General Surgery Coding Alert

Grasp measurement rules.

Replacement material, graft size, multiple wounds … all these factors and more will come into play when you’re coding a skin replacement surgery using skin substitute grafts for conditions such as burns.

Follow our experts’ tips to make sure you select the proper code and get all the pay your surgeon deserves for these services.

Tip 1: Capture Site Preparation

Skin replacement surgery consists of two basic steps: surgical preparation of the recipient site and placement of the graft with fixation. If you miss the separate skin preparation step, you’ll sacrifice pay your surgeon deserves.

Whether the surgeon performs both steps at a single encounter or delays grafting for a later time, report the surgical preparation using codes in the range 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 contractures …). Distinguish the codes based on body site, as follows:

• 15002 and +15003 for trunk, arms, legs (including wrist or ankle)
• 15004 and +15005 for face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits

Each pair of codes identifies the size of the defect created by the surgical preparation, with the first code (15002 or 15004) describing the first 100 sq cm for adults and children aged 10 and up, or 1 percent of body surface area for children under 10 years of age, including infants. The second code in each set (+15003 and +15005) are add-on codes that you should report for defect area beyond the initial size (for each additional 100 sq cm or 1 percent of body area or part thereof).

Service: The work described by these codes involves preparing a clean, viable wound surface for graft placement to heal by primary intention (not secondary intention). To report these codes, the surgeon’s documentation should demonstrate work such as removing nonviable tissue and/or releasing a scar contracture.

Terms: Primary intention means that the edges of the wound or graft are closed to allow them to grow together, while secondary intention refers to allowing an open wound to heal from the base up by building new tissue.

Size: To determine the surface area for code selection, add all areas within the same anatomic grouping, if the surgeon prepares multiple wounds.

Tip 2: Identify Type of Skin Substitute Graft

Peruse CPT^®’s “Skin Replacement Surgery” section, and you’ll see that the guidelines mention different types of skin grafts. You need to master the different graft options and know how to find the information in the surgeon’s note, because CPT^® includes different code sets for each type of graft.

Skin substitute grafts include the following:

• Non-autologous human skin (dermal or epidermal, cellular and acellular) grafts, including allografts (from a person other than the patient) and homografts (from cadavers)
• Non-human skin substitute grafts such as xenografts (from another animal such as pig)
• Biological products that form a sheet scaffolding for skin growth

Avoid: Don’t report a skin substitute graft when the surgeon applies non-graft wound dressings such as gel, powder, ointment, foam liquid, or injected skin substitutes, according to the guidelines. The skin substitute graft codes require some form of fixation, such as adhesives, sutures, or staples.

You’ll find the codes for skin substitute graft procedures in the range 15271-+15278 (Application of skin substitute graft …).

Like the site preparation codes, CPT^® distinguishes these codes by anatomic site and wound surface area, as follows:

• Trunk, arms, legs​

             o Total site less than 100 sq cm: 15271 first 25 sq cm or less; +15272 each additional 25 sq cm
             o Total site 100 sq cm or more: 15273 first 100 sq cm (or 1 percent body area infants and children); +15274 each additional 100 sq cm (or 1 percent body area infants and children)

• Face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/ or multiple digits

​             o Similar code pairs based on area: 15275 and +15276; 15277 and +15278

Remember: Wound surface area is what you should consider when selecting the code, not the size of the graft, cautions Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan.

Auto- is different: If you see the term “autograft” or “tissue cultured autograft,” then you are dealing with the harvest and/or application of an autologous skin graft. Autologous skin grafts are those that the surgeon harvests from another healthy part of the patient’s own body, and you would use different codes for those graft procedures.

Tip 3: Know What’s Included

You’ve learned that you can separately report the site preparation and the skin substitute graft placement procedures, but you may wonder what other services and materials in the op report are separately billable.

Include cleaning: When the surgeon performs a simple cleansing of the wound, that service is included within the skin substitute procedure codes, according to CPT^® instruction. That means you should never report 97602 (Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session) in addition to skin graft site preparation codes.

Include dressing: You might find documentation of wound dressing in the op report for skin substitute grafts, but you shouldn’t separately code routine dressing supplies for services performed in the office, according to CPT^® instruction. Supplies such as A6453 (Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard) are included in the skin application charge.

Include simple debridement: Skin replacement grafts include simple debridement of granulation tissue or recent avulsion. The National Correct Coding Initiative (NCCI) bundles skin substitute graft codes 15271-+15277 with skin and subcutaneous debridement code 11042 (Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less).

CPT^® considers debridement a separate procedure “only 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.”

“You can still separately code for deep debridement that includes muscle and bone,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington, using a code such as 11044 (Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq. cm or less).

Add skin substitute: When your surgeon performs a skin substitute graft, “the supply of the skin substitute/ graft should be reported separately,” according to CPT^® instruction. That means you should select the appropriate HCPCS Level II code such as Q4101 (Apligraf, per square centimeter) or C1763 (Connective tissue, non-human (includes synthetic)) for the graft material.

Bottom line: Accurately coding skin substitute grafts requires lots of specific information in the medical record. In addition to the type of graft material, the surgeon should also document site preparation and wound size, and number and location of grafts, according to Beresh.