter

Sign up for hcpcs Q4391 policy alerts

OpenPayer

HCPCS Level II Q4391: Amnioplast Double, Per Square Centimeter

Sign up for hcpcs Q4391 policy alerts

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related Payer Policy Updates

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related Payer Policy Updates

Related Codes

References

HCPCS Level II Q4391: Amnioplast Double, Per Square Centimeter

Sign up for hcpcs Q4391 policy alerts

HCPCS Level II Q4391: Amnioplast Double, Per Square Centimeter

Sign up for hcpcs Q4391 policy alerts

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related Payer Policy Updates

Related Codes

What does HCPCS code Q4391 represent and how is it billed?

Where is the amnioplast double (Q4391) typically applied in terms of site of service?

How does Q4391 relate to primary procedure codes and other supply codes?

For which clinical situations is a double-layer amnioplastic graft (Q4391) typically used?

Which payers are noted as covering Q4391 and where can I find payer-specific requirements?

References

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related Payer Policy Updates

Related Codes

What does HCPCS code Q4391 represent and how is it billed?

Where is the amnioplast double (Q4391) typically applied in terms of site of service?

How does Q4391 relate to primary procedure codes and other supply codes?

For which clinical situations is a double-layer amnioplastic graft (Q4391) typically used?

Which payers are noted as covering Q4391 and where can I find payer-specific requirements?

References