Otolaryngology Coding Alert

You'll have to differentiate between layers of skin when applying graft codes

With a host of new and revised codes for 2006, CPT gives you the specificity you need--and, hopefully, the reimbursement you deserve--for a variety of skin grafting techniques.

The overview: CPT has renamed the -Free Skin Grafts- subsection -Skin Replacement Surgery and Skin Substitutes.- This portion of CPT adds 37 brand-new codes, revises five codes and deletes four codes, and now includes a total of 54 codes (up from just 21 in 2005).

The advantages: Many of the new codes seem designed to represent some new techniques and procedures, says Teresa Thompson, CPC, CCC, with TM Consulting in Sequim, Wash. They include new codes for autografts (15100-15157), acellular dermal replacements (15170-15176), allografts (15300-15336), skin substitutes (15340-15366) and xenografts (15400-15431). Many of the codes are specific to particular products or technologies.

Describe Depth With New Codes

The expansion of the skin graft CPT codes allows you to specify the depth of the graft and/or the graft material the surgeon uses. The range of codes for autologous (autogenous) skin grafts (15100-15261), for instance, now includes codes for:

- split thickness autografts--15100-15101 and 15120-15121
- epidermal autografts--15110-15116
- dermal autografts--15130-15136
- tissue cultured epidermal autograft--15150-15157
- acellular dermal replacements (also called neodermis, skin substitute, AlloDerm or Dermagraft)--15170-15176. Until now, you probably struggled to get paid for some of these expensive and specialized products using a general skin graft code, says John Bishop, PA-C, CPC, president of Bishop & Associates in Tampa, Fla.

-Because an ENT can basically function as a facial plastic surgeon, any of the new skin codes that apply to the areas of face and neck are of interest for otolaryngology practices,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Shrewsbury, N.J.

Harvest a Code for Harvesting Cultured Autograft

You may now report harvesting of keratinocytes and dermal tissue for tissue-cultured skin grafts separately, when performed. The new code for harvesting cultured skin autografts is 15040 (Harvest of skin for tissue cultured skin autograft, 100 sq cm or less).

In the past, you could only report cultured skin graft harvests separately by reporting a biopsy code, which really didn't describe the procedure properly. As a result, many payers wouldn't reimburse the procedure separately, says John Bishop, PA-C, CPC, president of Bishop & Associates in Tampa, Fla.

Surface Area and Location Matter

Almost all of the new codes for special grafts specify a primary code for grafts of 100 cm or less and an add-on code for each additional 100 cm. Generally, one pair of codes describes grafts for trunk, arms and legs, with a second pair of codes (which would be more useful for ENTs) for the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits.

This arrangement is similar to the current skin graft codes, says Linda Gracey, CPC, a coder and medical billing supervisor at Johns Hopkins University School of Medicine in Baltimore.

Example: Consider the following code -family,- which specifies the depth (epidermal), type (autograft), location (face, scalp, etc.) and surface area of the graft:

- 15110--Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children

- +15111--... each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)

- 15115--Epidermal autograft, 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

- +15116--... each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (list separately in addition to code for primary procedure).

Measuring tip: To ensure accurate measurements, your surgeon can keep a sterile flexible ruler in the operating room so that he can measure the actual surface size of the wound rather than estimating the distance from edge to edge through the air.

Look for Allograft Revisions Also

You-ll now be using 15300-15321 (Allograft skin for temporary wound closure ...) and 15330-15336 (Acellular dermal allograft ...) rather than 15350-15351 (Application of allograft ...) for allografts or homografts (grafts of human skin taken from a cadaver or donor other than the patient).

CPT 2006 also introduces 15340-15361 (Tissue cultured allogeneic skin/dermal substitute ...) and 15170-15176 (Acellular dermal replacement ...) in place of the previous skin substitute codes 15342-15343 (Application of bilaminate skin substitute/neodermis ...).

Example: The ENT uses AlloDerm, an acellular dermal replacement, to repair a 70-sq-cm area on an adult patient's neck.

Old way: Previously, you would report 15342 to describe the first 25 sq cm and 15343 x 2 for the remaining 45 sq cm.

New way: In 2006, you should report one unit of 15175 (Acellular dermal replacement, 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) for the above procedure, Bishop says.

Xenograft Can Apply for Temporary Closure

You should look to 15400-15421 (Xenograft, skin [dermal], for temporary wound closure ...) for xenografts for temporary wound closure and 15430-15431 (Acellular xenograft implant ...) for acellular xenograft implants.

A xenograft describes -application of a non-human skin graft or biologic wound dressing (for instance, porcine tissue or pigskin) - following debridement- of a burn, injury, infection or surgery wound, CPT explains in a new note.

Example: The patient suffers burns of the right side of the face, including the cheek and other areas around the mouth and eyes, totaling approximately 90 sq cm. The ENT prepares the area and sutures the xenograft in place.

In this case, you should report 15420 (Xenograft, skin [dermal], for temporary wound closure, 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).

Report Site Preparation Separately

Prior to applying a skin (or skin replacement) graft, the surgeon will normally prepare the recipient site. You may report this preparation separately using 15000 (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; first 100 sq cm or one percent of body area of infants and children) and +15001 (... 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 added language to direct you, -Use 15000, 15001 for initial wound recipient site preparation.-

Example: After escharotomy (16035-16036) and debridement (16020-16030) but before placing a skin graft, the surgeon must prepare an area of 8 cm x 8 cm (64 sq cm) on a burn patient's left check/jaw by clearing all remaining eschar, skin debris and subcutaneous tissue. In this case, report 15000 to describe the site preparation.

The exceptions: You should not report site preparation 15000-15001 separately with xenograft codes 15430-15431 (see above for more information on these codes), according to CPT instructions.