Dermatology Coding Alert

Don't let confusion over the 20 skin graft codes get you down. Here are four easy steps to help you adopt a systematic, step-by-step approach for reporting every claim so that your dermatology practice won't lose out on skin graft reimbursement.
 
Step 1: Be sure to report site preparation. Site preparation is easy to overlook because it is a standard part of the grafting procedure. For example, after escharotomy (16035-16036) and debridement (16010-16030) but before placing a skin graft, the dermatologist must prepare the affected area by clearing all remaining eschar, skin debris and subcutaneous tissue. CPT Includes two codes to describe site preparation:

  15000 - Surgical preparation or creation of recipient site by excision of open wounds, burn eschar,
 or scar (including subcutaneous tissues); first 100 sq cm or one percent of body area of infants and children
  +15001 - ... 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).

So even though preparation is a standard part of the procedure, make sure you specify this part of your procedure with the appropriate CPT code so you don't miss out on your full reimbursement. When you bill 15000/15001, make sure the dermatologist's procedure notes clearly state that he or she performed the preparation along with the size of the area that received the graft.
 
For example, the dermatologist prepares an area of 14 cm x 14 cm on a burn patient's left leg to receive a skin graft. To determine the area in square centimeters (sq cm), simply multiply the length of the area by its width. In this case, report 15000, 15001 to describe the site preparation in a 196-sq-cm area.
 
Step 2: Specify the skin "donor." When donor skin completes the graft, the donor skin source determines your code choices, says M. Trayser Dunaway, MD, a physician in Camden, S.C. Possible sources include:
 
1. The patient's own skin, which the dermatologist transports from one area to another. Such grafts are further classified as:
 

split thickness (15100-15121), which is a thin skin layer from a donor site and includes both epidermis and some dermis. When reading documentation, note that dermatologists typically abbreviate "split-thickness skin graft" as "STSG."
 

full thickness (15200-15261), which is a thicker skin layer from a donor site and includes all of the epidermis and dermis.
 
2. The dermatologist places human skin from a donor other than the patient (including a cadaver). These grafts are called allografts or, in some cases, homografts. You report these using 15350 (Application of allograft, skin; 100 sq cm or less) and +15351 (... each additional 100 sq cm [list separately in addition to code for primary procedure]) if the graft is larger than 100 sq cm.  
 
3. The dermatologist uses nonhuman animal tissue, called a xenograft. You report these using 15400 (Application of xenograft, skin; 100 sq cm or less) and, as required, +15401 (... each additional 100 sq cm [list separately in addition to code for primary procedure]) depending on the size of the graft.
 
4. The dermatologist chooses an artificial skin substitute. You describe these grafts using 15342 (Application of bilaminate skin substitute/neodermis; 25 sq cm) and +15343 (... each additional 25 sq cm [list separately in addition to code for primary procedure]), again depending on the size of the graft.
 
Step 3: Always specify size and location. The size of the affected area determines all skin graft codes. For example, for allografts, xenografts and skin substitutes, you should apply a primary code (15350, 15400 and 15342, respectively) to describe the initial graft area (up to 100 sq cm for allograft and xenograft, or 25 sq cm for skin substitute), using the "each additional" codes (15351, 15401 and 15343, respectively) to report any area beyond that described by the primary code, says Kathleen Mueller, RN, CPC, CCS-P, a coding and reimbursement specialist in Lenzburg, Ill.
 
If necessary, you may report multiple units of the "each additional" codes. For example, a dermatologist uses a skin substitute to repair a 70-sq-cm area. In this case, you report 15342 to describe the first 25 sq cm and 15343 x 2 for the remaining 45 sq cm.
 
When reporting grafts using the patient's own skin, you should look for information in the dermatologist's documentation on the graft's size and location. For instance, 15100 (Split graft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children) specifies "trunk, arms, legs," while 15120 (Split graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children) applies to "face, scalp, eyelids, mouth," etc.
 
For example, the dermatologist places a full-thickness graft on a patient's forehead, totaling 36 sq cm. In this case, you select 15240 (Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 20 sq cm or less) for the first 20 cm and +15241 (... each additional 20 sq cm [list separately in addition to code for primary procedure]) for the remaining 16 sq cm. In order to report your skin graft procedures correctly, you must be sure that your dermatologist documents the size, location and depth of every graft. Otherwise, you run the risk of receiving reimbursement for a lower-paying split-thickness graft.
 
Step 4: Append modifiers for any staged, multiple treatments. If you expect separate payment, you must append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to any graft the dermatologist performs within the 90-day global period of an escharotomy.
 
And burn patients typically require several trips to the operating room after the dermatologist has performed a graft or flap. When reporting these additional procedures during the global period of a prior graft or flap, you should append modifier -58 to the appropriate procedure code(s), Mueller says. If the patient has multiple burns, and the dermatologist must place several different or similar grafts during the same session, you should append modifier -59 (Distinct procedural service) to indicate that the dermatologist placed the various grafts at different anatomic sites. For instance, for a 15-cm full-thickness graft to the nose and a separate 20-cm full-thickness graft to the cheek, you should report codes 15240, 15240-59.