Coding for skin replacement surgery in 2012

In 2012, comprehensive changes were made to the skin substitute codes, including the addition of new introductory language and the creation of eight new Current Procedural Terminology (CPT)* codes that describe topical application of skin substitute grafts (see Table 1). The 24 codes that previously described skin substitute grafts have been deleted from the guidelines. However, codes that describe surgical preparation for grafting (15002–15005) and autografts (15040–15261) have not changed.

Table 1. New skin replacement surgery codes 2012

Table 1. New skin replacement surgery codes 2012

The revised skin replacement surgery guidelines instruct coders on how to correctly report codes that reference measurements of 100 sq. cm or 1 percent of body area of infants and children. When determining the involvement of body size, the measurement of 100 sq cm is applicable to adults and children 10 years of age and older; percentages of body surface area apply to infants and children younger than 10 years of age. The measurements apply to the size of the recipient area. Procedures involving the wrist and/or ankle are reported with the anatomic codes for the arm or leg. Additionally, the graft is anchored using the provider’s choice of fixation, and when services are performed in the office, routine dressing supplies are not reported separately. These codes are not intended to be reported for the application of non-graft wound dressings (for example, gel, ointment, foam, liquid) or injected skin substitutes.

These codes were specifically created for treatment of wounds in burn and trauma patients. These codes were not intended to be used for abdominal wall fascial repair or fascial support—in other words, underlay or overlay support.

Definitions

A new subheading called “definitions” has been added that provides a more thorough explanation of surgical preparation, autografts/tissue cultured autografts, and skin substitute grafts. Surgical preparation describes the initial services related to preparing a clean and viable wound surface for placement of an autograft, flap, skin substitute graft, or for negative pressure wound therapy. Autografts/tissue-cultured autographs include the harvest and/or application of an autologous skin graft. Skin substitute grafts include non-autologous human skin (dermal or epidermal, cellular and acellular) grafts (such as homograft, allograft), non-human skin substitute grafts (for example, xenograft), and biological products. Both autografts and skin substitute grafts include removal of current graft and/or simple cleansing of the wound, when performed.

When a primary procedure requires an autograft or skin substitute graft for definitive skin closure (for example, radical mastectomy, deep tumor removal), report 15100–15278 in conjunction with the primary procedure.

The new CPT codes for skin substitutes include a change in reporting based on the wound surface areas and anatomic locations. In years past, the codes were defined based on the first 100 sq cm and then each additional 100 sq cm. CPT 2012 introduces four new sets of primary and add-on codes based on wounds “up to” 100 sq cm and wound surfaces “greater than or equal to” 100 sq cm. CPT continues to define the codes by anatomic location. Codes 15271 and 15275 are reported for the application of the first 25 sq cm of skin substitute grafts for total wound surface areas up to 100 sq cm. Each additional 25 sq cm graft is reported with add-on codes 15272 and 15276. Codes 15273 and 15277 are reported for the application of the first 100 sq cm of skin substitute grafts for total wound surface areas greater than or equal to 100 sq cm. Each additional 100 sq cm of graft are reported with add-on codes 15274 and 15278. Codes 15273, +15274, and 15277, +15278 are intended to describe the more intense services for the burn patient.

Table 2. Coding matrix for the new skin substitute graft codes

For multiple wounds, sum the surface area of all wounds requiring grafts from the same anatomic site and report the applicable primary code and add-on code in multiples, as appropriate.

Table 2 summarizes the coding matrix for the new skin substitute graft codes.

Biological implants

A new add-on code, 15777, Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk), has been established. For bilateral breast procedures, report 15777 with modifier 50. For implantation of synthetic mesh or other prosthesis for open incisional or ventral hernia repair or closure of a necrotizing soft tissue infection wound, report 49568 in conjunction with 49560–49566 or 11004–11006, as appropriate. Code 15777 is not to be used for the topical fixation of skin substitute graft to a wound surface, which should be reported with new codes 15271–15278.

Clinical examples

A 27-year-old male is admitted to the burn center with a 75 sq cm burn wound on the right thigh and a 75 sq cm wound on the left thigh. You excise the burns down to viable subcutaneous tissue and apply a skin substitute graft.

