Dermatology Coding Alert
Use Size, Location to Determine Graft Reporting
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Question: The dermatologist treated a burn patient who was receiving a skin graft. The area was 14 cm x 14 cm on the patient's left leg. How should I report this and receive full reimbursement? Answer: First, identify the defect by size and location and the type of graft. Grafts will include simple debridement of granulations or recent avulsion. Your dermatologist should clearly document the type of skin graft completed.
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Then, you can look to other codes such as 15000 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues]; first 100 sq cm or one percent of body area of infants and children) for the initial wound preparation of the graft area.
CPT also advises you to report 15100-15261 for autogenous skin grafts; for autogenous tissue-cultured skin grafts, use 15100-15121. These codes include harvesting of keratinocytes and their subsequent application. You should code procedures by recipient site. Use codes 15342 (Application of bilaminate skin substitute/neodermis; 25 sq cm) and +15343 (... each additional 25 sq cm [list separately in addition to code for primary procedure]) for application of skin substitute/neodermis. And, use modifier -58 (Staged or related procedure or service ...) for staged application procedure(s).
Don't forget: Repair of a donor site requiring skin graft or local flaps is added as an additional procedure.
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