Otolaryngology Coding Alert

Give yourself a Grafting 101 review

Otolaryngology Coding Alert's "Excision Requires Full-Thickness Skin Graft" caused numerous otolaryngology coders to ask about graft coding. If you're unsure about what a full-thickness graft includes, try this mini-quiz:
 
1. Fill in the blank: Graft codes, such as 15260 (Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less), don't include donor site repair requiring __________.
 
2. True or false: The correct anatomic location of a preauricular crease is the ear.
 
3. Complete the statement: You should report 15000 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues]; first 100 sq cm or one percent of body area of infants and children):
 
 a. when your otolaryngologist debrides a recipient site that he created during the same surgical session
 b. whenever you report a graft code, such as 15260 (Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less)
 c. when your otolaryngologist debrides intact skin
 d. appended with modifier -51 (Multiple procedures)
 e. never.

1. Separately Report Graft, Flap Donor Site Repair

Answer: Graft codes don't include donor site repair requiring skin graft or local flaps.

But when answering Otolaryngology Coding Alert's November 2003 "You Be the Coder" about nasal cancer excision and reconstruction, some otolaryngology coders also assigned 12052-51 (12052, Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) to cover the closure of the "deep defect." They based their coding on CPT's free skin grafts notes that state, "repair of a donor site requiring skin grafts or local flaps is to be added as an additional procedure." The note prompted them to ask why the answer didn't include 12052-51.
 
Here's why: CPT's note actually instructs you to separately report donor site repairs that require a flap or graft, says Stephen Sussman, MD, an otolaryngologist with Maui Medical Group in Wailuku, Hawaii. In "Excision Requires Full-Thickness Skin Graft," the surgeon uses a full-thickness skin graft to close the 3-cm nasal tip defect. Since the example doesn't mention that the otolaryngologist uses a graft or flap to close the preauricular crease donor site, he presumably closes the donor site with an intermediate repair (12052, Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm).
 
The graft code (15260) includes "direct closure of donor site," meaning simple (superficial), intermediate (layered closure), and complex (more than layered closure) repair. If, however, the donor site requires a skin graft, for instance a split graft (15120, Split graft, 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 [except 15050]) or local flap, such as an advancement flap (14040, Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less), you should separately report the repair, Sussman says.

2. Preauricular Crease Qualifies as Cheek

Answer: False. The correct anatomic location of a preauricular crease is the cheek, not the ear.
 
Although the preauricular crease occurs just before the ear, the crease is actually the cheek's lateral demarcation line. Therefore, a skin graft from the right preauricular crease, as appears in November's "You Be the Coder," qualifies as a cheek donor site, not an ear site, Sussman says.
 
This observation prompted some coders to report 15240 (Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 20 sq cm or less), not 15260. But the donor site doesn't matter when selecting the graft code. You should instead choose the free skin graft code based on the defect location's recipient area, according to CPT.
 
When you apply CPT's instruction to the "You Be the Coder," in which the otolaryngologist uses a full-thickness skin graft to close the 3-cm nasal tip defect, you should report 15260 to identify the defect's location - the nose. You should base the code selection on the recipient site or where the graft is going - the nose.

3. NCCI Includes 15000 With Excision Codes

Answer: C. You should report 15000 when your otolaryngologist debrides intact skin.
 
Because the otolaryngologist in the "You Be the Coder" presumably has to prepare the recipient site prior to covering the nasal defect with the graft, some coders wondered if they should separately report the procedure. "Should you assign add-on code 15000 in addition to the full skin graft and excision?" asks Ellen Allison, RHIA, CPC, physician billing coordinator at Roswell Park Cancer Institute in Buffalo, N.Y.
 
You shouldn't assign 15000 with lesion excision codes, according to the National Correct Coding Initiative. The edits bundle 15000 into benign lesion excision codes 11400-11444 and 11450-11470 and malignant lesion excision codes 11600-11624 and 11640-11643.
 
In "Excision Requires Full-Thickness Skin Graft," the otolaryngologist excises a 3-cm malignant lesion from the nose (11643, Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm). Because NCCI includes 15000 in 11643, you shouldn't separately report same-site surgical preparation.
 
These edits contain a "1" modifier indicator. So, if the otolaryngologist prepares one area for graft application and excises a different lesion, you should report the surgical preparation (15000) appended with modifier -59 (Distinct procedural service) to indicate a separate site from the excision (such as 11643). Because the primary procedure is the graft (for example, 15260), make sure to append modifier -51 to the excision code (such as 11643-51) to indicate a multiple procedure.
 
You should report 15000 when your otolaryngologist applies a graft to a recipient site that he didn't create in the same surgical session, if he documents the surgical preparation. In these cases, a surgeon previously excises the defect, so the skin is intact prior to graft application.
 
Suppose in November's "You Be the Coder" a dermatologist, rather than an otolaryngologist, performs the nasal excision (11643). The dermatologist then refers the patient to the otolaryngologist for reconstructive surgery. The otolaryngologist documents that he debrides the recipient site prior to applying the graft (15260). In this case, you should report 15260 for the skin graft and 15000 for preparing the recipient site.