Decipher integumentary codes for correct coding
Published November 2008
Integumentary tips and tricks
Decipher integumentary codes for correct coding
Differentiate transfers, flaps, and grafting procedures
Editor’s note: This is the second article in a two-part series. It is adapted from the May 28 HCPro audio conference, “Integumentary CPT Coding: Correct Common Errors for Closures, Transfers, Flaps, And Grafts.” The presenters were John F. Bishop, PA-C, CPC, MS, CWS, president of Bishop & Associates, Inc., in Tampa, FL, and Susan Garrison, CHCA, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPAR, executive vice president of healthcare consulting services at Magnus Confidential in Atlanta.
The integumentary system is the largest organ system of the human body, so the number of CPT codes used for integumentary procedures is equally large.
In part one, Garrison examined repairs, adjacent tissue transfers, and correct assessment of integumentary procedures.
Make sure a flap is a flap
Drawing a picture of a closure can help you code the procedure correctly, but you can’t bill for a closure as an adjacent tissue transfer (even if it looks like a W or a similar shape) when the physician documents “direct closure” in his or her operative notes, Bishop said.
“[That shape is] just the way it ended up,” he said. “The physician didn’t go to all the extra time and effort to develop the W closure or the V-Y advancement or whatever else.”
If the procedure requires a skin graft of some type to close the secondary defect, that is an additional procedure you can also code, Bishop said. If a patient has primary and secondary defects together, with a primary defect and a secondary defect resulting in a flap design, add the overall measurements.
Use the new, more exact skin preparation codes
CPT replaced codes 15000 and 15001 with more explicit codes for 2008, said Bishop. The new codes describe what the surgeon does to prepare a surface of nonintact skin.
Code 15002, surgical preparation or creation of recipient site by excision of open wounds, specifies trunk, arms, and legs and applies to the first 100 square centimeters, or to 1%, of an infant or child’s total body surface area. Report 15002 for:
- Surgical preparation of a burn eschar
- Wounds or scar incisions or excisions
- Scar contracture releases
Use the add-on code 15003 for each additional 100 square centimeters or 1% of an infant or child’s total body area.
Code 15004 and its add-on, 15005, are the same definitions as 15002 and 15003, respectively, but apply to the face, scalp, eyelids, mouth, neck, ears, orbital areas, periorbital areas, genitalia, hands, feet, and/or multiple digits. They follow the same measurement criteria, said Bishop.
Get familiar with the basic types of grafts
In split-thickness skin grafts (codes 15100, 15101, 15120, and 15121), the surgeon uses an instrument called a dermatome to remove a layer of tissue from the patient’s body, including the epidermis and a predetermined amount of dermis, said Bishop, adding that the graft’s destination determines how thick the split-thickness graft will be.
Many coders automatically start thinking of a split-thickness skin graft when they read the terms “skin graft” in an operative note, Bishop said. But that may or may not be true.
Use the size of the recipient site, not the donor site, when measuring a skin graft, Bishop said. Location is also important. Look at which area of the body the surgeon is applying various types of skin grafts, as well as the type of graft. “Ask, is this an autograft, is it an allograft, is it a xenograft or something new, synthetic or biologic?” he said.
Coders who know their anatomy will see a reference to a dermal autograft and make the connection, Bishop said. Dermis is the second layer of skin. Surgeons remove as much of the dermis as they need. Frequently, they also remove the outer layer (the epidermis) because the patient doesn’t need it, or the physician intends to use it elsewhere, he said.
In autograft procedures, clinicians normally just cover the donor site with dressings, which is not separately billable. “You’ve got to be very careful when you are reading,” Bishop said.
Take note of the application, Garrison said, adding that if a physician simply steri-strips a closure, the CPT Manual bundles it into the E/M service, and you should not code a minor procedure or a surgical procedure.
Full-thickness grafts require the physician to take all the epidermis and then the dermis down to the basement cell membrane of the dermis, Bishop said, adding that surgeons use full-thickness grafts when they want to match color and texture of the skin in like areas.
The CPT code for full-thickness graft includes direct closure of the donor site, regardless of where it’s from, Bishop said. Therefore, do not report direct closure as an additional charge.
Don’t be confused if the operative note states, “I did a full-thickness skin graft and then I did a complex closure of the wound of the donor site.”
