Surgical Preps: When Do You Code Them?

From A to Xenograph, specific language in the operative report should support the use of surgical prep codes.

By Ken Camilleis, CPC, CPC-I, CMRS

CPT® 2012 adds new instruction and definitions for surgical preparation of skin graft recipient sites (15002-15005). The area over which a skin graft/replacement is laid must be free of infection or disease. If it is necessary to cleanse the site, surgical preparation may be reported in addition to skin replacement/skin substitute surgery (15100-15278).

Note: For more information on skin replacement and skin substitute procedures, see Terri Brame’s, MBA, CPC, CGSC, CPC-H, CPC-I, CHC, article, “Grasp New Coding Details of Skin Replacement Surgery,” in the March 2012 Coding Edge, pages 28-31.

Know Where, How Much, Skin Is Prepared

Specific language must appear in the operative report to support surgical prep codes. A statement such as, “I prepped and draped the site” is inadequate because prepping and draping are routine with any surgical procedure. Rather, the documentation must specify how the preparation was accomplished prior to performing skin replacement/substitute surgery. For example: “The infection of the wound was so profound that it required extensive cutting and cleansing through to deep layers of subcutaneous tissue.”

When supported by documentation, site prep codes are assigned according to the anatomic area and total body surface area involved:

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

+15003 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)

15004 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; first 100 sq cm or 1% of body area of infants and children

+15005 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 preparation of wounds on the trunk, arms, and/or legs, report 15002 for the first 100 sq cm of site prep. For additional preparation (beyond 100 sq cm) in the same anatomic areas, report add-on 15003. Because 15003 is an add-on code, report it only in addition to 15002.

Likewise, for preparation of wounds of the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, report 15004 for the first 100 sq cm of site prep. For additional preparation (beyond 100 sq cm) in the same anatomic areas, report add-on 15005—again, only in addition to 15004.

Surgical preparation may be reported only once per wound. If the wound is prepared, but not grafted (for instance, grafting won’t occur until the next day), minimal preparation of the wound bed is included in the graft code, as is removing a previous graft.

Because site prep usually will accompany skin replacement surgery (15100-15278), modifier 51 Multiple procedures may be added to site prep codes 15002 or 15004 (for payers that require this modifier). Do not apply modifier 51 to 15003 or 15005; as add-on codes, they are “multiple procedure exempt.”

For example, a 2-year-old girl developed tinea nigra over her face, including her scalp, cheeks, mouth, and neck. The dermatomycosis caused severe contamination and some necrotization that encompassed 4 percent of her body surface. The surgeon thoroughly debrided the infected area before placing acellular dermal allograft over it. Proper coding is:

  • 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, for the first 1 percent of body area treated with allograft (human donor skin substitute).
  • +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) x 3 units, to describe placement of allograft on the additional 3 percent of body area.
  • 15004 to describe surgical prep of the first 1 percent of body area (modifier 51 may be appended for those payers that require it).
  • 15005 x 3 units, to report preparation of the additional 3 percent of body surface area.

Modifier 51 is not appended to 15278, 15777, or 15005 because these are add-on codes. The ICD-9-CM code for Tinea nigra is 111.1.

In a second example, a 47-year-old man suffered seven burns to his chest following an industrial accident six months ago. He now presents with infected and very painful scar tissue from three of the (third-degree) burns to the chest wall. Three full-thickness skin grafts are performed, taken from the right hip, including closure of the hip sites, as follows:

– Right sternal area, 6 x 4 sq cm

– Right sternal area, 9 x 6 sq cm

– Left sternal area, 8 x 5 sq cm

The surgeon discovered extensive eschar in each of these areas, which required extensive debridement. Proper coding is:

  • 15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less for the first 20 sq cm of the trunk treated with full thickness graft. The total area grafted in this case is 118 sq cm.
  • 15201 Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) x 5 units to report the additional 98 sq cm (beyond the initial 20 sq cm) of the trunk treated with full thickness grafts.
  • 15002 for the first 100 sq cm of site prep.
  • 15003 for the additional 18 sq cm of site prep.

For a diagnosis, you are not coding burns, but rather a late effect of burns. Report residual effect of the scar (709.2 Scar conditions and fibrosis of skin), followed by the late effect of a burn classified to category 942 (906.8 Late effect of burns of other specified sites).

Distinguish Site Prep from Wound Management

Codes 15002-15005 apply specifically to describe the work of “preparing a clean and viable wound surface for placement of an autograft, flap, skin substitute graft or for negative pressure wound therapy,” according to CPT® guidelines. Surgical prep codes would not be reported for removal of nonviable tissue or debris in a chronic wound when it is left to heal by secondary intention. When a wound requires serial debridement, report active wound management (97597-97598) or debridement (11042-11047). If a wound requires negative pressure wound therapy, 15002-15005 are applicable in addition to 97605-97606.

For instance, a 51-year-old woman presents for sharp debridement of a non-healing open wound to her arm. The wound resulted from an automobile collision three weeks ago, in which the patient was a passenger. Cleaning of the wound reveals remaining glass shards going down to tendon. Total area involved is 38 sq cm.

Because the non-healing wound is treated with debridement classified under Active Wound Care Management, report 97597 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less for the first 20 sq cm and 97598 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) for the remaining 18 sq cm. Don’t code 15002 because the patient’s wound is healing by secondary intention; that is, other than the debridement, no additional effort on the part of the dermatologist is required.

As a diagnosis, codes 884.2 Multiple and unspecified open wound of upper limb, with tendon involvement and E813.1 Motor vehicle traffic accident involving collision with other vehicle injuring passenger in motor vehicle other than motorcycle, respectively, describe an open wound of an arm with tendon involvement sustained in a motor vehicle accident (MVA) involving a collision with another vehicle in which the patient was a passenger.

In another example, a 67-year-old man presents for vacuum-assisted drainage during a dressing change following a 74 sq cm split-thickness skin graft to his left hip. The wound has been healing well and cleanly.

Wound vacuum management comes under the heading of Active Wound Care Management; Negative Pressure Wound Therapy. Code 97606 Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than or equal to 50 square centimeters represents this procedure. You would not code 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) because this was reported from a prior encounter; however, you would report 15002 because the patient’s wound is healing by the primary intention of the wound vac. Because the patient is not being treated for any condition at this time, only V58.31 Encounter for change or removal of surgical wound dressing is reported for the dressing change.

 

Kenneth Camilleis, CPC, CPC-I, CMRS, is a medical coding and billing specialist whose present focus is coding education. Mr. Camilleis is a full-time Professional Medical Coding Curriculum (PMCC) instructor and part-time educational consultant. He is the member development officer and is on the ICD-10 Advisory Committee for his local chapter.

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