Codes For Skin Replacement Surgery
• There are new codes for “Surgical Preparation,” formally called Wound Bed Preparation.
• CPT 15000 & 15001 have been deleted.
• The new Codes are:
• 15002
• 15003
• 15004
• 15005
• CPT 15002 – Surgical Preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children.
• CPT 15003 – Each additional 100sq cm or each additional 1% of body are of infants and children.
• CPT 15004 - Surgical Preparation or creation of recipient site by excision of open wounds, burn
eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, neck ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children.
• CPT 15005 - Each additional 100sq cm or each additional 1% of body are of infants and children.
Skin Replacement (CPT codes 15002 - 15005)
1. Per the definitions and the guidelines in CPT Code Book codes CPT codes 15002/15005 are not appropriate codes to use when performing a non-surgical application of a skin substitute.
2. CPT code 15002/15005 are only appropriately used in place of service inpatient hospital, outpatient hospital or ambulatory surgical center with regional or general anesthesia to resurface an area damaged by burns, traumatic injury or surgery. An operative report is required and must be available upon request.
Coding Guidelines
1. Active wound care, performed with minimal anesthesia is billed with either CPT code 97597 or 97598.
2. Significant debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 – 11047.
3. CPT codes 11043, 11046, 11044, and 11047 are usually appropriately billed in place of service inpatient hospital, outpatient hospital or ambulatory care center (ASC). Billing of these codes in another place of service is most likely a billing error and thus the service will be denied. If a provider feels that CPT 11043, 11046, 11044, or 11047 were actually performed in another place of service, a review of the denied claim should be requested and documentation, including an
operative report, should be submitted.
4. Use CPT codes 15271 - 15278 for the surgical preparation or creation of recipient site for the tissue skin graft.
5. To bill for an Apligraf® (HCPCS Q4101) package (equal to 44-sq. cm.). If more than 44-sq. cm. is needed for additional grafting, bill according to the number of single units of Apligraf®, indicate Apligraf® in Item 19 of the CMS 1500 Claim Form or the Comment Field for EMC claims.
6. Payment for Apligraf® for any single ulcer will not be made for re-treatment within 1 year after initial treatment.
7. Dermagraft® (HCPCS Q4106) is supplied frozen in a clear bag containing one piece of approximately 2 in. x 3 in. (5 cm. x 7.5 cm.) for a single use application.
8. Claims submitted for skin substitutes should bill the actual size used rounding up to the next whole number.
9. When submitting a claim for skin substitutes, providers are required to accept assignment for this service. Providers, who do not accept assignment, should bill the skin product on a separate claim from other services performed on the same day.
10. Products such as Integra are classified by the Federal Drug Administration as wound dressing and are thus not payable separately by Medicare Part B for outpatient services. The application of Integra or similar FDA classified products may be payable as an inpatient for its FDA approved indication for the treatment of life-threatening full-thickness or deep partial-thickness burns.
11. For services on or after November 1, 2007, the Oasis® Wound Matrix is covered and separately payable when used according to FDA labeled indications and in accordance with accepted standards of medical/surgical practice.
12. Payable places of service for TheraSkin® (HCPCS code Q4121) if billed by the facility: outpatient hospital, (22), emergency room (23), and ambulatory surgical center (24).
13. Payable places of service for TheraSkin® (HCPCS code Q4121) if billed by the physician or nonphysician
practitioner: office (11), urgent care facility (20), and independent clinic (49).
Billing Guidelines
Wound Care (CPT Codes 97597, 97598 and 11042-11047)
1. Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.
2. Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary.
3. CPT 97597 and/or CPT 97598 are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.
4. CPT code 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). Secretions of any consistency do not meet this definition. The mere removal of secretions (cleansing of a wound) does not represent a debridement service.
5. The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.
6. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.
7. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.
8. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.
9. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements.
10. CPT code 97602 has been assigned a status indicator "B" in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare.
11. Documentation must support the HCPCS being billed.
12. Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.
13. Infrared (97026), ultra-sound thermal (97035), phototherapy-ultraviolet (97028) modalities are not payable per the LCD.
Coding Guidelines
1. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.
2. Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.
3. CPT code 11043, 11046 and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).
4. CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and bone.
Reasons for Denial
1. Performing deep debridement in POS other than inpatient hospital, outpatient hospital or ASC
2. Billing of debridement by unqualified personal.
• There are new codes for “Surgical Preparation,” formally called Wound Bed Preparation.
