Download New biologic implant codes cause some confusion

CPT CORNER
New biologic implant codes cause some confusion
by raymond janevicius, md
I
n 2012, the allograft and xenograft
codes were all deleted and replaced by
eight “skin substitute graft” codes,
15271 through 15278. All non-integumentary uses for these biologic implants are now
to be reported with a new add-on code,
15777. Although the use of these codes is
straightforward, payers – including CMS –
have been inconsistent in their implementation of these codes, and correctly coded
claims for use of these products have
frequently been denied.
Terminology
When these products are used for integumentary coverage (e.g., wounds, burns),
this is considered “topical” or “surface” use.
When they are used in areas other than the
integument, this is considered “non-surface”
use. This terminology has been used in
AMA and ACS publications, so you will
see terms other than “integumentary” and
“non-integumentary” in discussions of
these products.
A review
The new “Skin Substitute Graft” codes
(15271-15278) are used for allografts and
xenografts, as well as other biological products that form a sheet scaffolding for skin
growth. These codes are not to be used for
non-graft wound dressings such as gels,
ointments, foams or liquids, nor for injected
skin substitutes.
These codes are reported by anatomic site
and surface area (see table below). The new
codes are to be used for topical placement of
these grafts, as in wound or burn coverage.
For a complete explanation for the use of
these codes, please see the January-February
2012 CPT Corner (“Multiple new CPT codes
appear in 2012”).
Thus, placement of a 5 sq cm piece of
Dermagraft® on a venous stasis ulcer is
reported with code 15271. This is the topical
(i.e., integumentary) application of a skin
substitute.
The CPT book makes it clear that these
new “Skin Substitute Graft” codes are not to
be used when these biologic implants are
placed in other anatomic areas (e.g., breast,
trunk). ASPS worked with other specialties
to create the add-on code 15777
(“Implantation of biologic implant”) to be
used in addition to the code for the primary
procedure.
For example, if a tissue-expander breast
reconstruction is performed with a product
NON-INTEGUMENTARY
PLACEMENT OF
BIOLOGIC IMPLANTS
SKIN SUBSTITUTE GRAFTS
SURFACE AREA
TRUNK, ARMS,
LEGS
(INCLUDING
WRISTS AND
ANKLES)
FACE, SCALP,
MOUTH, NECK,
GENITALIA,
HANDS, FEET,
AND/OR DIGITS
ALL NON-INTEGUMENTARY
ANATOMIC SITES
+15777
First 25 sq cm
15271
15275
Each additional 25 sq cm
+15272
+15276
+15777
First 100 sq cm
Total surface area
100 sq cm
Each additional 100 sq cm
15273
15277
+15777
+15274
+15278
+15777
Total surface area
< 100 sq cm
PRODUCTS THAT ARE USED AS SKIN
SUBSTITUTES OR BIOLOGIC IMPLANTS
AlloDerm
Acellular Human Dermis
AlloMax
Acellular Human Dermis
AlloPatch
Acellular Human Dermis
AlloSkin
Acellular Human Dermis
Apligaft
Human fibroblasts
Bovine collagen
ArthroFlex
Avaulta Plus
BioDfence
Conexa
Acellular Human Dermis
Collagen / polypropylene mesh
Human Amnion Allograft
Porcine derived
CorMatrix
Porcine small intestine
Dermagraft
Human fibroblast derived
DermaMatrix
Acellular Human Dermis
Durepair
Bovine Dermis (used for dural repairs)
Endoform
Ovine forestomach
Extracellular matrix
ENDURAgen
Porcine dermis
For eyelids
EZ Derm
Porcine dermal xenograft
FlexHD
Acellular Human Dermis
Integra
Bovine collagen bilayer wound matrix
Mediskin
MemoDerm
Oasis
Porcine xenograft
Acellular Human Dermis
Porcine small intestine extracellular matrix
Permacol
Porcine dermal collagen
Repriza
Acellular Human Dermis
Sugisis
Porcine small intestine extracellular matrix
Strattice
Acellular Porcine Dermis
SurgiMend
Fetal bovine dermal collagen
TheraSkin
Cryopreserved human allograft of epidermis and dermis
Transcyte
Human fibroblasts
Porcine dermis
Silicone membrane
Veritas Collagen Matrix
Bovine pericardium derived acellular collagen matrix
PRODUCTS THAT ARE
CONSIDERED DRESSINGS
Biobrane
Nylon mesh synthetic dressing
Cellerate
Powder / Gel
Cymetra
Powdered AlloDerm
CRXa
Powdered AlloDerm
Epicel
Cultured autologous epidermis
Hyalomatrix
Dressing
MatriStem
Porcine extracellular matrix in powder form
MediHoney
Gel
Talymed
TenoGlide
Shortened fibers of poly-N-acetyl glucosamine (pGlcNAc) isolated from microalgae
Bovine collagen and glycosaminoglycan for tendon protection
12 September 2012 Plastic Surgery News
such as AlloDerm® (an acellular dermal
matrix), the procedure is reported:
19357
Tissue expander placement for
breast reconstruction
15777
Placement of biologic implant
append modifier 50 for bilateral procedures.
