Vol. 15 •Issue 25 • Page 6
CCS Prep!
Make Sure You’re Covered on The New CPT Skin Grafting Codes
Outpatient coders preparing for the certified coding specialist (CCS) or CCS-P (physician-based) exams should be aware of comprehensive changes to the skin grafting codes in the CPT classification system for 2006. These revisions were made to more fully reflect actual medical practice and to more completely match the new skin substitute products currently available and in use. In addition, there are significant differences between the skin grafting and substitute products. Some are temporary vs. permanent and some are natural vs. manufactured.
In the CPT manual, the Free Skin Grafts subheading under the Repair (Closure) heading was deleted and replaced with a new subheading titled Skin Replacement Surgery and Skin Substitutes. Extensive new introductory language and guidelines were added and an important new guideline (listed below) was also added:
“These codes are not intended to be reported for simple graft application alone or application stabilized with dressings (e.g., by simple gauze wrap) without surgical fixation of the skin substitute/graft. The skin substitute/graft is anchored using the surgeon’s choice of fixation.”
This means that coders will have to review the operative report documentation very carefully to ensure that the fixation of the skin graft or skin substitute placement is clearly indicated by the surgeon.
To assign the skin grafting and replacement codes appropriately, the coder must have a basic understanding of the components of skin and subcutaneous tissue and how the grafts are used. The majority of the grafts are placed on the epidermal layer of skin, defined as the outermost superficial layer of skin and the dermal layer, defined as that below the epidermis, which contains blood and lymphatic vessels, nerves and nerve endings, glands and hair follicles. Grafts may be anatomically classified as epidermal, dermal, split-thickness or full-thickness. They may also be classified by origin:
• Autograft: the tissue is transplanted from one site on an individual to another site on the same individual;
• Allograft (homograft): tissue is transplanted from one individual to another of the same species;
• Xenograft (heterograft): tissue is transplanted from one species to another (e.g., pig or baboon to human).
Other essential definitions involve the specific materials that are used in skin grafting procedures. These include:
• Skin replacement: a tissue or graft that permanently replaces lost skin with healthy skin;
• Skin substitute: a biomaterial, engineered tissue or combination of materials and cells or tissues that can be substituted for skin autograft or allograft in a clinical procedure;
• Temporary wound cover: not the final resurfacing material but one that temporarily provides coverage of the wound surface until the skin surface can be permanently replaced.
New CPT codes were developed that classify the different types of services based on the definitions above and by the recipient site where the graft is placed. Because there are differing types of skin tissue and certain body sites carry their own specific issues related to grafting, the codes are also differentiated by site. Body sites that are considered “special body areas” include the following: face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and multiple digits.
Frequently assigned codes 15000 and 15001 were revised for 2006 and their use expanded. Currently (for 2005) the terminology reads:
15000 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues); first 100 sq cm or one percent of body area of infants and children
15001 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues); each additional 100 sq cm or each additional one percent of body area of infants and children (List separately in addition to code for primary procedure)
For 2006 the codes above were revised to include “incisional release of scar contracture” because this is a commonly performed procedure in burn cases.
Two other commonly assigned codes were also revised to ensure that their use is consistent with the addition of the new codes. These include codes 15100 and 15120, which both represent split-thickness skin grafting procedures. In place of “Split graft,” the terminology has been further revised to read “Split-thickness autograft.”
Two existing codes from 2005 (15400 and 15401) that represent xenografts were also revised to include terminology related to these grafts involving the dermal layer and being used for temporary wound closure. Because these grafts are taken from other species (most commonly porcine or pigskin), they are typically rejected after some time and so are used for temporary wound closure purposes. Products include EZ Derm™ and Mediskin®. Two new codes for related xenografts are available for use in 2006 (primary code 15430 for the first 100 square centimeters and corresponding add-on code 15431 for each additional 100 square centimeters). The most common products used are Oasis® and Surgisis® and these grafts are comprised of decellularized porcine connective tissue, whose strength make them ideal for soft tissue reinforcement grafting purposes.
New codes include 15110 and 15115, which represent epidermal autografts of various body sites. These primary codes involve the first 100 sq cm of the recipient site grafted. Corresponding add-on codes 15111 and 15116 are also available to reflect services that involve each additional 100 sq cm of epidermal autograft. Coders should review documentation to ensure that the graft only includes the most superficial epidermal layer, which is extremely thin (typically 5 Ð 6 thousandths of an inch), and is very hard to handle. These grafts are harvested from the patient’s own body (autograft).
Dermal autografts (involving the deeper layer of skin) correspond to primary codes 15130 and 15135, differentiated by body site of the recipient grafting site. These codes also involve the first 100 sq cm of the recipient site grafted and corresponding add-on codes 15131 and 15136 are also available to reflect services that involve each additional 100 sq cm of dermal autograft. Once again, documentation should specify that the grafts are harvested from the patient’s own body (autograft). These grafts may be harvested utilizing two passes of a dermatome.
When the operative report indicates that an autograft involves a tissue cultured process, codes 15150 through 15157 should be reported for these grafting procedures. The grafts themselves are cultured in smaller pieces, so the primary codes (15150 and 15155) include only the first 25 sq cm. Two add-on codes are available for each primary code, the first involving grafts with additional measurements of 1 sq cm to 75 sq cm (15151 and 15156) and the other involving each additional 100 sq cm (15152 and 15157). The tissue cultured process is typically used when the patient does not have enough unaffected (unburned) skin to provide a primary graft. A small portion of this tissue is taken and cultured in a lab, which greatly increases its size. This harvesting process may be reported separately with new code 15040. All of the codes in range 15040 through 15157 are found under the new Autograft/Tissue Cultured Autograft section. The grafting products that involve only the epidermal layer include CEA, Epicel® and EpiDex®.
Acellular dermal replacement grafts are reported with primary codes 15170 and 15175 for the first 100 sq cm, again differentiated by body site. The corresponding add-on codes represent each additional 100 sq cm. These grafts involve a synthetic replacement material in which the dermal layer is permanent, but a temporary silicone top layer requires epidermal grafting at a later date. The product most commonly used for this type of graft is Integra®.
Dermal grafts may also be placed using tissue from another human donor (allograft) or in combination with skin replacement products. Primary codes 15330 and 15335 are reported for these services for the first 100 sq cm, differentiated by body site, along with their corresponding add-on codes 15331 and 15336 for each additional 100 sq cm measured at the recipient site. Most commonly, the Alloderm® product is used for these procedures and it requires immediate concurrent coverage with human tissue.
Tissue cultured allogeneic skin substitute products are produced in the laboratory and contain both a dermal and epidermal layer; the product Apligraf® is commonly used for these procedures and primary code 15340, along with corresponding add-on code 15341 are reported for these services. These products are typically used in 25 sq cm increments and the codes match these dimensions.
When a tissue cultured allogeneic skin substitute product involves only the dermal layer, a code from the 15360 through 15366 range should be reported. These codes are also differentiated by body site and include primary codes (15360 and 15365) for the first 100 sq cm grafted at the recipient site and corresponding add-on codes (15361 and 15366) for each additional 100 sq cm. Common products currently available are derived from cultured allogeneic neonatal dermal fibroblasts and include Transcyte® and Dermagraft®.
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?
a. 15360
b. 15340, 11041
c. 15340
d. 15365
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
c. 15040
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 Ð 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 15400Ð15431; 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.
