Wiki Therion allograft placed "into" the surgical site

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heatherposchman1

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The provider performed a complete 5th metatarsal amputation (28140) and Hammer toe repairs 2nd/3rd digit same foot (28285 T6,T7).

"Bone wax was applied to the excised bone ends. 4x4cm amniotic Therion allograft was placed into the surgical site to potentially reduce adhesions."

Our coder billed 15275 (application skin substitute graft) and 15004 (surgical preparation or creation of recipient site). I most certainly do not think that 15004 is appropriate, and I'm thinking we can bill for the placement of the biologic allograft but I don't think that 15275 is the appropriate code since the allograft was not placed on the skin.

Any advise regarding the coding of the Therion allograft that was placed into the surgical site would be helpful.
 
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let me preface this with, I am not familiar with these codes.

but, per EncoderPro, 15004( I have bolded what I think is your answer):
Report 15005 in addition to 15004. These procedures are for preparation or creation of the recipient site only and should be reported with the appropriate skin graft/replacement codes, see 15050–15261 and 15271–15278. For nonviable tissue or debris from a chronic wound such as a venous or diabetic wound, see 97597-97598 or 11042-11047. For treatment of necrotizing soft tissue infections, see 11004-11008. Surgical trays, A4550, are not separately reimbursed by Medicare; however, other third-party payers may cover them. Check with the specific payer to determine coverage.

AND, per EncoderPro, 15275:
The physician applies a skin substitute for temporary wound closure to a wound on the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits. Skin substitutes are used as a temporary measure to close wounds and provide a barrier against infection and fluid loss, reduce pain, and promote healing of underlying tissues until a permanent graft can be applied. Common skin substitutes include acellular dermal replacement, temporary allograft, acellular dermal allograft, tissue cultured allogenic skin substitute, and xenografts. The skin substitute is fashioned to fit the size and contours of the previously prepared wound bed. It is then placed over the wound and sutured or stapled into place. These codes are reported for a total wound surface area of less than 100 sq cm. Report 15275 for the first 25 sq cm or less. Report 15276 for each additional 25 sq cm or less.

so, in conclusion, my guess would be that your coder is correct, at least with this range of codes. they seem to vary based on size and location.
 
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lgardner said:
let me preface this with, I am not familiar with these codes.

but, per EncoderPro, 15004( I have bolded what I think is your answer):
Report 15005 in addition to 15004. These procedures are for preparation or creation of the recipient site only and should be reported with the appropriate skin graft/replacement codes, see 15050–15261 and 15271–15278. For nonviable tissue or debris from a chronic wound such as a venous or diabetic wound, see 97597-97598 or 11042-11047. For treatment of necrotizing soft tissue infections, see 11004-11008. Surgical trays, A4550, are not separately reimbursed by Medicare; however, other third-party payers may cover them. Check with the specific payer to determine coverage.

AND, per EncoderPro, 15275:
The physician applies a skin substitute for temporary wound closure to a wound on the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits. Skin substitutes are used as a temporary measure to close wounds and provide a barrier against infection and fluid loss, reduce pain, and promote healing of underlying tissues until a permanent graft can be applied. Common skin substitutes include acellular dermal replacement, temporary allograft, acellular dermal allograft, tissue cultured allogenic skin substitute, and xenografts. The skin substitute is fashioned to fit the size and contours of the previously prepared wound bed. It is then placed over the wound and sutured or stapled into place. These codes are reported for a total wound surface area of less than 100 sq cm. Report 15275 for the first 25 sq cm or less. Report 15276 for each additional 25 sq cm or less.

so, in conclusion, my guess would be that your coder is correct, at least with this range of codes. they seem to vary based on size and location.
Click to expand...

Thank you for your reply.
 
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1heatherposchman said:
The provider performed a complete 5th metatarsal amputation (28140) and Hammer toe repairs 2nd/3rd digit same foot (28285 T6,T7).

"Bone wax was applied to the excised bone ends. 4x4cm amniotic Therion allograft was placed into the surgical site to potentially reduce adhesions."

Our coder billed 15275 (application skin substitute graft) and 15004 (surgical preparation or creation of recipient site). I most certainly do not think that 15004 is appropriate, and I'm thinking we can bill for the placement of the biologic allograft but I don't think that 15275 is the appropriate code since the allograft was not placed on the skin.

Any advise regarding the coding of the Therion allograft that was placed into the surgical site would be helpful.
Click to expand...
The application can be billed, not the prep.
 
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podcoder70 said:
I need to apologize for my original reply, I had not fully read the question. The 15275 and 15004 are for placement on the skin. Placement of allograft in the surgical scenario, as described, is included in the primary procedure.
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Thank you. We did realize last year that both codes were billed in error and not at all applicable to the procedure performed. That resulted in a full internal audit and LOTS of refunds to Medicare and other payers. The provider and coder now have a better understanding of those codes and correct usage. Unfortunately, when supply reps give surgeons "suggested" coding, and it is not verified by a coder, this results. Thank you again for your input.
 
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heatherposchman1 said:
Thank you. We did realize last year that both codes were billed in error and not at all applicable to the procedure performed. That resulted in a full internal audit and LOTS of refunds to Medicare and other payers. The provider and coder now have a better understanding of those codes and correct usage. Unfortunately, when supply reps give surgeons "suggested" coding, and it is not verified by a coder, this results. Thank you again for your input.
Click to expand...
I always advise my clients to not follow advice provided by reps.
 
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Hello, I have a coding scenario along these lines. the Podiatrist performed an ORIF of the ankle and she says she applied Allosync Bone graft to the fracture fragments and applied an amnion graft to the subq; the deeper layers and skin were reapproximated using monocryl, zipine sutures. would I only code the fracture repair? thank you
 
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I did get confirmation that allograft material placed inside of a wound (used for better healing and less adhesions from my understanding) is not billable (other than when used in breast reconstruction). They are billable only when used as wound closure or when the wound is left to heal by second intention. Also, bone grafting (20900 series) is only billable when the bone is harvested to graft.
 
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heatherposchman1 said:
I did get confirmation that allograft material placed inside of a wound (used for better healing and less adhesions from my understanding) is not billable (other than when used in breast reconstruction). They are billable only when used as wound closure or when the wound is left to heal by second intention. Also, bone grafting (20900 series) is only billable when the bone is harvested to graft.
Click to expand...
I really appreciate your response! I have looked everywhere for guidance and could not find it. It is confusing since there is not an NCCI edit. Thank you Heather!!
 
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