“My billing team and I have a difference of opinion. If we apply more than one graft, they have been using modifier -76. It is getting paid, but I am not sure that is the appropriate use of the modifier. I just assumed we bill for total units. However, each graft has a unit number. So, if we bill double the units, we need a way to alert the insurance company as to why the units are doubled. This is why we started using the 76 Modifier. Any input would be appreciated.”
There is absolutely no reason to bill for the application of CTP on 2 separate lines appending the 2nd line with the 76 Modifier. The 76 modifier is defined as the following: REPEATED PROCEDURE BY THE SAME PHYSICIAN – “It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.”
Clearly, this is not the case here. This is not a scenario where another procedure is being performed subsequent to the original procedure. If more than one graft package/CTP is needed to apply to the ulcers, it is not billed with the 76 Modifier appended to the application of the 2nd graft package/CTP. It is essentially part of the same procedure set.
Here are the CPT codes for the application of CTPs:
CPT 15271: Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
CPT 15272: Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) – Add-on code
Example:
CTP to 78 sq cm of leg
CPT 15271 X 1 unit
CPT 15272 X 3 units
CPT 15273: Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
CPT 15274: Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) – Add-on code
CPT 15275: Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
CPT 15276: Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) – Add-on code
CPT 15277: Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
CPT 15278: Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) – Add-on code
JW / JC Modifiers: The JC modifier which was used for the amount of CTP applied is no longer utilized. The JW modifier is used for the amount of CTP wasted.
Example:
Code product using 2 lines.
Units of CTP used: Q code X units.
Units of CTP discarded: Q code X units – JW mod.
Line 1 + Line 2 = Total CTP product
Example:
A 6 sq. cm. piece of CTP is used to cover a 5 sq. cm. foot ulcer. Three lines are billed on the claim form.
CPT 15275
Q4160 5 units – KX
Q4160 1 unit – JW – KX
As of July 1, 2023, the following rules went into effect:
JW and JZ Modifier Billing Guidelines:
JZ Modifier is a HCPCS Level II modifier reported on a claim to attest that no amount of CTP was discarded and is eligible for payment.
To submit claims for a waste-required claim, submit two complete claim lines.
Claim line #1:
HCPCS Level II code for CTP applied
No modifier appended
Number of units of CTP applied
Calculated submitted price for ONLY the amount of CTP applied
Claim line #2
HCPCS Level II code for CTP wasted
JW modifier appended to HCPCS Level II code to indicate CTP wasted
Number of units of CTP wasted
Calculated submitted price for ONLY the amount of CTP wasted
To submit claims for a non-discarded claim, submit one complete claim line.
HCPCS Level II code for CTP applied
JZ modifier to indicate no waste of CTP
Number of units of CTP applied
Calculated submitted price for the amount of CTP applied
This is my opinion.
Michael G. Warshaw
DPM, CPC
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