General Surgery Coding Alert

Step 2: Determine the Skin 'Donor'
 
The donor skin to complete the graft can come from a number of sources, which, in turn, affects your code choices, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. The sources can include:
 
1. The patient's own skin, which the surgeon transports from one area to another. Such grafts are further classified as:

a.) 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 surgeons typically abbreviate "split thickness skin graft" as "STSG."

b.) Full thickness (15200-15261), which is a thicker skin layer from a donor site and includes all of the epidermis and dermis.
 
2. The surgeon places human skin from a donor other than the patient (including a cadaver). These grafts are called allografts or, in some cases, homografts. You should report these using 15350 (Application of allograft, skin; 100 sq cm or less) and, if necessary, +15351 (... each additional 100 sq cm [list separately in addition to code for primary procedure]).
 
3. The surgeon uses nonhuman animal tissue, called a xenograft. You may 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]).
  
4. The surgeon chooses an artificial skin substitute. You may 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]).

Step 3: Document Size and Location

All skin graft codes are classified according to the size of the affected area. 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 surgeon uses a skin substitute to repair a 70-sq-cm area. In this case, you would 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 on the graft 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 surgeon places a full-thickness graft on a patient's forehead, totaling 36 sq cm. In this case, you should 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.
 
Because selection of the correct code depends on complete information, coders must be sure that their surgeons document the size, location and depth of every graft. "Some surgeons omit almost all the relevant information," Elvidge says. "They may write 'Graft was applied' and neglect to mention the thickness, where it was placed or how big it was." She adds that if the surgeon performs a full-thickness graft, he or she should note the specific layers of skin involved; otherwise, you may only bill for a (lower-paying) split-thickness graft.

Step 4: Use Modifiers for 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 surgeon performs within the 90-day global period of an escharotomy.
 
In addition, burn patients typically require several trips to the operating room after the surgeon 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 surgeon must place several different or similar grafts during the same session, you should append modifier -59 (Distinct procedural service) to indicate that the surgeon 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, report 15240, 15240-59.