General Surgery Coding Alert

Use our 4-step method to select the right code What's your method for choosing among the more than 20 skin graft codes? To ensure complete and proper coding, our experts recommend that you adopt a systematic, step-by-step approach for every claim, beginning with reporting site preparation and ending with proper modifier use for staged or multiple procedures. Step 1: Report Site Preparation Coding for skin grafts involves a number of steps. For example, after escharotomy (16035-16036) and debridement (16010-16030) but before placing a skin graft, the surgeon must prepare the affected area by clearing all remaining eschar, skin debris and subcutaneous tissue. CPT includes two codes to describe site preparation:

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

+15001 - ... each additional 100 sq cm or each additional one percent of body area of infants and children (list separately in addition to code for primary procedure).
 
Overlooking site preparation is easy because it is a standard part of grafting procedures. But CPT includes specific codes for the work involved, and if you fail to report them you're losing reimbursement. To bill 15000/15001 correctly, be sure the surgeon's procedure notes clearly state that he or she performed the preparation. Documentation should also specify the size of the area that will receive the graft. To determine the area in square centimeters (sq cm), simply multiply the length of the area by its width.
 
For example, the surgeon prepares an area of 14 cm x 14 cm (196 sq cm) on a burn patient's left leg to receive a skin graft. In this case report 15000, 15001 to describe the site preparation. Step 2: Determine the Skin 'Donor'
 
The donor skin to complete the graft can come from a number of sources, which, in turn, affects your code choices, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. The sources can include:
 
1. The patient's own skin, which the surgeon transports from one area to another. Such grafts are further classified as:

a.) Split thickness (15100-15121), which is a thin skin layer from a donor site and includes both epidermis and some dermis. When reading documentation, note that surgeons typically abbreviate "split thickness skin graft" as "STSG."

b.) Full thickness (15200-15261), which is a thicker skin layer from a donor site and includes all of the epidermis and dermis.
 
2. The surgeon places human skin from a donor other than the patient (including a cadaver). These grafts are called allografts or, in some cases, homografts. You should report these using 15350 (Application of allograft, skin; 100 sq cm or [...]