General Surgery Coding Alert

No fixation means no separate service.

The codes and rules for reporting skin replacement and skin substitutes aren't new, but they're certainly clearer since CPT® 2011 added two new introductory sections.

Let our experts help you navigate the CPT® instructions to learn when and how to accurately report skin replacement and skin substitute grafts.

Know When Not to Use These Codes

You'll find over 50 codes that describe various surgical steps and types of skin replacement/ substitute procedures in the range 15002 - +15431. See table on page 66 for code groupings.

Question: Should you report the appropriate code(s) from this range every time your surgeon uses a skin replacement or skin substitute to heal a wound?

Answer: No. Don't code a skin replacement or skin substitute application if the surgeon simply applies skin replacement/substitute to the wound, even if he stabilizes it with dressing.

CPT® instruction: Instead, use these codes only when "the skin substitute/graft is anchored using the surgeon's choice of fixation." The surgeon's fixation might involve adhesives, sutures, or staples, for instance.

"Look for documentation of fixation in the op note before you use any skin replacement or skin substitute codes," says Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS, President of Askmueller Consulting, LLC in Lenzburg, Ill.

Recognize What 'Application' Services Include

"Surgeons often perform skin replacement or skin substitute grafts following other surgical treatment for traumatic wounds, burn eschar, or necrotizing infection," says M. Tray Dunaway, MD, FACS, CSP, a surgeon, author, speaker, and coding educator with Healthcare Value Inc. in Camden, S.C. That means you're likely to use graft codes following other procedures such as 16035 (Escharotomy; initial incision).

When the surgeon applies and fixes skin or a skin substitute, you'll need to know which services you should -- and shouldn't -- code in addition to the proper graft code.

Include dressing: When you report a skin or skin substitute graft, you shouldn't separately code routine dressing supplies, according to CPT® instruction. Supplies such as A6453 (Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard) are included in the skin application charge.

Watch for substitute charge: When your surgeon performs a skin substitute graft in the office, "the supply of the skin substitute/graft should be reported separately," according to CPT® instruction. That means you should select the appropriate HCPCS Level II code such as Q4101 (Apligraf, per square centimeter).

Don't code debridement: The new introduction section also states that "application includes simple debridement of granulation tissue or recent avulsion." That's why you'll find Correct Coding Initiative (CCI) edits that bundle most codes in the range 15002-+15431 with 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq.cm. or less).

That's a change: "The application codes originally did not include debridement, but with the code revisions, skin and subcutaneous debridements are bundled," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.

"You can still code separately for really deep debridements that include muscle and bone," she says. Capture the deep debridement using a code such as 11044 (Debridement, bone [includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed]; first 20 sq. cm or less).

In many cases, however, you can charge separately for site preparation prior to graft application -- and that's the topic of the next section.

Jump on Site Prep Opportunities and Pitfalls

"Prior to applying a skin (or skin replacement) graft, the surgeon will normally prepare the recipient site," Dunaway says.

You may report this preparation separately using the appropriate code from the range 15002-+15005 (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, ...) -- sometimes.

Beware: You can't always separately code site prep. The new CPT® introduction to 15002-+15005 lists the conditions the surgeon must meet to justify using code(s) to describe the "services related to preparing a clean and viable wound surface," prior to placing skin replacement or substitutes.

Look at the following list to ensure that your surgeon's op note documents appropriate conditions before using any of these codes:

• "Appreciable nonviable tissue is removed to treat a burn, traumatic wound or a necrotizing infection"
• Or, "the clean wound bed may also be created by incisional release of a scar contracture resulting in a surface defect from separation of tissues"
• "The intent is to heal the wound by primary intention" such as skin replacement or skin substitute.

"Even if patient conditions require the graft to be delayed, you can bill the site prep based on intent for subsequent grafting," Bucknam says.

Don't use 15002-+15005 under the following circumstances, according to CPT® introductory sections and text notes following codes:

• "For removal of nonviable tissue/debris in a chronic wound (e.g., venous or diabetic) when the wound is left to heal by secondary intention"
• "When a primary procedure such as ... deep tumor removal requires skin graft for definitive closure"
• "With 15340-+15341" (Tissue cultured allogeneic skin substitute; ...)
• With 15430-+15431 (Acellular xenograft implant; ...).

Instead, for cleaning chronic wounds left to heal without a graft, choose a debridement code, such as 11042, or an active wound care code, such as 97597 (Debridement [e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound [e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of whirlpool, when performed and instruction[s] for ongoing care, per session, total wound[s] surface area; first 20 sq. cm. or less).

When the surgeon uses a graft to close a primary procedure site, instead of a site prep code, you should report the appropriate surgical code to describe the procedure that creates the defect, such as 21933 (Excision, tumor, soft tissue of back or flank, subfascial [e.g., intramuscular]; 5 cm. or greater).