General Surgery Coding Alert

Question: Previously, General Surgery Coding Alert recommended reporting allograft codes 15300-15366 with modifier 58 for replacement grafts during the global period of the original graft placement. I have seen no information, however, on the xenograft codes, and specifically Oasis grafts as reported by 15430 and 15431. Should I also report follow-up units of 15430 and 15431 with modifier 58 separately for graft re-applications during the global period?

Ohio Subscriber

Answer: In fact, application guidelines for 15430 (Acellular xenograft implant; first 100 sq cm or less, or 1% of body area of infants and children) and +15431 (... each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof [list separately in addition to code for primary procedure]) are not consistent with guidelines for allografts 15300-15366.

Just as with allografts, the surgeon may have to re-apply acellular grafts multiple times during the postoperative period. Unlike with allografts, however, the surgeon cannot report those re-applications separately with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended.

Rather, application of an acellular xenograft as described by 15430 and 15431 includes all necessary re-applications during the 90-day global period of the initial procedure.

One typical local coverage determination (LCD) for Medicare explains, "The application of Oasis Wound Matrix to human wounds is not a one-time application and requires reapplication every 5-7 days - it is inappropriate to bill application codes multiple times within a 90-day period. Therefore, the use of the following modifiers is not appropriate."

The LCD also dictates that Medicare will pay 15430-15431 "no more frequently than at 90-day intervals" and that if the wound doesn't show "measurable response after 12 weeks of applications, future applications will not be considered reasonable and necessary and will not be reimbursed."

As if to offset the greater work included in 15430-15431, the Medicare physician fee schedule assigns a higher total relative value to acellular xenografts than to similar allograft codes 15300-15366.