Podiatry Coding & Billing Alert

Hint: Use square centimeters for ATTs.

In Podiatry Coding and Billing Alert volume 14, number 9, you learned all about how to handle coding for laceration repairs from speaker Corrie Alvarez, CPC, CPC-I, CEDC, CPMA, CEMC, CRC, CPCO, at the session “Skin Repairs and Grafts” during HEALTHCON Regional 2022. This month, take a look at how to report adjacent tissue transfers (ATTs), skin replacement surgery, and skin substitutes.

Read on to learn more.

Tip 1: Handle ATT/Rearrangement This Way

Adjacent tissue transfer (ATT) or rearrangement includes Z-plasty, W-plasty, Y-plasty, rotation flaps, and advancement flaps, Alvarez said. Since straight-line scars draw attention easily, a Z-plasty can break up the scar into smaller units, making the scar less noticeable.

Report 14000 (Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less)-+14302 (Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)) “for excision (including lesion) and/or repair by adjacent tissue transfer or arrangement (eg Z-plasty, V-Y plasty, rotation flaps, random island flap, advancement flap),” per the CPT^® guidelines. “Undermining alone of adjacent tissues to achieve closure without additional incisions does not constitute adjacent tissue transfer-see complex repair codes 13100-13160. The excision of a benign lesion (11400-11446) or malignant lesion (11600-11646) is not separately reportable with codes 14000-+14302.”

Undermining defined: Undermining is the technique of using sterile scissors to bluntly dissect the dermal layer away from the underlying connective tissue, according to Alvarez.

A skin graft that is necessary to close a secondary defect “is considered an additional procedure,” per the CPT^® guidelines. “For purposes of code selection, the term ‘defect’ includes the primary and secondary defects. The primary defect resulting from the excision and the secondary defect resulting from flap design to perform the reconstruction are measured together to determine the code.”

To report ATTs for podiatry, look at 14040 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/ or feet; defect 10 sq cm or less), 14041 (… defect 10.1 sq cm to 30.0 sq cm), as well as 14301 (Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm) and +14302 (… each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)).

In order to code ATTs, the surgeon must make incisions and intentionally move the tissue around and make flaps, Alvarez explains.

Follow these coding rules when reporting ATTs, according to Alvarez:

• Use square centimeters (cm).
• Code the recipient site, not where the graft was taken from.
• Don’t code obtaining the graft separately, as it is included.
• If the donor site needs a skin graft or flap to repair it, code this as another procedure.

Tip 2: Learn About Different Graft Types for Skin Replacement Surgery, Skin Substitutes

Alvarez also discussed skin replacement surgery and skin substitutes.

For podiatry, you should look to 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)-+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, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)) for surgical preparation.

For podiatry-related autografts/tissue cultured autografts, look to 15040 (Harvest of skin for tissue cultured skin autograft, 100 sq cm or less)-+15157 (Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; 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)) and 15220 (Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less) through +15241 (Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)).

You can separately report the supply of skin substitute grafts, according to CPT^®. For podiatry, look to codes 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)-+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)).

Don’t miss: “Procedures involving wrist and/or ankle are reported with codes that include arm or leg in the descriptor,” per the CPT^® guidelines.

Graft types: Alvarez also discussed different graft types you may see in your podiatrist’s documentation. These include the following:

• Autograft (aka autologous): From the patient’s body
• Allograft (aka heterologous): From human donor
• Xenograft (aka heterograft): Taken from a different species
• Tissue cultured epidermal autograft: Grown from patient’s own skin cells
• Skin substitute grafts: Substitutes for skin

Tip 3: Pinpoint Important Skin Flap Terms

Your podiatrist may also document skin flaps, so you should familiarize yourself with the following, per Alvarez:

• Flap: A mass of tissue for grafting
• Composite: Graft that includes more than one type of tissue
• Free fascia: Requires elevation and transfer of fascia with microvascular (veins) anastomosis
• Split: Mainly epidermis and little of dermis
• Full: Both layers: epidermis, dermis; and subcutaneous tissue
• Pedicle: Full thickness of skin and subcutaneous tissue, attached by tissue through which it receives its blood supply

You may also see key terms such as advancement flap, free flap, myocutaneous flap, full-thickness skin graft (FTSG), and split-thickness skin graft (STSG) in the documentation, per Alvarez. FTSG refers to both layers. STSG refers to mainly the epidermis.

To report skin flaps for podiatry, you should look to 15572 (Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs), 15574 (Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet), 15610 (Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs), and 15620 (Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet).

The skin flap codes are based on type and location, Alvarez said. These codes do not include an extensive immobilizing device and/or closure.