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Codes 16020 and 16030
Codes 15002-15003
Coding Fasciotomies

Codes 16020-16030

Questions regarding the correct coding of procedure codes 16020-16030:

1. Must a debridement be performed with the dressing change in order to
use these codes?

2. In the burn primer it addresses the dressings on a grafted area and
states when performed in the operating room for a complication to report the code
with a modifier -78.  Can you also report this code on a grafted burn with
modifier -58?  There are instances when the burn area is quite large and the
patient is taken back to the OR to have his dressings changed--they would
need anesthesia or conscious sedation to make them comfortable in order to
perform the dressing changes.

ABA Coding Response

Thank you for your important inquiry.  Because other members may have the same question, the substance of this response will be inserted into the forthcoming 2008 update of the ABA Coding and Reimbursement Primer.  It will appear under each topic, “Debridement” and “Dressings.”

 Question 1:     Must a debridement be performed with the dressing change in order to
use these codes?

The common portion of codes 16020-16030 states (boldface added):

“Dressings and/or debridement of partial-thickness burns, initial or subsequent;…”

The “and/or” in the code descriptor indicates that codes 16020-16030 may be used to report a debridement or a dressing change when one or the other is performed at the encounter, or to report both a debridement and a dressing change when both are performed at the same encounter.  A debridement does not have to be performed with the dressing change in order to use these codes.

• Note: When both debridement and dressing change are performed at the same encounter, select the single most appropriate code from 16020-16030 to report them.

Question 2:     In the burn primer it addresses the dressings on a grafted area and
states when performed in the operating room for a complication to report the code with a modifier -78.  Can you also report this code on a grafted burn with modifier -58?  There are instances when the burn area is quite large and the patient is taken back to the OR to have his dressings changed--they would need anesthesia or conscious sedation to make them comfortable in order to perform the dressing changes.

To reiterate the information on page 140 of the 2007 Primer, routine dressing changes on a grafted area are included in the global surgery package for the graft procedure. 

However, in cases where the patient must be taken to the operating room for the dressing change under anesthesia or conscious sedation, the dressing change may be reported in the absence of payer guidelines to the contrary.  The conditions under which you may use modifier 58 are explained below.

The new, 2008 revised CPT language of modifiers 58 and 78 provide clarification of the guidelines under which you may use these modifiers.  (Italics indicate new language.)

• Modifier 58 may now be used to report a procedure that was a) planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure.
  
  The former phrase, “planned prospectively at the time of the original procedure” was replaced with “planned or anticipated.”
  
  When the physician anticipates the need to perform dressing change in the operating room under anesthesia or conscious sedation because of the extent of the graft and the patient’s need for pain management during the procedure, modifier 58 may be appended to the applicable code from 16020-16030.
  
  However, when the return to the operating room is required because of an unanticipated clinical condition (e.g., complication, graft non-take or replacement graft), modifier 58 does not apply.  See modifier 78 instead.
  
• Modifier 78 is used to report an “unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period.”
  
  When the patient is returned to the operating/procedure room to treat an unanticipated clinical condition such as a complication or the need for graft replacement, modifier 78 may be appended to the applicable surgical procedure code.

Note the addition of the term, “procedure” room, in the definition of modifier 78.  This term was added to avoid limiting this reporting to inpatient procedures only.

For the exact language of each modifier and to be able to identify all 2008 revisions to the language for each modifier, refer to the 2008 CPT book and to the AMA’s CPT 2008 Changes book.

Codes 15002-15003

My question is with the use of the codes 15002/15003 and the use of Biobrane.  The code(s) states “surgical preparation or creation of recipient site…”.  My understanding is that the burn site is being prepped for some type of skin replacement.  This would entail using addition codes for the placement.  I understand that Biobrane may be used as a dressing or replacement, depending on the surgeons use.  My experience is that using a dermal replacement may be done at the time of the prep or at a later date.  This would be dictated in the op report to support the code and compliance.  If the surgeon is using the Biobrane as a dressing, with no intention of ever grafting that burn site, would 15002 still be the appropriate code?  The plastic surgeons are using codes 15002/15003 for every type of debridement performed.  An example of this would be a patient who had a sub q retained bullet removed, it was not deep, and the surgeon used 15002 to debride the cavity where the bullet was removed and left the would open instead of suturing the area for healing purposes.

ABA Coding Response
There are several issues your inquiry raises and a response to each follows.

Please note that the ABA Primer follows National Standard coding guidelines set by the American Medical Association (e.g., CPT, CPT Assistant) and, where so stated, by Medicare.

Excision versus Debridement

Excision and debridement are two distinctly different surgical procedures.  Each is based on the specific technique used by the surgeon.  Please refer to the definitions of debridement and excision that appear in the box on page 125 of the ABA 2007 Coding Primer and the excerpt below.  These definitions will aid you and the surgeons in selecting the appropriate code for reporting purposes.