• CPT 15000 & 15001 have been deleted.
• The new Codes are:
• 15002
• 15003
• 15004
• 15005
• CPT 15002 – Surgical Preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children.
• CPT 15003 – Each additional 100sq cm or each additional 1% of body are of infants and children.
• CPT 15004 - Surgical Preparation or creation of recipient site by excision of open wounds, burn
eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, neck ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children.
• CPT 15005 - Each additional 100sq cm or each additional 1% of body are of infants and children.
Skin Replacement (CPT codes 15002 - 15005)
1. Per the definitions and the guidelines in CPT Code Book codes CPT codes 15002/15005 are not appropriate codes to use when performing a non-surgical application of a skin substitute.
2. CPT code 15002/15005 are only appropriately used in place of service inpatient hospital, outpatient hospital or ambulatory surgical center with regional or general anesthesia to resurface an area damaged by burns, traumatic injury or surgery. An operative report is required and must be available upon request.
Coding Guidelines
1. Active wound care, performed with minimal anesthesia is billed with either CPT code 97597 or 97598.
2. Significant debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 – 11047.
3. CPT codes 11043, 11046, 11044, and 11047 are usually appropriately billed in place of service inpatient hospital, outpatient hospital or ambulatory care center (ASC). Billing of these codes in another place of service is most likely a billing error and thus the service will be denied. If a provider feels that CPT 11043, 11046, 11044, or 11047 were actually performed in another place of service, a review of the denied claim should be requested and documentation, including an
operative report, should be submitted.
4. Use CPT codes 15271 - 15278 for the surgical preparation or creation of recipient site for the tissue skin graft.
5. To bill for an Apligraf® (HCPCS Q4101) package (equal to 44-sq. cm.). If more than 44-sq. cm. is needed for additional grafting, bill according to the number of single units of Apligraf®, indicate Apligraf® in Item 19 of the CMS 1500 Claim Form or the Comment Field for EMC claims.
6. Payment for Apligraf® for any single ulcer will not be made for re-treatment within 1 year after initial treatment.
7. Dermagraft® (HCPCS Q4106) is supplied frozen in a clear bag containing one piece of approximately 2 in. x 3 in. (5 cm. x 7.5 cm.) for a single use application.
8. Claims submitted for skin substitutes should bill the actual size used rounding up to the next whole number.
9. When submitting a claim for skin substitutes, providers are required to accept assignment for this service. Providers, who do not accept assignment, should bill the skin product on a separate claim from other services performed on the same day.
10. Products such as Integra are classified by the Federal Drug Administration as wound dressing and are thus not payable separately by Medicare Part B for outpatient services. The application of Integra or similar FDA classified products may be payable as an inpatient for its FDA approved indication for the treatment of life-threatening full-thickness or deep partial-thickness burns.
11. For services on or after November 1, 2007, the Oasis® Wound Matrix is covered and separately payable when used according to FDA labeled indications and in accordance with accepted standards of medical/surgical practice.
12. Payable places of service for TheraSkin® (HCPCS code Q4121) if billed by the facility: outpatient hospital, (22), emergency room (23), and ambulatory surgical center (24).
13. Payable places of service for TheraSkin® (HCPCS code Q4121) if billed by the physician or nonphysician
practitioner: office (11), urgent care facility (20), and independent clinic (49).
Billing Guidelines
Wound Care (CPT Codes 97597, 97598 and 11042-11047)
1. Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.
2. Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary.
3. CPT 97597 and/or CPT 97598 are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.
4. CPT code 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). Secretions of any consistency do not meet this definition. The mere removal of secretions (cleansing of a wound) does not represent a debridement service.
5. The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.
6. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.
7. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.
8. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.
9. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements.
10. CPT code 97602 has been assigned a status indicator "B" in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare.
11. Documentation must support the HCPCS being billed.
12. Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.
13. Infrared (97026), ultra-sound thermal (97035), phototherapy-ultraviolet (97028) modalities are not payable per the LCD.
Coding Guidelines
1. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.
2. Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.
3. CPT code 11043, 11046 and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).
4. CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and bone.
Reasons for Denial
1. Performing deep debridement in POS other than inpatient hospital, outpatient hospital or ASC
2. Billing of debridement by unqualified personal.
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