Q: [Skin Grafts] – If you have a patient
that is getting an autologous split thickness graft, taken from the thigh and attached to
the tip of the nose, is it alright to use one code like 15120 for the harvesting and
attachment? Is it OK if you don’t need two codes, how do I know when to use one or two
codes for a procedure? A: The bottom-line is, you’re most likely
going to be reporting two codes. When I teach this in class, I tell the students to think
about if you’ve ever had to lay sod down. Maybe it’s a new home or you had to dig
up your yard and you had to put new grass down because you want to be there more quickly,
so you don’t just buy the sod and just plunk it down and hope for the best. You prepare
the soil before you lay the sod down so that the roots will take and grow and live there
as if it was always there. It’s the same with skin grafts. We need
to prepare that recipient site and then we need to report the grafting code. It’s really
a two-code story. What I did here is I just grabbed a few. There’s
many skin grafting codes in the integumentary system so I just grabbed a couple here. On
the left hand side, I had the surgical prep bubbles. If you’re familiar with our teaching
techniques, we tend to bubble our CPT codes and highlight everything after the semicolon.
These are the two bubbles in the surgical prep. We’ve got the 15002 bubble and the
15004 bubble. The way we teach it is always compare and contrast, what’s the difference
between these two bubbles? When you look closely, its location, location, location. So, the
first bubble is of the trunk, arm or legs; and the second bubble is of everything else:
face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits.
What those areas have to do with each other? I don’t really know. But, you’ve got your
top code that is for the first 100 sq cm. And the indented code in each bubble is for
each additional 100 sq cm, or part thereof. This phrase “or part thereof” I think
they added around 2009, and I was very glad because I would get this a lot as an instructor.
Well, do I need to have another full 100 sq cm? What if I have 150? Well, now that they’ve
added that phrase, “or part thereof” you would report 15002, for example, for the first
100 and then you report the add-on code, 15003, for the additional 50. You do not need to
have a full 100 to code the add-on code because of that phrase “or part thereof.” So I
was very happy to see that because it made it very clear.
The other thing when you’re dealing with this is to know when they’re talking about
trunk, arms, or legs, versus all the other areas, are they talking about the donor area,
like, in the example of this question, the thigh was the donor area and the nose was
the recipient, so we want to code based on the recipient area. That’s in the guidelines
for the skin grafting, so be aware of that. What I like to do when I teach my students
is write it down in every bubble: recipient, recipient, recipient. So, when you’re doing
it on the job or for a board exam, it jumps right out at you, there’s no digging in
the guidelines to find that it’s right there. The other side of the story is coding the
actual graft procedure itself. Here, I’ve got two bubbles, the 15100 bubble and the
15120 bubble. And as you may have already guessed, the difference between the two is
location, location, location; so the 15100 mirrors the 15002. This is for the trunk,
arms, and legs; and the 15120 is for the face, scalp and everything else.
They do the same thing, first 100 sq cm, each additional 100 or part thereof. These are
both split thickness auto grafts. There are many other types of grafts, there’s full
thickness. You can use these dermal skin grafts which are, if you picture the skin, you have
the epidermis and then you have the dermis, that’s the true skin. So, whenever you see
skin and already see split thickness, just think of that dermis. Then, below it, you
have “subcu” (subcutaneous); you go down to fascia, muscle and bone.
Split thickness and full thickness, these are all indicating they’re coming from the
patient themselves versus a cadaver. They do have allografts and homografts that come
from cadaver. So, just like there were blood banks, there’s also skin banks, tendon banks,
and in areas to get this kind of tissue. Just be aware that there’re lots of different
bubbles in the skin grafting. I picked these two because the question was specifically
asking about a split thickness graft. OK? These are also of the recipient site, so in
our example where they’re transferring it from the thigh to the nose, the recipient
site is the nose; so we’re going to be in this bubble, the 15120 bubble. So, that’s
how the grafting works. I have a few notes here.
By the way, all of these answer sheets we provide to our Replay Club members and they
get all the answer sheets. On the live webinar, you get to hear everything, you get to get
all the information and the 1.5 CEUs, but the Replay Club members get all these great
answer sheets. Here are some tips, you want to know the type
of graft. Autograft – from the patient; there’s split (through part of the dermis); full is
going all the way, the whole dermis. And if you think about that sod illustration, the
more you take from the original area, the deeper you go, the better it’s going to
take on where you transplant it; but it’s also going to be more damaging to the original
area. In this example of the thigh to the nose,
if they took a full thickness, and you’re going to have a pretty bad scar on the thigh,
it’s like a tradeoff when you’re doing an autograft. Dermal – these are fairly new
codes for dermal; they literally take the full dermis and then they cut it in half,
and then they put the upper layer back on the original donor area and they take that
middle layer and use it on the recipient area. That’s pretty neat.
For a long time, like, “Alright, they’ve got dermal, they’ve got split. I don’t
get it.” So, I finally just googled it, that’s what I tell everybody, “Try to
Google and be your own researcher and you can find the answers.” If you’re like,
“Hmm, I wonder why that’s like this, or different” just Google it and you’ll probably
be able to help yourself. We talked about allografts and homografts
– those are from cadavers. “Allo” and “homo” means “same” so in this case,
same species. Then we’ve got skin substitutes, that uses the medical term “xeno” – xenograft.
Xenografts can be an animal graft, like, porcine, comes from a pig. Then, there’s this man
made. They actually use material that is totally not organic or biologic. Just be aware of
those differences so you can abstract for that in the reports.
You’ll also see in the skin grafting section, culturing or not. Sometimes they’ll take,
let’s just say that with our example from the thigh, they’ll take it and they’ll
culture, put it in some sort of solution to make it take better when they put it on the
recipient’s site; so there’s a little bit of a delay from when they take it from
the donor area and they culture it, and then they put it on the recipient’s area.
We talked about #3, Recipient or Donor Area – the graft codes are usually based on recipient
area. Be aware of that. And that’s why in this case, the donor area was the thigh and
the recipient was the nose; so we went with the nose bubble.
The other big thing to be aware of are measurements. You’ll notice that everything in CPT is
in centimeters, not inches, so be aware of that. If you have a report or, God forbid,
they put it in inches, you will have to convert it. Sq cm is just length x width. There’s
a lot of math in the integumentary system. I always say think about getting carpet for
your living room, how would you figure it out? Length times width, and that’s what
we’re talking about here because they’re trying to figure out how vast an area are
we talking about. Then, we talked about “or part thereof.”
Be aware of that, that you only need to have a portion of that add-on code to be able to
report the whole add-on code. That is the answer for our skin grafts.