Excerpt:
“…Debridement is the removal of loose, devitalized, necrotic and/or contaminated tissue, foreign bodies, and other debris on the wound, using mechanical or sharp techniques.  …Burn wound excision is a surgical procedure…that generally utilizes a surgical technique called ‘tangential excision’ that involves excision of successive layers of burn wound and results in a large open area that must be covered.  Other techniques, such as full thickness excision, may be used…”

The selection of a code for excision or debridement depends on what the physician has documented in the operative report/medical record.  If wound excision is documented, the applicable code from among codes 15002-15005 may be reported, as appropriate, regardless of the type of coverage planned.  The planned type of coverage, whether Biobrane, a skin graft, or another material, does not dictate the code for the surgical procedure.  Rather, the narrative description of the operative procedure dictates which code should be selected for reporting the service.

If debridement is documented, the applicable debridement code may be reported.  For debridement of burn wounds, see burn wound debridement codes 16020-16030.  For debridement of other wounds, refer to CPT debridement codes 11000-11001, 11004-11008, or 11040-11044.

Codes 15002-15005 (Surgical preparation or creation of recipient site by excision…) apply only to excision and should never be used to report debridement.The two procedures are not the same and, even though some may use the terms interchangeably, such usage is not appropriate.

It is important to recall that the Notes in CPT following the sub-heading “Skin Replacement Surgery and Skin Substitutes” indicate that the listed procedures—excisions and grafts/skin substitutes—include simple debridement of granulation tissue or recent avulsion.

Biobrane is a Dressing Only; Application is not Separately Reportable

Biobrane is not a skin substitute or replacement.  It is considered a dressing only.

The relevant guidelines in the 2007 ABA Primer are outlined in A and B, below.  They are based on the 5th parenthetical note that follows code 15005 in CPT 2007 which states the following rule:

“(For excision to prepare or create recipient site with dressings or materials not listed in 15040-15431, use 15002-15005 only.)”

The ABA guidelines are also based on long-standing CPT and AMA guidelines (since 1998), now deleted in favor of the above note, which indicated the fact that Biobrane is a dressing and that its application is included in the respective CPT code for wound excision.

A. Guidelines for application of Biobrane are included in the 2007 ABA Primer in the section entitled Excision Burn & Non-burn Wounds under the heading “Reporting Guidelines,” bullet #2, page 146 (print and online edition).

• “When excision is performed to prepare or create the recipient site, application of dressings or materials that are not described in codes 15040-15431 is not separately reportable.  Report code(s) 15002-15003 and/or 15004-15005 only, as appropriate.  Examples of materials or dressings that are not separately reportable include but are not limited to Biobrane, Xeroform, Adaptic and Exudry.”

B. The above guidelines also appear in the Reporting Guidelines on page 156 of the 2007 ABA Primer under the Heading “Skin Replacement Surgery and Skin Substitutes—Grafts” in bullet #3.

Use of 15002-15003 for Debridement Accompanying Removal of Embedded Foreign Body

As noted above, reporting an excision code for a documented debridement is not appropriate.  To do so, may incur an audit liability and may represent a false claim.

Both the AMA and Medicare (in its memoranda) have published guidelines that require the physician to report the code that accurately describes the procedure performed (i.e., documented in the medical record).

From the Introduction to the 2007 CPT book:

“Select the name of the procedure or service that accurately identifies the service performed.  Do not select a CPT code that merely approximates the service provided.”

The following is for informational purposes only.  In the example you describe, it appears that the essential surgical procedure performed was actually the removal of a foreign body from within or embedded in the subcutaneous tissue with the debridement being an incidental part of that procedure.  Without the actual operative report documentation, it is not possible to definitively state that this was the case.  However, if it was, either code 10120 (Incision and removal of foreign body, subcutaneous tissues, simple) or 10121 (Incision and removal of foreign body, subcutaneous tissues, complicated) may have been reported instead.    

Fasciotomy coding

If a surgeon does fasciotomies and then goes back and sutures them closed, are the closures billable or is it considered bundled into the fasciotomies?

ABA Coding Response
Thank you for your important inquiry.  Because other members may have encountered the same question, the substance of this response will be inserted into the forthcoming 2008 update of the ABA Coding and Reimbursement Primer.  It will appear under the topic “Fasciotomy”The following information assumes that no other surgical procedure, such as wound excision (15002-15005), is performed on the fasciotomy site at the same time as the closure.  That is, the fasciotomy closure is the only procedure performed on the fascotomy site at the operative encounter.In the absence of payer guidelines to the contrary, delayed or secondary closure of a fasciotomy wound may be billed separately.The following codes are available for reporting closure of the fasciotomy:

• Repair (Closure) of wounds, 12001-13153.  Assign the appropriate code for simple, intermediate or complex closure based on the information documented  in the patient record and the guidelines in CPT under the heading “Repair (Closure).”
• If secondary closure is extensive or complicated, refer to code 13160.