General Surgery Coding Alert

Tip:Watch for the AlloDerm coding changes coming on July 1.

Surgeons now commonly use AlloDerm in a variety of surgeries, including breast reconstruction procedures. This product and the work associated with using it can present some unique coding challenges.

Let our experts help you sort through some of the breast reconstruction surgery coding myths you might encounter. Uncover the truth about AlloDerm coding using this case study presented by Dolores D. Carey, CCS-P, physician-based coder for Loyola University Physician Foundation in Maywood, Ill.

Operative note: The surgeon performed a bilateral mastectomy. He created a submuscular pocket on the patients left side after achieving meticulous hemostasis and removing the pec inferiorly. He placed an implant --- medium-height Contour Profile Mentor 275cc - into the pocket after achieving meticulous hemostasis. Next, the surgeon fashioned AlloDerm acellular dermis for the inferior pole in a standard fashion and sutured it in place with #2-0 PDS sutures after a fill of 120cc over a drain. He then performed the exact same procedure on the patients right side. Once satisfied, the surgeon placed the patient in a seated position and noted the implants were in good position related to her cleavage and inframammary fold. He placed the patient back in the supine position. He copiously irrigated the region using antibiotics solutions, placed drains, and closed.

Myth #1: Report 15330-15336 for Sling Placement

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When your surgeon uses AlloDerm during breast reconstruction, you may think you should code 15330 (Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children), and then add +15331 (& each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof [List separately in addition to code for primary procedure]) if necessary, based on the size of the AlloDerm sling.

Reality: You should use codes 15330-15336 when your surgeon uses a product like AlloDerm to repair the skin. These codes are meant to describe the work your physician does placing a skin graft. However, if your surgeon uses this product for other types of repairs -- for example, breast reconstruction, fascial reconstruction for very large hernial defects, or repair of the pericardium -- other codes are appropriate, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Childrens University Medical Group Compliance Program.

This is a common question because AlloDerm and other similar products are being used for many different kinds of repairs, Bucknam explains. Physicians often use AlloDerm in breast reconstruction, complex  abdominalwall, and hernia repair patients, confirms Mary Hayter, vice president of government affairs at LifeCell, which processes AlloDerm Regenerative Tissue Matrix.

Proper code choice: In this case, the best code to report for the Alloderm sling placement is the unlisted breast procedure code: 19499 (Unlisted procedure, breast).

Alternative: You could append modifier 22 (Increased procedural services) to the main breast reconstruction procedure code you report for this procedure, instead of reporting the unlisted code. This would be another way to capture payment for the extra work and time associated with the AlloDerm sling placement.

Myth #2: Report HCPCS Code for the Surgeon

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You may also think you should report the appropriate HCPCS code for the material your surgeon used. Reality: If you are coding for the surgeon who is operating in a facility setting, you will not report a HCPCS code, Bucknam says. The facility will report the proper HCPCS code to seek reimbursement for the AlloDerm product.

Facility coders: If you code for the surgeon and the facility, take note of some upcoming HCPCS changes. Prior to this year, you would have used J7344 (Dermal [substitute] tissue of human origin, with or without other bioengineered or processed elements, without metabolically active elements, per square centimeter) for AlloDerm. For the first half of 2009, the correct HCPCS code for AlloDerm has been Q4100 (Skin substitute, not otherwise specified).

Starting July 1, however, there will be two new HCPCS codes that relate to skin substitutes, as follows:

" Q4115 -- Skin substitute, Alloskin, per square centimeter

" Q4116 -- Skin substitute, Alloderm, per square centimeter.

Last fall, CMS made some HCPCS code changes to tissue and skin substitute products, moving them from the J code category to the Q codes, Hayter says. In that transition, AlloDerm, which had been assigned code J7344 in 2006, was left without a code. Were pleased about the new AlloDerm HCPCS code Q4116 since these codes are critically important for reimbursement for outpatient hospital services.