Part B Insider (Multispecialty) Coding Alert

Tip: Graft size has nothing to do with code selection, say experts.

Whether it’s for treating burn victims, trauma victims, victims of infection, or other specific surgeries, your dermatology practice is sure to see its share of skin graft coding. Options for skin grafts are varied – autograft (when the grafted skin is harvested from elsewhere on the patient’s body), allograft (skin harvested from another human), and skin substitutes are some of the tools your dermatologist has.

With all these options, questions are sure to arise. Read on for our expert answers to some frequently asked skin graft questions.

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

Answer: You should report grafts according to location and size, which the dermatologist should record at the time of the procedure, experts say. Dermatologists need to be specific in their op notes about both the size of the wound and the size of the graft.

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.

Example: The dermatologist excises a 3-cm melanoma with a 2.5-cm margin from a patient’s left arm, then applies a 40-sq.-cm skin substitute graft with sutures and dresses the area. In the current example, the dermatologist documents an 8-cm excision, but a 40-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: When should I code for site prep?

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

If the dermatologist applies the skin substitute graft immediately following a surgical excision, so 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 15100-+15278 in addition to the primary procedure, and skip the surgical preparation codes.

Learn limitations: You should only report a surgical preparation code with the skin-substitute graft when the dermatologist 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: How do I code for a full-thickness graft of the forehead over 20 sq cm?

Answer: You have a CPT^® code to cover the first 20 sq cm: 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). For anything beyond that, you should report +15241 (... each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure]) for each additional 20 sq cm.

Example: The dermatologist placed a full-thickness graft on a patient’s forehead, totaling 36 sq cm. In this case, you select CPT^® code 15240 for the first 20 cm and +15241 for the remaining 16 sq cm.

In order to report your skin graft procedures correctly, you must be sure that your dermatologist documents the size, location and depth of every graft. Otherwise, you run the risk of receiving reimbursement for a lower-paying split-thickness graft.

The full-thickness graft codes for other areas of the body follow a similar pattern: one CPT^® code for the first 20 sq cm (e.g., 15260, Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less) and an add-on code for each additional 20 sq cm (e.g., 15261, … each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure])

The same pattern holds for most of the other autograft codes: one CPT^® code representing an initial area (e.g., 15120, Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children [except 15050]) and an add-on code you can report multiple times for each additional area (e.g., 15121, … 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]).

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

Answer: When the dermatologist 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 dermatologist 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 dermatologist’s fixation might involve adhesives, sutures, or staples, for instance.

Make sure the op note documents fixation before you use skin replacement graft codes. 

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