The last type of graft represented by new codes for 2006 involves allograft skin used for temporary wound closure. This skin is from human cadavers and is obtained from skin banks. To ensure consistency with other codes in the Skin Replacement Surgery and Skin Substitutes section of CPT, the primary codes (15300 and 15320) are differentiated by body site and involve the first 100 sq cm and the corresponding add-on codes (15301 and 15321) represent any additional 100 sq cm grafted.
Coders should carefully review the revised section in the CPT manual before attempting to assign these codes. There are many parenthetical instructional notations among the codes, some indicating whether or not it is appropriate to assign additional codes for wound preparation, debridement or other related services. And it's important to note that only the sections containing codes for adjacent tissue transfer or rearrangement and free full-thickness skin grafts remain unchanged from 2005. In some cases codes from one of those sections may be reported in combination with the new 2006 codes.
Obviously, it is now necessary that the coder have much more specific information concerning the type of graft utilized to assign complete and accurate CPT codes for these services. The following questions should be asked to ensure that the appropriate code is selected:
Which body site is involved in the area to be grafted (the recipient site)?
Is the body site one of the "special body areas" mentioned above, which may affect code selection?
What is the size of the recipient site to be grafted? To assign appropriate square centimeters, the coder may in some cases be required to multiply the length of the recipient site (in cm) by the width of the recipient site (in cm) to compute the square centimeters value.
Which skin layers are involved in the grafting procedure: dermal, epidermal or both?
What is the source of the grafting material? Is it from the same individual, from another human source, another species or is it a synthetic material?
If it is a synthetic material, which type of material was utilized?
In many cases the information concerning the source of skin grafting materials (particularly if not harvested from the same individual on the same operative episode) may be found in the medical record in areas other than the operative report. Any time a product is implanted into a patient, regulations require that a sticker or some other form of documentation be affixed to the patient's medical record, detailing the specific type, when manufactured, etc. Some facilities that provide a high volume of these procedures have developed specific forms for the medical records that contain all of the information in the questions listed above. If any of the essential documentation is missing, the coder should refer the record back to the surgeon for clarification before reporting these very specific CPT codes.
After reviewing the new codes in the 2006 CPT manual, test your knowledge with the questions below:
1. A 72-year-old woman with Type 2 diabetes mellitus is seen in the wound care center with a 4 X 4 cm non-infected full-thickness chronic ulceration of the plantar aspect of the left heel. The physician determines that a debridement procedure, followed by placement of a tissue-cultured allogeneic skin substitute would benefit the patient. The wound is debrided, measured and after graft materials were obtained an approximately 25 sq cm tissue-cultured allogeneic skin substitute was fenestrated, grafted to the excised surface and secured with interrupted sutures. Which CPT code(s) reflect this service best?
b. 15340, 11041
2. A 30-year-old airline mechanic suffered deep partial thickness burns of the right arm and shoulder, involving 8 percent total body surface. He was taken to surgery and had surgical preparation of the burn on the arm and shoulder with excision down to viable dermal tissue. After adequate hemostasis was ob-tained in the excised surface, approximately 300 sq cm of xenograft was grafted to the recipient site (arm and shoulder) and secured with 45 interrupted sutures. Which CPT code(s) reflect this service best?
a. 15300, 15301
b. 15400, 15401, 15401
c. 15420, 15421, 15421
d. 15400, 15401, 15401, 15000, 15001, 15001
3. An 8-year-old girl was found and rescued from a burning building with 80 percent total body surface extensive full-thickness burns. She was initially treated with excision, but due to the extent of the burn and lack of sufficient donor sites, the excised wounds were covered with cadaveric allograft and/or other skin substitute/replacement. On this surgical episode, a split-thickness skin biopsy was harvested for the preparation of cultured autologous skin grafts to be applied in 3 to 4 weeks or when available. A total of 100 sq cm split-thickness skin graft 0.010 to 0.015 inches in depth was harvested using a dermatome. Which CPT code(s) reflect this service best?
a. 15100, 15000
b. 11100, 15000
d. 15150, 15151 n
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), an Ingenix company, which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement and compliance.
Answers to CCS PREP!: 1. c: The procedure involved only 25 sq cm of a tissue-cultured allogeneic skin substitute (not a dermal substitute) so code 15340 is most appropriate. There is a parenthetical guideline under code 15341, indicating that no codes from the 11040 11042 (debridement) section should be used in addition to the 15340, 15341 codes. The debridement is included in the 15340 code; 2. d: The xenograft recipient site involved the shoulder and arm, which are found in code terminology at 15400. Code 15400 is reported for the first 100 sq cm grafted, and then add-on code 15401 is reported twice for the second and third 100 sq cm grafted. Because burn wound preparation was also performed, it should also be reported with codes 15000 for the first 100 sq cm and 15001 reported twice for the second and third 100 sq cm excised. There is a parenthetical guideline under code 15001, indicating that for excision with immediate xenogeneic dermis placement use 15000, 15001 in conjunction with 1540015431; 3. c: The only procedure that was performed on this surgical episode was the harvesting of skin grafting material that will be sent to a laboratory and a tissue cultured skin autograft will be done after the grafting material is ready (typically 3 to 4 weeks). No actual grafting or biopsy procedure was performed on this visit so none of the other codes are appropriate.