Question: Following escharotomy (16035-16036) and debridement (16020-16030), and prior to placing a skin graft, the surgeon prepared an area of 12 cm x 12 cm (144 sq. cm) on a burn patient’s right leg by clearing all remaining eschar, skin debris and subcutaneous tissue. May I report site preparation (15002) separately in this case?
Pennsylvania Subscriber
Answer: Depending on the exact type of graft the surgeon places, you probably may report 15002 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues], or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or one percent of body area of infants and children: APC 0135) to describe the site preparation. Note that because the total area the surgeon prepared exceeds 100 sq. cm, you may also be able to report +15003 (... each additional 100 sq cm or each additional one percent of body area of infants and children [list separately in addition to code for primary procedure]: APC 0135).CPT includes specific language directing you to use 15002 and/or 15003 “for initial wound recipient site preparation.” The site preparation is separate from escharotomy, debridement and (in most cases) placement of the graft itself.
The exceptions: You should not report site preparation (15002-15003) separately with xenograft codes 15430-+15431, according to CPT instructions.