“That’s called … being a good surgeon, and that’s exactly what you are supposed to do,” Bishop said.
Watch for product names in operative reports
Codes 15170–15176 are acellular replacement codes, but Bishop said that surgeons may not document that term. Instead, look at the description of the product itself. For example, you may find names such as Integra? or PriMatrix?.
AlloDerm? (CPT codes 15330–15336) is a product that has been around for a while but is now becoming very popular with physicians, Bishop said. “We’re using AlloDerm nowadays not just for tissue coverage for burns and wounds and bad road rashes, but for reconstruction,” he said. Typical reconstructive uses for this product include:
- Abdominal wall reconstruction for hernia
Other products becoming popular in wound care include Apligraf? (CPT codes 15340–15341) and Dermagraft? (CPT codes 15360–15366). Coders will see more and more of the products covered by these codes appearing in different types of specialties, Bishop said. “This is not just plastic surgery; this is general surgery,” he added.
Integra is still the only product that will allow the patient to regenerate a whole new layer of cells, which eliminates the need for subsequent major skin grafting, Bishop said.
Sometimes, these patients may require only epidermal autografts. Another new product, Strattice?, is specifically for breast reconstruction.
Finally, OASIS? and Surgisis? are also quite common in the OR, said Bishop. Surgisis is popular in general surgery and in some plastic reconstructive procedures, whereas OASIS is popular in wound centers for temporary wound coverage.
Codes 15400–15421 apply to xenogenic dermis, or pig skin. The more common names for these products are EZDerm? and Mediskin?, but there are several others. Report human cadaver skin using the 15300–15321 range of codes, Bishop said.
CPT guidelines state that you cannot report Apligraf and codes 15340 and 15341 in conjunction with codes 11040–11042 (lower-level full thickness–type of wound or tissue debridement). CPT guidelines also state not to report these codes with the wound bed preparation codes, 15002–15005.
This guideline also applies to OASIS, said Bishop. CPT warns coders not to report these codes for OASIS with the lower- or upper-level debridement codes (11040–11042) or the 15002–15005 wound bed preparation codes.
In these cases, some payers will allow you to report an E/M code for debridement or closure of these wounds, Bishop said. But the physician documentation must support these codes and clearly explain the procedures the physician has performed.
Don’t cut corners with debridement
The descriptors for surgical debridement codes 11040–11044 are explicit.
A surgeon’s note saying, “I debrided to healthy tissue” means absolutely nothing, Bishop said, adding that he would return this to the physician, saying, “Redictate this, show exactly what level, so I can give you reimbursement based on what you tell me.”
It’s important to remember that codes 11043 and 11044 are debridements down to the deep fascia muscle or down into bone, as opposed to 11040–11042.
“Sometimes, you may have an E/M code with that, because that E/M frequently requires a modifier and often it is going to be -25 [Significant, separately identifiable E/M service by the same physician on the same day of service],” said Bishop.
Instruct your surgeons or providers that they need to measure each limb of the Z-, Y-, or W-plasties they perform.
Add those measurements together to arrive at the final size and choose the correct one.
A surgeon may document, “I did a Z-plasty,” but the Z-plasty should include three measurements, said Bishop.
“What matters is did they give you all the measurements, or did they just give you a total measurement for the Z-plasty? “If [one total measurement] is all they gave you, then that’s all they’re going to get credit for,” he said.
Bishop recommended using requests for measurements as an educational opportunity. Ask physicians to measure all sides of the Z-plasty and let them know that you require the same measurements for V-W, V-Y, and other procedures.
As in other cases, when you’re coding an incision and drainage, deep abscess or hematomas, in the soft tissues of the neck or of the thorax, don’t assume that an integumentary code is the only solution, Garrison explained.
Another code in a different section of the CPT Manual might be closer to the description. Be aware of all the code options when coding these procedures to arrive at the most specific code that best represents the procedure, Garrison said.
“We do have other [incision and drainage] codes in the beginning of CPT for simple integumentary areas,” said Bishop. “An incision and drainage, deep abscess or hematoma, has its own code. So the difference between those two codes is the layer of depth that the documentation supports.”
Editor’s note: To purchase a CD of this audio conference, go to the HCMarketplace Web site at www.hcmarketplace.com/prod-6429.html.