Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services described by current procedural terminology (CPT) codes 15004, 15005, 15002, and 15003 provided on October 5, 2020.
You asked the Plan to pay for CPT codes 15004, 15005, 15002, and 15003. You say that the medical records support the billing of CPT codes 15004, 15005, 15002, and 15003 provided on October 5, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 15004, 15005, 15002, and 15003 provided on October 5, 2020.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 15004 is Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children. The CPT Code Manual definition of code 15005 is Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 15002 is Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. The CPT Code Manual definition of code 15003 is Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for CPT codes 15004, 15005, 15002, and 15003.
Our reviewer says that the medical records do not support the billing of CPT codes 15004, 15005, 15002, and 15003 provided on October 5, 2020. Our physician reviewer found the enrollee is with flame burns to face, hands, and upper extremities. In summary, CPT code 15002 and 15004 are base codes addressing the first 100 cm2 of area of excision for site preparation for defined anatomic regions. CPT 15003 and 15005 are add on codes for additional 100 cm2 areas. In this case, the operative report indicates that blisters and nonviable superficial tissue was removed. The documentation does not indicate that open wounds or burn eschar were excised but rather debrided. The required elements of CPT codes 15002 and 15004 are not satisfied. Because the base codes are not properly billable, the add on codes of 15003 and 15005 are also not properly billable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 15004, 15005, 15002, and 15003 have not been met. Therefore, we decided that the Plan does not have to pay for the wound care services described by current procedural terminology (CPT) codes 15004, 15005, 15002, and 15003 provided on October 5, 2020.