CPT Codes for Skin Replacement and Skin Substitute Grafts

Revised CPT instruction clarifies coding.

Although the codes and rules for reporting skin replacement and skin substitutes are not new, ever since 2011 CPT codes added a couple of new introductory sections it certainly looks clearer. Read on and take some lessons on ways to report skin replacement and skin substitute grafts:

When you shouldn't use these codes

There are over 50 codes that describe the various surgical steps and types of skin replacement/substitute procedures in the range 15002 - +15431.

So questions may arise whether you should report the proper codes from this range every time your surgeon makes use of a skin replacement or skin substitute to heal a wound. Well, in this case you shouldn't code a skin replacement or skin substitute application if the surgeon just applies skin replacement/substitute to the wound, even if he makes it stable by dressing.

Instead here's what you should do: You should use these codes only when the skin substitute/graft is anchored using the surgeon's option of fixation. Say for instance it might include adhesives, sutures, or staples.

You should look for documentation of fixation in the op note before you make use of any skin replacement or skin substitute codes.

Be familiar with what ‘application' services include

Many a time surgeons carry out skin replacement or skin substitute grafts post other surgical treatment for distressing wounds, burn eschar, or necrotizing infection. When the surgeon applies and fixes skin or a skin substitute you will need to understand which services you should and should not code in apart from the proper graft code.

You should include dressing: As per CPT instruction, when you report a skin or skin substitute graft, you should not code routine dressing supplies separately. Supplies like A6453 are included in the skin application charge.

Dermatology Coding Alert: Master Your Derm ASC Coding

Numerous changes affecting ASCs every year are enough to confuse you. Still, few aspects of ASC reimbursement continue to be the same. Read further to know how the ASC rules affect you and what dermatology codes you should choose in such a case. These expert tips will surely take you a step ahead in perfecting your dermatology medical billing and coding.

1. ASC-allowed services: Know where to find them. CMS has a very specific list of codes payable for ASCs, but if you don't know how to access the list, you could be losing your reimbursement.

You can download the most recent ASC-allowable codes from the CMS website. It includes both the current quarter as well as previous quarters in case you're battling older claims.

2. 'Same-day global' rule. Each procedure the ASC bills takes a "same-day" global period as the ASC is only reporting facility fees and not physician work services. This is applicable to the coder working for the ASC and not the physician who performed the service.

In case the physician returned the patient to the ASC the day after the initial surgery, the ASC coder is supposed to report the suitable control-of-bleeding code with no modifier. On the other hand, the surgeon's coder would report the bleeding-control code with modifier 78 appended because the physician's services follow the standard global rule.

The ASC coder should go by the "same-day" global rule, but the physician's coder should follow standard global period rules from the fee schedule.

3. You Can Avoid modifier SG. In the past, the ASC coder had to list modifier SG (ASC facility service) as the first modifier on the claim in case he billed Medicare for any service performed in the ASC. However, that all changed with the CMS Transmittal 1410, which stated that the SG modifier is no longer applicable for Medicare services for services on or after January 1, 2008.

4. Discontinued surgery modifiers may differ. ASC coders may sometimes use modifier 52 (Reduced services) but would not use modifier 53 (Discontinued procedure). Instead, insurers generally want ASC coders to call on modifiers 73 (Discontinued outpatient hospital/ASC procedure before administration of anesthesia) or 74 (Discontinued outpatient hospital/ASC procedure after the administration of anesthesia), as appropriate.

When the physician gets back to the ASC with the patient to perform the aborted procedure at a later date or time, the ASC will get full reimbursement for the completed procedure.

5. Keep in contact with the surgeon's coder. You could lose your reimbursements when the physician and the ASC report separate codes for the same procedure. Remember, the physician and ASC should report the same codes for each surgery, any coding differences should be fixed before the claim is submitted.

Want to get more tips like these to master dermatology medical billing and coding? Click here to read the entire article and to get access to our monthly Dermatology Coding Alert: Your practical adviser for ethically optimizing dermatology medical billing and coding , payment, and efficiency for dermatology practices

Vitiligo Treatment : Know Whether to Apply 96900 or 96910

Avoid misrepresenting phototherapy services and know what dermatology codes apply

You need to examine your dermatologist's documentation to define what type of light, wavelength, and materials he used while providing phototherapy treatment to vitiligo /dychromia patients. Read this article to know what dermatology codes you should choose in such a case and how to overcome both E/M and multiequipment correct coding initiative (CCI) challenges.

In case you are charging for an office visit on the same day as phototherapy, the reimbursement might depend on the fact whether your physician's documentation includes a different diagnosis code. Experts maintain that the payers might reimburse at times if the doctor examines the patient for a different problem, hence with a different diagnosis code.

For patients having vitiligo (709.01), your dermatologist might use narrow band UVB phototherapy. The phototherapy is administered for two to three times per week for several months until the patient attains repigmentation of the skin. For this procedure, you need to pinpoint what types of phototherapy, UVA or UVB, the physician used as well as the varying wavelengths.

