General Surgery Coding Alert

Know when to capture pay for preparation, placement, and more.

With new codes and an updated introduction, CPT® 2012 has you renovating your skin replacement coding skills, once again.

Although you learned how size matters with new codes 15271-+15278 (Application of skin substitute graft ...) in "Skin Substitute Coding Overhaul Simplifies Processes" (General Surgery Coding Alert Vol. 14 No. 1), you'll need to make sure you also understand the updated CPT® instruction for skin replacement surgery.

Follow this large-tumor-excision repair example to master five tools to ensure accurate, complete claims.

Scenario: The surgeon excises a 2.5 cm melanoma with a 3 cm margin from a patient's right thigh, then applies a 40 sq. cm skin substitute graft with sutures and dresses the area.

Tip 1: Calculate Size for Excision Procedure

You'll turn to the integumentary malignant-lesion-excision codes to report your surgeon's work in excising the melanoma. Choose 11606 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm).

"You should calculate the excision size as the lesion diameter plus two times the margin width," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. For the above scenario, that calculation is 2.5 cm plus (3 cm x 2) = 8.5 cm.

Tip 2: Know When to Skip Surgical Prep

"Be careful not to automatically report surgical preparation when your surgeon performs a skin substitute graft," Bucknam warns.

In this example, the surgeon applies the skin substitute graft immediately following a surgical excision, so you should not additionally report a surgical preparation code (15002-+15005, 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, ...)

Instead, according to CPT® instruction, "When a primary procedure requires a skin substitute ...for definitive skin closure (e.g., ... deep tumor removal)," you should report the appropriate graft code in the range 15100-+15278 (... autograft ... skin substitute graft ...) in addition to the primary procedure (11606 in this case), and skip the surgical preparation codes.

Learn limitations: You should only report a surgical preparation code with the skin-substitute graft when the surgeon fulfills at least one of these conditions, according to CPT® instruction:

• "Appreciable nonviable tissue is removed to treat a burn, traumatic wound or a necrotizing infection"
• Or, "the clean wound bed may also be created by incisional release of a scar contracture resulting in a surface defect from separation of tissues"
• "The intent is to heal the wound by primary intention" such as autograft or skin substitute graft.

Tip 3: Establish Fixation

When the surgeon applies a skin-substitute graft, you should select the proper code(s) from the range 15271-+15278 -- sometimes.

Attachment required: Don't code a skin substitute graft if the surgeon simply applies skin substitute to the wound, even if he stabilizes it with dressing.

CPT® instruction: Instead, use these codes only when "the graft is anchored using the provider's choice of fixation." The surgeon's fixation might involve adhesives, sutures, or staples, for instance.

Make sure the op note documents fixation before you use skin replacement graft codes, says Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS, President of Askmueller Consulting, LLC in Lenzburg, Ill.

Tip 4: Distinguish Wound vs. Graft Size

"You should report grafts according to location and size, which the surgeon should record at the time of the procedure," Mueller says. Surgeons need to be specific in their op notes about both the size of the wound and the size of the graft.

Here's why: "If the patient has a large wound but the surgeon covers only part of the wound with skin substitute, you should still select the skin substitute code based on the larger wound size," Bucknam says.

Example: In the current example, the surgeon documents an 8.5 cm excision (56.75 sq. cm), but a 40 sq. cm skin substitute graft. That means you should code the skin substitute graft as 15271 (Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area) plus two units of +15272 (... each additional 25 sq. cm wound surface area, or part thereof [List separately in addition to code for primary procedure]). If you erroneously based the code on the graft size rather than the wound size, you would report 15271 and one unit of +15272, costing your practice $27.23 (Medicare Physician Fee Schedule non-facility national rate, conversion factor 34.0376).

Tip 5: Recognize Included Services

According to CPT® 2012 instruction, skin substitute grafts include any of the following services, if applicable:

• removal of current graft
• simple cleansing of the wound
• routine dressing supplies
• debridement (except "when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized  or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure").

Code separately: You should separately report debridement if your surgeon documents conditions outlined in the preceding exception.

CPT® instruction also states that "the supply of skin substitute graft(s) should be reported separately in conjunction with 15271-15278." That means you should select the appropriate HCPCS Level II code, such as Q4102 (Oasis wound matrix, per square centimeter).