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AppropriatCeloBsilulirnegsof Surgical Skin Substitute Grafts; 15271-15278 te Alexander Miller, M.D. ASMS 2019 lica No relevant conflicts of interest

Codes include

? Application of graft

? Code by location and sq cm

? Dermal scaffolding material ? Dehydrated amnion-chorion

membrane

Do NOT include ? Powder sprinkled on ? Gel ? Ointment ? Foam ? Liquid ? Injected material

Code separately for substitute material:

Dermal scaffolding: Q4110, per sq. cm.

1

Dehydrated membrane: Q4131, per sq. cm. 2

r Dup Prior to delayed skin grafting you debride some of the exuberant granulation

Answer: A. 15260, Full thickness skin that has been allowed to fill a previously deep defect and then do a full

graft, noo thickness skin graft harvest form the left preauricular skin.

se How would you CPT code for the debridement and the

te skin graft?

A. CPT 15260, full thickness skin graft, nose

u B. CPT 11042. Debridement, subcutaneous tissue and CPT 15260, Full thickness skin graft, nose ib3

Skin replacement surgery consists of surgical preparation and topical placement of an autograft Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure. CPT? 2017

Debridement of a skin wound (e.g., CPT codes 11000, 11042-11047, 97597, 97598) prior to a graft/skin substitute is included in the skin graft/skin substitute procedure (CPT codes 15050-15278) and should not be reported separately.

2017 NCCI Policy Manual, Chapter III-10

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Sktin GDrafts istr Skin Grafts CPT? Guidelines Surgical Preparation 15002-15005

? Removable of "appreciable"non-

o viable tissue (burn, trauma,

necrotizing infection) ? Includes incisional release of a scar

or contracture

N ? Wound may be: grafted immediately or delayed ? Not used for chronic ulcers/wounds

healed by secondary intention (use active wound care management or debridement codes)

Skin Graft 15050-15278

? Includes: ? Harvest of graft ? Removal of current graft or simple cleansing of wound ? Debridement billed separately only when: prolonged cleansing due to "gross contamination", "appreciable amounts" of devitalized/contaminated tissue removed, or when not immediately followed with graft

oConclusion: usual graft bed preparation, including for delayed grafting, is not

D separately reportable

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Includes

? Simple cleansing of defect or removal of old graft

? Harvesting of graft ? Linear repair of graft donor

site (if done) ? Placement of graft ? Anchoring/suturing/stapling of

graft ? Dressings

Does Not Include

? Surgical preparation of wound bed (for traumatic, burn, necrotic wounds ? NOT for clean surgical excision wounds (CPT? 1500215005)

? Prolonged cleansing, removal of "appreciable amounts" of devitalized or contaminated tissue" (CPT? 97602)

? Donor site repair with flap or graft

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Pinch Graft vsc.oFduilnl gthickness graft te 15050 Pinch Graft

? Single or multiple grafts, to cover area up to 2 cm diameter

lica ? Notonface

15200, 15220, 15240, 15260+: FTSG

? Routine wound bed preparation, including debridement, is not separately reportable

? Excision, Mohs surgery to create defect are separately reportable

? How a graft is harvested does not matter (dermatome, freehand blade)

? Code selection based upon:

? Site of wound ? Size of wound (sq cm surface area)

One week after you do a flap repair following an excision of a cheek BCC your patient returns to your group practice for suture removal. As you are away, another physician of your specialty who is in your group practice evaluates the patient, who is new to this physician, removes the sutures, and advises on aftercare.

How would the evaluation, suture removal and patient counseling be CPT coded?

A. CPT 99202, as the patient is new to the physician B. CPT 99212, as the patient is not new to the

dermatology group practice C. No charge and no code

8

Answer: C. No charge and no code Globaol SurrgicalDFollowu-uppPeriods When services are furnished by a physician of the same specialty within a group

practice the services are considered part of the global surgical package. Separate

te coding/billing is not appropriate.

If the patient were new to a physician of a different specialty within the group practice or the physician of any specialty were independent of the group practice, then an appropriate E/M office visit would be billable.

u Global Surgery Fact Sheet, Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

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0 Days: Minor

10 Days: Minor 90 Days: Major

Procedure

Procedure

Procedure

Biopsy (11100...)

Destruction

Flaps

Shave removal

(17000 - 17286)

Grafts

(11300 ? 11313)

Debridement (11000, 11011-42)

Mohs (17311 ?

Excisions (11400 ? 11646)

Repairs (12001 ? 13153)

Tissue Expanders

Destruction of Vascular Proliferative Lesion (17106 ? 08)

17315)

Dermabrasion,

No modifier is needed when an E/M or a surgical service is

Chemical Peel

done at any day following a zero day global surgical procedure

ComtplexDRepaiirstr Case 1 Excision of standing cones (Burow triangles, dog ears) does not justify a complex

repair code.

Complex repair

o Layered closure plus

"extensive" undermining,

retention sutures, scar

revision, debridement (for

N traumatic lacerations,

avulsions)

You excise a scalp tumor and repair the defect with a "kite graft".

