Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound preparation services coded as 15002 provided on November 13, 2020.  You asked the Plan to pay for the wound preparation services. You say that this procedure as billed is supported in the medical documentation. The Plan denied your request. The Plan says the code as billed is not supported in the medical documentation submitted.  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 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.  We asked our coder 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 the wound preparation services. Our reviewer says that the documentation does not support payment for the code as billed. Our reviewer found the medical records provided does not include sufficient documentation the validate that a 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 was performed on November 3, 2021, therefore this procedure cannot be verified.  Per the National Correct Coding Initiative Policy Manual regarding CPT code 15002, "The physician prepares tissue to receive a free skin graft needed to close or repair a defect. Skin, subcutaneous tissue, scars, burn eschar, and lesions are excised to provide a healthy, vascular tissue bed (where new vessels have been formed) onto which a skin graft will be placed. Alternatively, the physician may prepare tissue by incising or excising a scar contracture that is causing excessive tightening of the skin. Simple debridement of granulations or of recent avulsion is included. Report 15002 for the first 100 sq cm or 1 percent of body area of infants and children for grafts of the trunk arms and legs. Report 15003 for each additional 100 sq cm (or part thereof) of graft area or each additional 1 percent of surface body area in infants and children within the same areas. Report 15003 in addition to 15002. These procedures are for preparation or creation of the recipient site. Free grafts should be listed by the appropriate code number when the graft, immediate or delayed, is applied. Identify by size and location of the defect (recipient area) and the type of graft. Surgical trays, A4550, are not separately reimbursed by Medicare; however, other third-party payers may cover them. Check with the specific payer to determine coverage." This description was not documented in the operative note.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wound preparation services have not been met. Therefore, we decided that the Plan does not have to pay for the wound preparation services coded as 15002 provided on November 13, 2020.