Subcutaneous vs Subfascial

Question:

If the provider says in their documentation that they went into the subcutaneous tissue and to the fascia to excise a 4 cm lipoma from the back, is this subfascial? This always trips me up when coding!  

Answer:
In the scenario above, this is only to the fascia, not through or below the fascia. The lipoma excision is only within the subcutaneous tissue.

Based on the scenario presented, the appropriate CPT code is 21931.  

*This response is based on the best information available as of 12/5/24.

Two Surgeons, Same Practice, Co-Surgery?

Question:

I have a case where two surgeons from the same practice are reconstructing the abdominal wall following tumor resection. They each perform their own side of the component separation, surgeon A on the right and surgeon B on the left. Each surgeon dictated their own op-notes for the side they performed, and now they want to bill as co-surgeons. I’m unsure if this is appropriate, so I seek KZA’s advice.

Answer:
Great question! While your surgeons each dictated their operative notes, this alone does not support co-surgery, modifier 62. Co-surgery from a surgeon's perspective is different from a coding perspective.

From a coding perspective, co-surgery involves two surgeons, typically of different specialties, with different skill sets, each performing separate portions (s) or parts of a procedure as defined by a CPT code.  Each surgeon would dictate their own operative note detailing their portions of the procedure performed. Again, this typically involves surgeons from different specialties, not two surgeons of the same specialty.

In the scenario above, two plastic surgeons perform one side of this bilateral component separation.

They should each be reporting their own CPT code,15734.

• Surgeon A: 15734

• Surgeon B: 15734 -XP

*Modifiers as directed by your payor. CPT code 15734 does not allow for RT/LT.  

*This response is based on the best information available as of 11/14/24.

Converting Dimensions

Question:

My surgeon placed integra and dictated the integra dimensions in inches instead of centimeters. Can the inches be converted into centimeters to determine code selection?

Answer:

Thank you for your inquiry.  

From a best practice standpoint, the physician is encouraged to document the size based on CPT requirements, e.g. centimeters in this scenario.  The risk is that an error may be made in performing the conversion if this activity is not regularly performed.

*This response is based on the best information available as of 10/31/24.

Collagen Dressings

Question:

Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?

Answer:

Thank you for your inquiry.  Several factors have to be considered.

First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.

Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.

Per Medicare Claims Processing Manual, Chapter 12, Section 40.1

o   Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket.  Depending on medical necessity, the dressings may or may not be covered under a home health benefit.

Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.

Per Medicare LCD L33831:

Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)

A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal.  They can stay in place for up to 7 days.  Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.

To justify payment for DMEPOS items, suppliers must meet the following requirements:

• Standard Written Order Criteria (SWO)

• Medical Record Information (including continued need/use if applicable)

• Correct Coding

• Proof of Delivery

Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.

Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.

LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings. 

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831

As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).

*This response is based on the best information available as of 10/17/24.

Polydactyly Excision

Question:

We have a new surgeon in our practice who does hand surgery. I usually don’t code for hand surgery and have never coded a case before for polydactyly excision; how does one code this procedure? The documentation does not reflect any bony work.

Answer:

Within the hand section of the CPT book, you will find CPT code 26587. This code is for the reconstruction of polydactylous digit, soft tissue, and bone. Below this, there is a parenthetical note that states that for excision of polydactylous digit, soft tissue, only use CPT 11200. The documentation within the note will lead you to the appropriate code to report. Based on your scenario presented, CPT 11200 is applicable.

*This response is based on the best information available as of 9/11/24.

Micromatrix

Question:

I'm new to plastics coding and have seen a couple of cases in which Acell Micromatrix is being documented. I have conflicting recommendations on whether to report this with a code from the 1527x series in CPT.  However, I'm not confident with the advice.   I am seeking an expert opinion and realize I should have started with KZA. Two questions:  1) is this separately reportable and 2) if yes, is CPT code 15271 the correct code?

Answer:

No, this is not separately reportable according to CPT Guidelines in the treatment of open wounds. Acell Micromatrix is a micronized particle (powder) and is considered a non-graft wound dressing. The CPT Guidelines for skin substitute grafts (page 100 of the 2024 CPT manual) instruct you to use the codes for biological products that form a sheet scaffolding to promote skin growth.   CPT instructs the skin substitute codes are not to be used for non-graft dressings such as the Acell Micromatrix, a powder.  KZA appreciates your inquiry as these codes are always under scrutiny. If you are in the office setting (non-facility) and purchased the Micromatrix, you may look to report HCPCS code Q4118 for the supply purchased and the application of the non-graft wound dressing would be captured in the appropriate evaluation and management level code.

*This response is based on the best information available as of 7/11/24.