Common errors in skin substitute claims

One of the most common errors seen in skin substitute claims is the inappropriate application of drug waste modifiers, which are as follows:

• -JW (Drug amount discarded/not administered to any patient)
• -JZ (Zero drug amount discarded/not administered to any patient)

Organizations should train coders on CMS’ drug waste modifier policy and consider implementing claim scrubbers to flag missing or incorrect modifiers before submission, says Betty A. Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, senior consultant and owner of Compliant Health Care Solutions in Port Charlotte, Florida.

Organizations need to validate that the amount of units billed corresponds with the amount of units applied, says Christine Hall, CHC, CDEO, CPC, CPB, CPMA, CRC, CEMA, CPC-I, CEO and senior consultant for Stirling Global Solutions, LLC, in Port St. Lucie, Florida.

“Encourage coders to cross-reference operative reports and supply logs to confirm that product usage aligns with the code reported,” she says.

Hovey recommends working with IT teams to develop an EHR prompt to ensure precise measurements get captured, as many facilities misreport the number of applied or discarded units. For example, they may bill for the entire product size when only a portion was used, or fail to adjust to payer-specific unit calculations.

“Train staff to document exact square centimeters applied and discarded, and verify units against payers’ billing rules,” she says.

Revenue integrity professionals should understand proper Healthcare Common Procedure Coding System (HCPCS) code selection for skin substitute claims. Hovey recommends maintaining an updated product-code crosswalk that is verified against the HCPCS Level II code list. In addition, she suggests training coders to confirm the product’s National Drug Code and brand name in the documentation before coding.

There can be a lot of variation in payers’ coverage criteria for skin substitute products, and organizations run the risk of billing for off-label applications not supported by local coverage determinations (LCD) if they aren’t aware of the differences. It’s important to review LCDs and payers’ policies before the product application, notes Hovey.

Skin substitute claims must also include the appropriate Current Procedural Terminology (CPT®) code to reflect the graft application. CPT code selection for skin substitute grafts is based on the location and size of the defect; codes 15271–13274 are used to report application on the arms, legs, or trunk, and codes 15275–15278 are for other locations on the body.

Editor’s note: This is an excerpt from, “Ensuring appropriate coding and documentation for skin substitute claims,” in the July 2025 issue of the NAHRI Journal.