The reportable procedures in this case are as follows:

15002, Surgical preparation, trunk, arms, legs, first 100 sq cm
+15003, Surgical preparation, trunk, arms, legs, additional 100 sq cm, or part thereof
15273, Skin substitute graft, trunk, arms, legs, first 100 sq cm
+15274, Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof

Both wounds are from the same anatomic location listed in the code descriptor (legs), thus, the wounds are added together for a total of 150 sq cm. Surgical preparation of 150 sq cm wounds of the right and left thighs is reported with codes 15002, first 100 sq cm, and +15003, additional 100 sq cm, or part thereof. The application of skin grafts to the right and left thighs is reported with codes 15273, first 100 sq cm, and +15274, additional 100 sq cm, or part thereof.

A mechanic was admitted to hospital with burns on both arms and hands, after his gasoline-saturated clothing was ignited from a spark. Surgical excision of the burn tissue from his right hand beginning at the wrist was performed two days ago (reported separately). He now undergoes application of 250 sq cm of skin substitute graft on his arms and 180 sq cm of skin substitute graft on his hands and fingers.

The reportable procedures in this case are as follows:

Arms:
15273, Skin substitute graft, trunk, arms, legs, first 100 sq cm
+15274, Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof
+15274-59,     Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof

Hands, fingers:
15277, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, first 100 sq cm
+15278, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, additional 100 sq cm, or part thereof

The arms and hands and fingers are listed in different anatomic locations; thus, it would not be appropriate to add the wound sizes together. Procedures involving the wrist and/or ankle are reported with codes that include arm or leg in the descriptor. Instead, report 15273 and 15274 for the application of skin grafts of the arm, and codes 15277 and 15278 for application of skin grafts of the hands and fingers.

A 45-year-old female is admitted to the hospital with burns on the face, ears, and feet measuring a total of 225 sq cm. Surgical excision of the burn tissue was performed three days ago (reported separately). She undergoes application of 225 sq cm of skin substitute grafts on her face, ears, and feet.

The reportable procedures in this case are as follows:

15277, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, first 100 sq cm
+15278, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, additional 100 sq cm, or part thereof
+15278, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, additional 100 sq cm, or part thereof

The appropriate codes to use for application of the first 100 sq cm of skin substitute grafts for total wound surface areas greater than or equal to 100 sq cm, and each additional 100 sq cm, are 15277 and 15278. The parenthetical instructions following add-on code +15276 instruct that it may only be used in conjunction with code 15275. Therefore, it would not be appropriate to report add-on code +15276 in conjunction with 15277 for the additional 25 sq cm.

A 50-year-old male is admitted to the hospital with a grease burn on his right arm. You excise the burns down to viable subcutaneous tissue and apply a skin substitute graft.

The reportable procedures in this case are as follows:

15002, Surgical preparation, trunk, arms, legs, first 100 sq cm
15273, Skin substitute graft, trunk, arms, legs, first 100 sq cm

Surgical preparation of 100 sq cm wounds of the right arm is reported with code 15002, first 100 sq cm. The application of the first 100 sq cm of skin substitute grafts for total wound surface areas greater than or equal to 100 sq cm is reported with code 15273.

A 50-year-old female undergoes a unilateral total (simple) mastectomy with immediate placement of a tissue expander for reconstruction. A 75 sq cm piece of acellular dermal matrix is sutured to the subpectoral pocket rim before the skin flaps are brought together. The skin is closed primarily.

The reportable procedures in this case are as follows:

19303, Mastectomy, simple, complete
19357, Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
15777, Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk)

The simple unilateral mastectomy is reported with code 19303. The implantation of acellular dermal matrix is reported with 15777.

Payor issues to consider

CPT instructs the use of modifier 51 on subsequent stand-alone codes. Some Medicare payors may not require the use of this modifier, thus it is critical to obtain written instructions from the payors for accurate claim format submission. Modifier 51 accurately identifies the subsequent procedure as nonprimary and subject to the multiple procedure payment formula.

Remember, never append modifier 51 to an add-on code because the add-on code has already been revalued for intraoperative work only.

Some payors may require modifiers on the add-on codes or may require the add-on codes to be reported in units. Verify with the payors the appropriate format for claim submission and payment processing.

If you have additional coding questions, contact the ACS Coding Hotline at 800-227-7911 between 7:00 am and 4:00 pm Mountain time, excluding holidays.


Editor’s note
Accurate coding is the responsibility of the provider. This summary is only a resource to assist in the billing process.


*All specific references to CPT (Current Procedural Terminology) terminology and phraseology are © 2011 American Medical Association. All rights reserved.

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