In case your dermatologist used tar or or petrolatum with the light treatment, you should code 96910 (Photochemotherapy; tar and ultraviolet B [Goeckerman treatment] or petrolatum and ultraviolet B). Through this procedure, the dermatologist runs ultraviolet B light, with dosages cautiously increased as the treatment develops, resulting in longer times spent under the light source.

You should report 96900 (Actinotherapy [ultraviolet light]) in case the patient applies the treatment herself.

Note: You should always check with your payer for their rules.

In case, your dermatolist prescribed psolarens combined with ultraviolet A (UVA) light therapy, you should use 96912 (Photochemotherapy; psoralens and ultraviolet A [PUVA]). If your dermatologist doesn't use tars, petrolatum or psolarens with the light treatment, the code that remains is 96900.

The difference: UVA phototherapy is generally given with a lightsensitizing tablet named psoralen (PUVA therapy). Occasionally a light-sensitizing cream or lotion having psoralen is used in localized skin areas (for instance feet [topical PUVA]). On the other hand, UVB phototherapy uses the sunburning part of the UV spectrum.

Don't take risks: If you code either 96910 or 96912 when your dermatologist uses merely a light source in the treatment or the patient applies a topical agent, you could be accused of misrepresentation of service. It could be a fraudulent claim under the Federal False Claims Act.

Want to get more tips like these to master dermatology medical billing and coding? Click here to read the entire article and to get access to our monthly Dermatology Coding Alert: Your practical adviser for ethically optimizing dermatology medical billing and coding, payment, and efficiency for dermatology practices

HCPCS Codes: Couple of Temporary G codes for the Current Year

This year there are a couple of temporary G codes that you need to use.

In a particular situation, your dermatologist applies a tissue-cultured skin or dermal substitute for Medicare patients with lower extremity ulcers owing to venous stasis or diabetes. If you are to report such a situation, you have a couple of temporary 'G' codes for the present year.

Be it Apligraf or Dermagraft, you should zero in on G0440 and G0441 to report your surgeon's work in the present year. This is a change from using the current CPT codes for the service, which depend on the type of skin or dermal substitutes which are: Apligraf -- 15340-+15341, Dermagraft -- 15360-+15361.

Note: For most non-Medicare payers you should continue to use the 15300-series codes.

Sometimes your surgeon may prefer one skin or dermal substitute product or the other for clinical reasons in particular cases. In such cases coverage quirks for the CPT codes can provide payment cracks that sway product choice.

Challenge: What was worrying for general surgeons, podiatrists, plastic surgeons and wound care specialists was that Apligraf had a 90-day global period in comparison to Dermagraft, which had a 30-day global period. This lead providers to use one product over another to get financial advantage.

What's more, 15340-+15341 include site preparation and debridement, when you can bill those services separately with 15360-+15366.

Utilized for either Apligraf or Dermagraft, codes G0440-G0441 have 0 global days and include the site preparation and debridement services. The just-in codes together with a 0-day global billing period will do away with unequal financial incentives in the selection of products for the treatment of chronic wounds along with ensuring that physicians make their treatment decisions based on clinical benefit only.

In the future: For new or revised codes pertaining to these services, look to CPT 2012.

ICD-9 2012: Perfect your HTN Coding

ICD-9 2012 codes go into effect on October 1 this year. Like other practices, your cardiology practice too will be impacted by this year's list of ICD-9 codes. And since Hypertension (HTN) is on the rise in the US, it's essential that your HTN coding is top-quality. Or else many of your claims will be in the danger zone.

Here are some rules to polish your HTN coding to perfection:

Utilize the Hypertension Table: This Hypertension Table simplifies your search and can be found under the ICD-9 index entry "Hypertension". It not only shows the basic 401.x (Essential hypertension) codes but also the codes for conditions owing to or associated with HTN. What's more, the table helps clarify when you code choices differ for malignant, benign or unspecified conditions.

Documentation & 401.x 4th Digit

Be it malignant (.0), benign (.1), or unspecified (.9), while reporting codes from 401.x, you must select a fourth digit to complete the code. You shouldn't use either 0 malignant or .1 benign unless medical record documentation supports such a designation.

'Hypertensive' aids 402.x Use

If a patient has both heart disease and HTN, knowing whether the HTN caused the heart condition is key to correct coding. See whether the patient has a condition described under heart disease codes 425.8, 429.0-429.3, 429.8, and 429.9. What's more, you should also check the documentation for a stated or implied causal relationship to HTN.

Think that HTN and chronic kidney disease are connected

ICD-9 codes presume a causal relationship between HTN and chronic kidney disease. If documentation shows a patient ahs HTN and a condition that falls under 585.x or 587, then you should report a code from 403.x even if there is no indication one lead to the other. You should also report the pertinent 585.x code to indicate the CKD stage.

Hypertensive Heart and CKD

A single code from 404.xx indicates the patient has both hypertensive heart disease and hypertensive CKD. You should once again assume a relationship between the HTN and CKD. When the patient suffers from hypertensive heart disease and CKD, you should select a code from 404.xx and not report 402.x (hypertensive heart disease) and 403.x (hypertensive CKD) together.

