Exploring The Potential Of Acellular Dermis Grafts For Wound Healing And Soft Tissue Repair

Author(s): 
J. Palmer Branch, DPM, FACFAS

Repair of Achilles tendon –primary –open or percutaneous – 27650
With graft – primary 27652

Repair, secondary, Achilles tendon with or without graft - 27654

Repair of flexor tendon (primary or secondary)
Foot - 28200
Ankle/leg - 27658

Repair of flexor tendon with free graft (includes obtaining graft)
Foot - 28202
Ankle/leg - 27665

   There has been some debate among various coding experts on whether the acellular dermis graft warrants the graft repair code. It is the opinion of this author that the application and suturing or weaving of an acellular dermis graft to strengthen the repair site does represent adequate work to warrant billing of this higher level code.

Ankle Ligament Repair

Primary Brostrom repair – single ligament – 27695
Both collateral ligaments – 27696
Secondary anatomic ligament reconstruction with graft- 27698

   It would be my opinion that the simple onlay graft of the dermis graft over a Brostrom-type repair would be billable as a primary repair. Procedures where the dermis graft is used in more substantial ligament reconstructive techniques would be more appropriately billed at the higher code level.

Joint Resurfacing

Arthroplasty of first metatarsophalangeal joint – 28292 (generally applicable for use of dermis graft resurfacing)

Arthroplasty of first metatarsophalangeal joint with metallic or silicone implant- 28293

Arthroplasty of lesser metatarsophalangeal joint – 28288
(same code for ostectomy, partial of each metatarsal head)

Arthroplasty of ankle – 27700

   Although there is a code for ankle arthroplasty with implant (27702), this generally refers to the metallic ankle implants. This is significantly different from the resurfacing procedure. Consideration could be given for use of the ankle arthroplasty code with a -22 modifier (“additional work”) or to use the unlisted procedure code (28899). Preauthorization from private insurance carriers may be necessary, depending on the payor.24,25

In Conclusion

Acellular dermis grafts are useful and versatile tools to have in one’s surgical armamentarium. A thorough understanding of the basic science of wound and graft healing, particularly how the grafts serve as scaffolds for new tissue ingrowth, enhances the ability to use these grafts more effectively. Although still very useful in wound healing, additional applications of acellular dermis grafts including tendon repair, ligament reconstruction, soft tissue supplementation and joint resurfacing should be given due consideration in surgical planning to optimize patient outcomes.

   Dr. Branch is in private practice with several offices in the Atlanta area. He is board certified in both foot surgery and reconstructive rearfoot and ankle surgery.

References
1. Beniker D, McQuillan D, Livesey S, et al. The use of acellular dermal matrix as a scaffold for periosteum replacement. Orthopedics. 2003; 26(5):591-6.

2. Barber FA, McGarry JE, Herbert MA. A biomechanical study of Achilles tendon repair augmentation using GraftJacket® matrix. Foot and Ankle International. 23(4):329-33, 2008.

3. Liden BA, Simmons M. Histologic evaluation of a 6-month GraftJacket® matrix biopsy used for Achilles tendon augmentation. J Amer Pod Med Assoc. 2009; 99(2):104-7.

4. Brady C. Ankle stabilization surgical technique using the split peroneus longus tendon (surgical protocol). Available at
http://www.biomet.com/sportsmedicine/getfile.cfm?id=2438&rt=inline .

5. Lee MS. GraftJacket augmentation of chronic Achilles tendon ruptures. Orthopedics. 2004; 27(1 Suppl):s151-3.

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