Billing and Coding for Skin Substitute Grafts

Wound care is a specialty with stringent rules and regulations. It is necessary to follow Medicare billing guidelines for skin substitutes. The specialty electronic medical record (EMR) information is critical for demonstrating that the practice follows clinical, financial, and operational guidelines. When a patient calls to schedule a service, the documentation process begins. Are you fed up with the complicated Billing and Coding for Skin Substitute Grafts? Do you require a list of important Medicare billing guidelines for skin substitutes? If you answered yes, keep reading.

The Medicare billing guidelines for skin substitutes provided below cover various aspects of medical billing during the grafting. Let’s go over the key points of Medicare’s skin substitute guidelines:

Deleted Skin Graft Codes (Product-based Codes)

The American Medical Association (AMA) deleted and replaced the “product-based” allograft and xenograft codes with a series of new codes involved in placing the grafts based on the physician’s effort. These are as follows:

  • 15170-15176
  • 15300, 15301
  • 15320, 15321
  • 15330, 15331
  • 15335, 15336
  • 15340, 15341
  • 15360, 15361
  • 15365, 15366
  • 15400, 15401
  • 15420, 15421
  • 15430, 15431

Addition to Skin Graft Codes

15271-15278 is the new CPT code series for skin substitute grafts. These unique codes are classified as per the anatomic site (general and specific body areas) and size (wounds with a total surface area less than 100 sq. cm, equal to, or greater than 100 sq. cm). In CPT, coding these grafts by size is a novel concept.

Skin Substitute Grafts Coding by Site and Size

  1. Total surface area by anatomical grouping less than 100 cm2

Trunk, Legs, Arms

  • 1-25 cm2: 15271
  • 26-50 cm2: +15272 x 1
  • 51-75 cm2: +15272 x 2
  • 76-99 cm2: +15272 x 3

Face, Neck, Scalp, Ears, Hands, Genitalia, Feet, Digits

  • 1-25 cm2: 15275
  • 26-50 cm2: +15276 x 1
  • 51-75 cm2: +15276 x 2
  • 76-99 cm2: +15276 x 3

2. Total surface area by anatomical grouping greater than or equal to 100 cm2

Trunk, Legs, Arms

  • 100 cm2: 15273
  • 101-200 cm2: +15274 x 1
  • 201-300 cm2: +15274 x 2
  • 301-400 cm2: +15274 x 3

Face, Neck, Scalp, Ears, Hands, Genitalia, Feet, Digits

  • 100 cm2: 15277
  • 101-200 cm2: +15278 x 1
  • 201-300 cm2: +15278 x 2
  • 301-400 cm2: +15278 x 3

Medical Billing Steps of Skin Substitute Grafts Coding

If you’re looking for correct skin substitute grafts coding, follow the three steps required and recommended for medical billing by the experts:

Step 1: Anatomic Grouping:

Like other skin replacement surgery codes, wounds are classified into general and specific body areas. All wounds should be combined by anatomic grouping.

Step 2: Total Wound Surface Area:

Determine whether the total surface area of the wound or combined wounds is less than 100 sq. cm, equal to, or greater than 100 sq. cm. As the work involved in treating small and large wounds differs, separate codes are based on the total surface area.

For instance, wounds with a total surface area of less than 100 sq. cm may be treated in the office. In contrast, larger wounds are usually treated in a hospital OR setting and require more intensive post-operative care. This coding structure makes relative value unit (RVU) valuation more accurate.

Step 3: Specific Wound/Wound Grouping Total Surface Area:

To report the correct parent code and any add-on codes, the total surface area of the wound is considered once more.

Consider a burn wound on a patient’s back caused by a hot water scald. The total surface area of the burn is 150 square cm or 10 x 15 cm. Consider 15271-+15274 as the back is part of the trunk. Because the total wound surface area is 150 sq. cm, you would use 15273 and +15274, which apply to wounds with a total surface area greater than or equal to 100 sq. cm.

For the first 100 square cm, the parent code, 15273, is reported. For the remaining 50 square cm, add-on code 15274 is reported x 1.

Billing Tips to Guide for Skin Substitute Grafts Coding

As per the professional coders, the following are the top three billing tips that can guide you for accurate skin substitute grafts coding:

Tip 1: Identify Skin Substitute Graft Type

As CPT includes different sets of codes for each type of graft, you must be familiar with the various graft options and how to locate the information in the surgeon’s note.

Avoid: When the surgeon relates non-graft wound dressings such as powder, gel, foam liquid, ointment, or injected skin substitutes, do not report a skin substitute graft as per the guidelines. However, skin substitute graft codes require some form of fixation, such as sutures, adhesives, or staples.

Tip 2: Capture Site Preparation

Skin replacement surgery is divided into two steps: surgical preparation of the recipient site and graft placement with fixation. You will be underpaying your surgeon if you skip the separate skin preparation step.

Whether the surgeon performs both steps in a single visit or postpones grafting until a later date, report the surgical preparation using codes in the 15002-+15005 range.

Tip 3: Know What’s Included

You can bill the skin substitute graft placement procedures and site preparation separately. Still, you should know what other materials and services in the op report are billable separately. It includes:

  • Cleaning: Never report code 97602 in combination with skin graft site preparation codes.
  • Dressing: No separate coding for routine dressing supplies for office services but supplies like A6453 should become part of the skin application charge.
  • Simple Debridement: NCCI bundles code range 15271-+15277 of skin substitute graft with code 11042 of skin and subcutaneous debridement.
  • Skin Substitute: Choose the appropriate HCPCS Level II code, like Q4101, for the graft material.

Outsource to 24/7 Medical Billing Services!

The Medicare billing guidelines for skin substitutes cover every step of the process, from prior authorization to medical necessity.

Billing for skin substitutes necessitates careful consideration of authorization, coding and modifier details, allowance limit, and product disposal. 24/7 Medical Billing experts are here to help you navigate the complex billing process for skin substitutes. Contact us right away if you need help with graft billing.

See also: How To Be Careful About CPT Coding And Modifiers While Working On Wound Care?

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