You bill:

A) Full thickness skin graft and complex repair

B) Skin graft only

Nothing is said in CPT about

standing cone removal

Excision of standing cones

Standing cones

o (Burow triangles)

lengthens the line of closure Complex repair codes are

stratified via location and length

D 12

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Case 1: Answer Case 2 te B) Skin graft only is coded and billed

CPT instructs that harvesting and repairing the skin graft donor site is included in the skin

a graft code (and its valuation). o If the repair of the donor site requires a flap or another graft, then that is billable lic 13

You repair a nasal defect with both an adjacent tissue rearrangement (CPT 14060) and a full thickness skin graft (CPT 15260). Q: Are both a skin graft and a flap code billable? (Yes/No)

14

Case 2: Answer orFlapDcodinug p A: Yes, both flap and graft are reasonable to

bill

te NCCI edits do not pair CPT 14060 and 15260. However, billing Medicare for the two

procedures linked to one diagnosis code (same site) will very likely result in a denial

u of payment.

Use modifier .76 to differentiate that two separate procedures were done on one and

ib the same site.

3 mos. post op

Proper CPT? code determined by: Location of

defect (predominantly on eyelid and nose) NOT by flap source (cheek) Sum the sq cm of defect + sq cm of raised flap

otCaseD3 istr Case 3: Answer Three weeks after excising a basal cell carcinoma on the nose and repairing surgical

defect with a cheek to nose interpolation flap you divide and inset the flap.

NYou bill:

A. CPT 15630, division and inset, at nose B. CPT 15620, division and inset, at cheek C. CPT 15620.58, division and inset, at cheek D. CPT 15630.58, division and inset, at nose

Do 17

Three weeks after excising a basal cell carcinoma on the nose and repairing the surgical defect with a cheek to nose interpolation flap you divide and inset the flap.

You bill:

A. CPT 15630, division and inset, at nose B. CPT 15620, division and inset, at cheek C. CPT 15620.58, division and inset, at cheek D. CPT 15630.58, division and inset, at nose

18

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Case 3: Answer Interpolation Flaps te Both the attachment of the flap to the nose (CPT 15576) and the division and inset at

the nose (CPT 15630) are reported based upon the site of the surgical defect to which the flap is attached.

Modifier 58 is appended because the division and inset occurs during the 90 day

a global period of the initial interpolation flap procedure.

Modifier 58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional

lic During the Postoperative Period:

CPT Assistant, March 2010, page 4

19

Code determined by recipient site

Excision of lesion is reported separately (unlike adjacent tissue rearrangement)

Primary closure of flap donor site included in code

Division and inset: CPT? 15600-15630 Determined by recipient location of the flap

CPT? 15576: cheek to nose interpolation flap

CPT? 15630: sectioning of flap, at nose Add modifier .58 to indicate staged procedure

r Dup Case 4: Bilateral advancement flaps o You code for:

A) One flap (adjacent tissue rearrangement) B) Two flaps (adjacent tissue rearrangements)

ibute 2 stage Mohs defect

Bilateral advancement-rotation flaps

Case 4: Answer

A) One flap (adjacent tissue rearrangement)

Sum the area of the defect plus that of each of the raised flaps to generate the appropriate CPT code: 14021

CPT Assistant , July 2008, pg. 5

How about this case? How to code?

1 month postoperative

Case 5: Determinting aDppropriiaste flatprcode Areas

Square: base x height Triangle: ? base x height

Do No Circle: =

Sum: Area of defect + areas of raised flaps, including the Burows triangles. CPT illustrates squares and quadrangles

Case 6: Cheek advancement

This should be coded as: A) Flap (adjacent tissue rearrangement) B) Complex repair

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Case 6: Answer Case 7: Nasalis muscle based flap te B) Complex repair

CPT?: "Undermining alone of adjacent tissues to achieve closure, without additional incision, does not constitute adjacent tissue transfer, see

a complex repair codes 13100-13160)"

CPT Assistant, April 2014, page 10:

lic "Excess tissue removal does not constitute adjacent tissue transfer."

That is, removal of standing cones/dog ears/ Burows triangles does not make it a flap.

A) CPT? 14060, adjacent tissue rearrangement, nose, 10 sq cm B) CPT? 15740, flap, island pedicle C) CPT? 15732, muscle, myocutaneous, or fasciocutaneous flap, head and neck

6 days post-op

Case 7: Answer Coding naosalisrmusDcle baused apnd V-Y flaps The nasalis muscle flap is really an island advancement or V-Y flap.

15740, Island pedicle requires "identification and dissection of an anatomically named axial

vessel".

te 15732, Myocutaneous flap refers to large muscle (temporalis, masseter, sternocleidomastoid, levator scapulae) based flaps ibu 1 month postop

14060, 14061: Flap, nose

Includes V-Y plasty

Sum excision plus raised flap defects

15740: Island pedicle

Requires ID and dissection of named axial vessel

15733: Myocutaneous flap

New code for 2018

"For...V-Y sq flaps...without clearly defined anatomically named vessels see 14000-

14302"

Has named vascular pedicle (buccinators, genioglossus, temporalis, masseter, SCM,

levator scapulae)

Case 8: NosetflapDor chiesek fltapr? Case 8: Answer A) Cheekflap,14041 Do No B) Noseflap,14061

A or B

Retain consistency: If billing diagnosis is a nose tumor, and a cheek flap is coded,

that may create some

adjudication questions. Correlate the site diagnosis with

the site specific repair code Additional approach: bill for the

anatomical site that contains greater

than 50% of the surface area of the

defect

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