Wiki Skin Graft Billing help

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pensmemories

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Hello All,
First time posting and New to the CPB program, I have a question about billing skin grafts in podiatry. The doctor billed Q4159, 15275 and 97597 , Medicare paid for the Q4159 and 15275 no problem but they have denied 97597 stating bundled. The Doctor feels this is incorrect as 97597 is considered the prepping and/or debriding of the wound, and the 15275 is the application of graft. And Medicare has paid for services when billed with 11042 59 modifier
When I look codes up on First Coast Service Options the NCCI edits show they are payable together. So my question is what modifier would I use? (I have tried with and without the 59 modifier and both denied).
Thank you in advance for your time, just want some expert advise before I continue.
 
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pensmemories said:
Hello All,
First time posting and New to the CPB program, I have a question about billing skin grafts in podiatry. The doctor billed Q4159, 15275 and 97597 , Medicare paid for the Q4159 and 15275 no problem but they have denied 97597 stating bundled. The Doctor feels this is incorrect as 97597 is considered the prepping and/or debriding of the wound, and the 15275 is the application of graft. And Medicare has paid for services when billed with 11042 59 modifier
When I look codes up on First Coast Service Options the NCCI edits show they are payable together. So my question is what modifier would I use? (I have tried with and without the 59 modifier and both denied).
Thank you in advance for your time, just want some expert advise before I continue.
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Hi and welcome to the forum!

The doctor is incorrect in this case - debridement of a wound is included in the reimbursement paid for CPT 15275 under CMS policy. The denial is correct if 97597 was reported for preparation of the wound prior to skin substitute application.

Per the NCCI Policy Manual, Chapter III, Section I, paragraph 2: "Debridement of a skin wound (e.g., CPT codes 11000, 11042-11047, 97597, 97598) before a graft/skin substitute is included in the skin graft/skin substitute procedure (CPT codes 15050-15278) and shall not be reported separately. If the recipient site requires excision of open wounds, burn eschar, or scar or incisional release of scar contracture, CPT codes 15002- 15005 may be separately reportable for certain types of skin grafts/skin substitutes."
You can find this section of the manual on the CMS website here: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-3.pdf

The reason that reimbursement is allowed when a modifier 59 is appended to a debridement code is for situations where multiple wounds are treated at the same encounter, for example when one wound is debrided but a different wound is treated with a skin substitute. It would not be appropriate to append the modifier to obtain additional payment if the debridement and the skin substitute were both done on the same wound.
 
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