Podiatry Coding & Billing Alert

Learn which common podiatry products line up with new skin graft codes

Other than the common encounters of foot sprains and fractures, your podiatry office may also have come across wound care cases that require skin repair or replacement. Having the knowhow of newly emerged skin graft technology and its related CPT® codes will enable you to recoup hitherto unaccepted podiatry graft procedures.

Choose Wisely for Podiatric Graft Codes

Among the multiple codes available in CPT® for wound care procedures, there are only a few that qualify for podiatric skin graft procedures.

For reporting skin substitution procedures such as allograft, xenograft you have a choice of four CPT® codes,

•  15275 (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area)and 15276+ (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof [List separately in addition to code for primary procedure])
  
•  15277 (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children) and 15278+ (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof [List separately in addition to code for primary procedure]) For Medicare patients you will use HCPCS skin repair code range (Q4100-Q4121) based upon the type of graft used.
  

Reason: A lot of the old codes just don’t apply now, especially the codes from the 15340-15431 range as they have been deleted. The above given codes replaced the old codes for skin substitutes. You should be using the new codes to report grafts with products like Apligraf or Dermagraft.

Caution: Don’t even think of using other codes in the 15271-15278 (Skin Substitute Grafts) range as podiatric graft procedures can only be reported with codes that include feet, ankle in the descriptor of the code.

“Acellular collagen matrix, such as Oasis, falls into the acellular xenograft category. Podiatrists often use Oasis, a matrix derived from porcine submucosal tissue, to treat ulcers for diabetic patients. In the past, Medicare carriers have hammered home that this product should be considered a ‘wound care dressing’ and not a xenograft. However, it is now being covered as Xenograft,” says Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.

Example: How should you report the treatment of a foot wound of less than 50 sq cm that requires both the application of Dermagraft and wound VAC within the global period?

Answer: You would code the wound treatment as follows:

For the wound preparation, select 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 1% of body area of infants and children);

For the Dermagraft application, report 15275 (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area) and 15276 (…each additional 25 sq cm wound surface area, or part thereof [List separately in addition to code for primary procedure])

For the final step, the wound VAC application, report 97605 (Negative pressure wound therapy [e.g., vacuum-assisted drainage collection], utilizing durable medical equipment [DME], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session; total wound[s] surface area less than or equal to 50 square centimeters).

Diligently Prepare Graft Procedure Documentation

Make sure you have complied with the following points before submitting your claim for best results.

1. Check that the repaired wound(s) have been measured and recorded in centimeters, whether curved, angular, or stellate.

2. Ensure while filling the claim that when multiple wounds are repaired, you have added together the lengths of those wounds in the same classification and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the midfoot and extremities. However, do not add together lengths of different classifications (e.g., intermediate and complex repairs).

3. When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier 59 (Distinct Procedural Service) or X(ESPU) modifier as applicable.

4. If involvement of nerves, blood vessels, and tendons is indicated in the physician notes, report under the appropriate system (Nervous, Cardiovascular, Musculoskeletal) for repair of these structures. The repair of these associated wounds is included in the primary procedure unless it qualifies as a complex repair, in which case modifier 59 applies.

“Don’t report ligation separately as CPT® considers simple ligation of vessels in an open wound as part of any wound closure. Additionally, simple ‘exploration’ of nerves, blood vessels or tendons exposed in an open wound is also considered part of the essential treatment of the wound and is not a separate procedure unless appreciable dissection is required,” cautions Beresh. Mind the New Modifiers JC and JD for Skin Substitution

You have two main modifiers JC (Skin substitute used as a graft) and JD (Skin substitute not used as a graft) used as graft procedure modifiers. As Medicare didn’t release usage directives with the release of skin substitute modifiers JC and JD, Medicare contractors can come up with their own directions for the modifiers’ use. You should connect with your payers to learn their policies and to get a firm grip on the difference between the two modifiers. Combine JC with graft and JD with dressing: You will use the JC and JD modifiers when you’re coding for bioengineered skin substitutes. The difference between the two modifiers is whether the skin substitute is used as a graft or as a skin covering.

The definition of a skin graft for this purpose is whether the skin substitute is implanted into the wound to be incorporated in the healing of the wound. If the skin substitute is used to cover a wound or to protect it from contamination or fluid loss, then it is not a graft, but a dressing and you would use modifier JD. While coding for the appropriate graft procedure, you will have to the use the JC or JD along with a site modifier — either RT (Right side) or LT (Left side).

When to use JC: A Medicare patient presents with diabetic foot ulcers that aren’t healing. Your podiatrist decides to treat the ulcers with debridement and application of a skin substitute in order to promote healing. You would report code Q4101 (Apligraf, per square centimeter) for the skin substitute material with modifier JC attached to alert payers that the material was used as a graft and either RT or LT.

When to use JD: Another patient presents with a diabetic foot ulcer on her left foot that is healing slowly. Your physician decides to use some skin graft material as part of the dressing to protect the wound from fluid loss and contamination to promote healing. You would report the code for the material such as Apligraf (15275-15278), with modifier JD attached indicating that the material was used as a dressing and LT to indicate the left foot.