Again, this makes no sense. Through the
efforts of ASPS, however, as of July 1, this
error has been corrected. Code 15777 is now
a modifier 50 “eligible” code, as originally
intended.
Commercial products
Abdominal wall reconstruction
There’s sometimes confusion regarding
whether a particular product qualifies as a
skin substitute or a biologic implant. The
accompanying table lists those common
commercial products that are used as skin
substitute grafts or biologic implants, and
those that are considered dressings. The lists
are not exhaustive, so refer to the package
inserts and company websites to determine
the nature of products used. Note also that
some of these products may not be reimbursed by certain payers, so it’s important to
check specific payer medical policies regarding these products.
Proper use of skin substitute and
biologic implant codes
The problems
Although the CPT book is clear, some payers
have denied claims for code 15777, indicating that this code should only be used if the
implant is placed in the skin. Yes, read that
one again. Claims are denied for nonintegumentary use of code 15777, even
though the code was specifically created for
non-integumentary use of biologic
implants.
Of course this makes no sense. A biologic
implant used for skin replacement is reported with the “Skin Substitute Graft” codes,
15271 through 15278. Using code 15777
would be inappropriate in these circumstances. Code 15777 has been specifically
created for use of biologic implants in nonskin-replacement situations.
ASPS is working to clarify this issue with
payers. Your denied claims may require
explanatory letters, including substantiation
with sources such as CPT Corner.
Since the introduction of code 15777 this
year, many ASPS surgeons have had the
bilateral use of 15777 (i.e., use of modifier 50
for bilateral procedures) denied as “ineligible” for modifier 50 use, even though the
CPT book specifically directs surgeons to
When a biologic implant is used in conjunction with hernia repair, code 49568 is appropriate. When a biologic implant is used for
abdominal wall reconstruction, but no hernia is present, report code 15777.
I
All previous allograft and xenograft codes
(pre-2012) have been deleted.
I New codes have been created for “Skin
Substitute Grafts” (15271-15278).
I These new codes have zero-day global
periods.
I These new “Skin Substitute Graft” codes
are used for integumentary (“surface” or
“topical”) applications of skin substitute
grafts.
I When biologic implants are placed in
non-integumentary areas (“non-surface”), a new code, 15777 is to be reported.
I The same commercial product may
sometimes be used as either a “skin substitute” or a “biologic implant,” depending on where it’s used (integumentary,
i.e., “surface,” vs. non-integumentary; i.e.,
soft tissue support).
I Code 15777 is an add-on code and is to
be reported in addition to the primary
procedure.
I If the surgeon provides the product, the
cost of the product is separately billable
with an appropriate HCPCS code. These
codes can be found on line at:
cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMatters
Articles/Downloads/MM7754.pdf PSN
Dr. Janevicius is the Society’s representative to
the AMA CPT Advisory Committee.