Head Diagnoses? Think 2 Codes

If the patient is diagnosed with hypertensive cerebrovascular disease, you should first go for the proper code from 430-438.x first and then report the proper hypertension code, 401.x-405.x.

Urology Coding Alert: Verify Your Group's Signature Compliance

Be careful of EMR signature pitfalls.

Including provider signatures is a basic documentation requirement for your patient charts as well as daily challenge. Here's how you can verify your group's signature compliance.

According to CMS documents, "Medicare needs a legible identifier for services that are provided/ordered." That "identifier", or signature, can be electronic or handwritten, as long as the provider fulfils certain criteria. Readable first and last names, a Readable first initial with last name, or even an unreadable signature over a printed or typed name are adequate and acceptable. Moreover, you're also covered in case the provider's signature is illegible but is on a page with further information classifying the signer (letterhead, addressograph, etc.).

Ensure that you include the provider's credentials. The credentials can be with the signature or they can also be identified elsewhere on the note.

Example: Pre-printed forms might list the physician's name and credentials anywhere: at the top, side, or end. All of these qualify as standard documentation as long as the coder or auditor is able to identify the provider's credentials.

You can also use a signature log to support your urologist's documentation. The log should cover each provider's printed or typed name and credentials as well as their signatures and initials. You can reference the signature log to verify a note that includes an otherwise unidentifiable signature.

Tip: You should update signature logs at least once a year. Make distinct logs by provider (physicians, CRNAs, AAs, residents, etc.) to make the tracking easier.

Remember: Stamped signatures don't meet the CMS requirements because anyone who has an access to the stamp, could use it. It doesn't validate that the billing provider was himself the author of the supporting documentation. You can, though, use a typed or printed block print name under the provider's signature to noticeably identify an illegible signature.

Don't Let EMRs Do All Your Work

Some coders -- or providers -- consider that electronic medical records (EMRs) do all the documentation work, but that's not essentially the case. Even electronic signatures must fulfil certain requirements.

Considerations: As your providers include EMR in their everyday care, you should double check the electronic signature's wording. It should say ‘Electronically signed by' or ‘Authenticated by' also include the date.

There are multiple ways of phrasing and formatting the electronic signature. You should verify that the format you're implementing is accepted by CMS.

Warning: Electronic signatures could be misused or abused. The safety of system and software products against unauthorized modifications should be ensured. Electronic capabilities should follow recognized standards and laws. You should consult your healthcare attorney and/or malpractice insurer to ensure compliance.

Urology Coding Alert : Avoid the Pressure of Choosing Physical Examination Levels

1995 vs. 1997 guidelines: Choose one per claim, but you should feel free to use either one for different claims.

Determining the Physical Examination Level


There are two sets of guidelines you should know before determining the level of the physical examination key element for your E/M coding: 1995 and 1997 medical guidelines.

Both sets of guidelines help you decide which of the following listed four levels of examinations your urologist accomplished during an E/M service:

problem-focused,

detailed,

expanded problem focused,

and comprehensive.

The level of exam is a key factor in determining which code you should report: 99201- 99205 (Office or other outpatient visit for the E/M of a new patient, which needs these 3 basic components …) for new patients or 99212-99215 (Office or other outpatient visit for the E/M of an established patient, which requires at least 2 of these 3 basic components …) for established patients.

1995 and 1997 Guidelines: What's the Difference

The most significant difference between these two sets of guidelines is the exam element.

1997: The 1997 guidelines involve specific physical exam elements that must be addressed in the documentation. If a physician addresses elements other than those specified in the guidelines, the physician will not essentially receive credit for that particular element in the level of service. Also, if the language relating to an exam element included in the documentation is different from the one in the guidelines, an auditor who has not had much clinical experience may reject the element from being credited in the level of service.

1995: The 1995 guidelines are comparatively less restrictive. They let the physician make any comment in any of the designated body areas and/or organ systems he examines. What the physician examines within the areas and systems and the language he or she chooses to document are eventually decided by the physician.

Which Guidelines Should You Use?

It is not required that you pick one set of guidelines and stick with them whenevr you code an E/M service. You can switch between 1995 and 1997 and choose whichever set of guidelines is most beneficial for each encounter.

Important: The key, however, is that, for a single encounter you should use either 1995 or 1997 guidelines. Keep in mind that the guidelines are only for the reporting of the physical examination. The remaining two key components, history and medical decision making, continue to be the same. It doesn't matter which physical examination guidelines you use.

Besides, practices should know if there are any special requirements of their contracts with their insurers.

So which guideline should you use? That also depends on your urologist and how does he document. Usually the 1995 documentation guidelines are going to be more beneficial for most practices. The reason being that they are more flexible and they also reflect the way most physicians were trained to document. However, some physicians may have been trained or may have developed decent documentation practices around the 1997 guidelines, and this may be beneficial to them.

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