General Surgery Coding Alert

Hint: Graft size doesn’t matter.

If your surgeon treats burn victims, trauma patients, or others suffering from serious skin conditions, you need to know how to code skin substitute grafts.

With so many facts — wound size, graft size, site prep, attachment method, and more — you need to master a lot of details to make sure you choose the correct code and capture the pay your surgeon deserves.

Do this: Use the following four questions and answers to hone your skin substitute graft coding know-how.

Question 1: To select a CPT® code for skin substitute grafting, should I use the wound size or the size of the actual graft?

Answer 1: You should report grafts according to wound location and size, which the surgeon should record at the time of the procedure, experts say. Surgeons need to be specific in their op notes about both the size of the wound and the size of the graft. Experts recommend that surgeons use a flexible ruler to measure the size of the wound, because wounds are not flat and the extra size for the depth can make a difference in coding and in reimbursement.

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. The opposite is also true, which you can see in the following example.

Example: The surgeon excises a 1-cm melanoma with a 2-cm margin from a patient’s left arm, then applies a 30-sq.-cm skin substitute graft with sutures and dresses the area. In the current example, the surgeon documents a 5-cm diameter excision (19.6 sq cm), but a 30-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), says Pamela Biffle, CPC, CPC-P, CPC-I, CPCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas.

Watch out: “The size of the graft has nothing to do with the code selection,” Biffle warns. “Wound surface area is all that matters.” Therefore, if you erroneously based the code on the graft size rather than the wound size, you would report 15271 and one unit of +15272 (…each additional 25 sq cm wound surface area, or part thereof [List separately in addition to code for primary procedure]).

Question 2: When should I code for site prep with a skin substitute graft?

Answer 2: Be careful not to automatically report surgical preparation when your surgeon performs a skin substitute graft.

If the surgeon applies the skin substitute graft immediately following a surgical excision, 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 15271-+15278 in addition to the primary procedure, and skip the surgical preparation codes.

Learn limitations: You should report a surgical preparation code with the skin-substitute graft only 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.

Question 3: How do I code for a skin substitute graft of more than 25 sq cm, of the forehead, for instance?

Answer 3: You have a CPT® code to cover the first 25 sq cm: 15275 (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area). For anything beyond that, you should report +15276 (...each additional 25 sq cm wound surface area, or part thereof [List separately in addition to code for primary procedure]) for each additional 25 sq cm.

Example: The surgeon placed a skin substitute graft on a patient’s forehead, totaling 36 sq cm. In this case, you select 15275 for the first 25 cm and +15276 for the remaining 11 sq cm.

To report your skin graft procedures correctly, you must be sure that your surgeon documents the size, location, and depth of every graft. Otherwise, you run the risk of receiving payment for a lower-paying graft code.

The same pattern holds for most other graft codes, in which your report one code for the initial area, and a second code for each additional specific area for large grafts.

Question 4: How do I code if the surgeon simply applies skin substitute to the wound, stabilizing it with dressing, but does not fixate it?

Answer 4: 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.