New biologic implant codes cause some confusion

By Raymond Janevicius, MD
10/05/2012 at 2:00PM

In 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 such as AlloDerm® (an acellular dermal matrix), the procedure is reported:

  • 19357 Tissue expander placement for breast reconstruction
  • 15777 Placement of biologic implant



Commercial products

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.

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 non-integumentary 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 non-skin-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 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.



Abdominal wall reconstruction

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.
Proper use of skin substitute and biologic implant codes

  • All previous allograft and xenograft codes (pre-2012) have been deleted.
  • New codes have been created for "Skin Substitute Grafts" (15271-15278).
  • These new codes have zero-day global periods.
  • These new "Skin Substitute Graft" codes are used for integumentary ("surface" or "topical") applications of skin substitute grafts.
  • When biologic implants are placed in non-integumentary areas ("non-surface"), a new code, 15777 is to be reported.
  • 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).
  • Code 15777 is an add-on code and is to be reported in addition to the primary procedure.
  • If the surgeon provides the product, the cost of the product is separately billable with an appropriate HCPCS code. These codes can be found online at cms.gov.

Dr. Janevicius is the Society's representative to the AMA CPT Advisory Committee.

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