General Surgery Coding Alert

Question: Following escharotomy (16035-16036) and debridement (16020-16030) and prior to placing a skin graft, the surgeon prepared an area of 12 cm x 12 cm (144 sq cm) on a burn patient's right leg by clearing all remaining eschar, skin debris and subcutaneous tissue. May I report site preparation (15002)?

Pennsylvania Subscriber

Answer: Depending on the exact type of graft the surgeon places, you may probably report 15002 (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, trunk, arms, legs; first 100 sq cm or one percent of body area of infants and children) to describe the site preparation.

Because the total area the surgeon prepared exceeds 100 sq cm, you may also be able to report +15003 (... 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]).

CPT has specific language directing you to use 15002-15005 "for initial wound recipient site preparation." The site preparation is separate from escharotomy, debridement and (in most cases) placement of the graft itself.

The exceptions: You should not report site preparation (15002-15005) separately with xenograft codes 15430-15431, according to CPT instructions.

-- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.