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Emerald Isle, NC
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CPT 15777: Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure)

Within the notes for this code it states when using a biological implant for soft tissue reinforcement in areas other than the breast/trunk to report 17999. I see this soft tissue reinforcement often when reviewing superior capsular reconstruction.

Here is where I need clarity or guidance:

My physician states because the code description states (ie, breast, trunk) this is not limiting the use to only breast or trunk but giving an example. In the past (years ago) I too believed this, and I actually was the one to suggest it's use initially. However, it is clearly stated within the notes and instructions to use unlisted procedure code 17999 when using a biological implant in areas other than breast or trunk. I have since been using the unlisted code outlining what it is representing, what CPT it is compared to, and how it was utilized within the procedure. Like with any unlisted code, it is more difficult to have this paid. Currently faced with a denial wanting a LMN (which I typically write) but my surgeon is wanting to void the unlisted and code 15777 (is quite adamant). I do not feel comfortable with this choice seeing how the code book guides its users to use the unlisted code in this scenario.

Are there any suggestions on this, or better yet- a clear guideline regarding the scope of CPT 15777 and whether or not it is truly limited to breast/trunk?
 
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175
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Morganton, NC
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Hello LaurenBrooke,

According to the lay description of CPT 15777 it is specifically for soft tissue defects of the breast and trunk.
CPT 15777: The physician inserts a biologic implant to correct a soft tissue defect of the trunk or breast caused by trauma or surgery. Biologic implants are usually porcine or allogenic grafts that have been decellularized. When tissue is decellularized, the cells, cell debris, DNA, and RNA are removed in a way that is not damaging to the collagen matrix, reducing the probability of rejection.

Have you tried looking at the companies website that makes the soft tissue allograft for example Arthrex? Sometimes they give codes/guidelines on coding and reimbursement of their products. According to the Arthrex FAQ you may need to check out payer guidelines but they do recommend using CPT 17999 for reporting the soft tissue use of ArthroFLEX dermal allograft. Also, some payers might deny the allograft as not medically necessary.
 
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