Dressing or Graft?
Reimbursement Hinges on Answer
By Linda Martien, CPC-EDS, CPC-H
When we discuss skin substitutes, CPT® refers us to the “Allograft/Tissue Cultured Allogenic Skin Substitute” and “Xenograft” headings. This classification of skin products does not include autologous human skin grafts, as they are processed skin products from other humans or animals. They do not come from the patient’s body. These skin substitutes can be cultured, irradiated or altered before being applied to the patient’s burn, ulcer or wound.
CPT® offers the code range 15300–15366 for allogenic skin substitutes and 15400–15431 for xenografic skin substitutes. When coding these charts, it is important to know what’s being applied and its origin. You’ll be surprised at what you find! Most important, too, is to be familiar with your national and local coverage determinations. Not all skin substitutes are covered by all payers. Always check your NCD or LCD before ordering a product from your physician.
Your LCD will also tell you what the utilization guidelines are for a product. Most are approved only for venous stasis or lower extremity neuropathic diabetic ulcers. Contraindications may include infection, osteomyelitis, neuropathic diabetic ulcers without pedal pulses, uncontrolled diabetes (based on documentation in the medical record), active Charcot arthropathy, vasculitis, uncontrolled rheumatoid arthritis and/or rheumatoid ulcers, other uncontrolled collagen vascular disease, patients treated with high doses of corticosteroids or immunosuppressants, and patients who have undergone radiation and/or chemotherapy within the month immediately preceding the proposed placement of the skin substitute.
Allografts for temporary wound closures are defined by body areas and the first 100 square cm, and then each additional 100 square cm (15300–15321). Skin allografts that are acellular dermal allografts are defined similarly with codes 15330–15336. Tissue cultured allogenic skin substitutes (15340–15341) are reported a little differently, as they are captured per 25 square cm and are not further defined by body area.
With the tissue cultured allogenic skin substitutes, you would not use the preparation of site codes (15002–15005), nor would you apply the excisional debridement codes (11040–11044). You would, however, use the tissue cultured allogenic dermal substitutes (15360–15366) for the capture method of body area per first and each additional 100 square cm.
Xenografts (such as porcine grafts or pigskin) are also captured by body area and by first/each additional 100 square cm (15400–15421). You will code the acellular xenograft implant according to the first and each additional 100 square cm, or 1 percent of body area of infants and children (15430–15431). With this code, you would not report the excisional debridement codes (11040–11044).
Verify with your product representative the FDA approval of the product and the code assignment from the AMA for the application. The product rep should be able to supply both for a new product. The FDA determined that these are one-time use products. Remnants left after one patient may not be used on another patient. These products, for the most part, have a finite shelf life and are only good for a limited period of time. Medicare states since these are one-time use items, that the entire piece of the skin substitute may be billed, regardless of the size of the piece applied to the ulcer, wound or burn.
Payers tend to look at these products (such as Apligraf® [newborn foreskin tissue], Oasis® [porcine intestinal mucosa tissue], Dermagraft® [newborn foreskin tissue], GammaGraft® [cadaver tissue], to name a few) as being either metabolically active or not. This is an important determination, as payers who do not consider the product metabolically active consider them as no more than collagen dressings. The impact of this comes down to being paid or not being paid for the application of the skin substitute. When the product is considered a dressing, it should be bundled into the procedure performed, such as a debridement.
Charge capture for these products and their application may also be problematic, as the size of the product (billed with J codes) is often much different from the application criteria.
A piece of Apligraf® is 44 square cm. The tissue is applied to an ulcer on the right medial malleolus which is 36 square cm. Remember, the FDA and CMS state that these products are for a one-time use only, and providers may bill for the entire piece of the product, regardless of how much was actually applied or used. Keep in mind that some payers also require documentation of product waste.
To bill for the product and application, look to the 15340–15341 code set in addition to J7340. Your claim form might look like this:
|J7340||44||Dermal & epidermal tissue, human origin with or without bioengineered elements, with metabolically active elements, per square cm|
|Tissue cultured allogenic skin substitute; first 25 sq cm|
|15341||1||… each additional 25 sq cm|
Remember, skin substitute products come in a variety of sizes, so it is important to know exactly which size of the product was used in addition to the size of the ulcer(s), wound(s) or burn(s) covered. The square centimeters of the ulcers, wounds or burns are cumulative of the areas covered by the skin substitutes. That, coupled with knowledge of your payer coverage determinations, will ensure accurate and timely code assignment, charge capture and reimbursement.