Medicare Benefits Schedule - Item 46120

Excised burn wound closure, to an area of at least 50% but less than 60% of total body surface, if the service:

(a) is performed at the same time as the procedure for the primary burn wound excision; and
(b) involves:

(i) autologous skin grafting for definitive closure; or
(ii) autologous skin cell suspension for definitive closure; or
(iii) autologous skin cell suspension in conjunction with autologous skin grafting for definitive closure; or
(iv) allogenic skin grafting, or biosynthetic skin substitutes, to temporize the excised wound;

excluding aftercare (H)

Multiple Operation Rule

(Anaes.) (Assist.)

Fee: $2,553.45 Benefit: 75% = $1,915.10

(See para TN.8.273, TN.8.274, TN.8.301 of explanatory notes to this Category)

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Item 46100 is a modifier item that provides extra funding for burns involving the hands, face and anterior neck.

The modifier item can be co-claimed for the excision of burnt tissue items 46101 to 46111, the immediate closure items 46113 to 46123 and the delayed definitive closure items 46130 to 46135, where excision of burnt tissue or definitive burn wound closure involves greater than 1% of the hands, face or anterior neck.

The modifier item does not apply to whole of face burns items 46112, 46124 or 46136. This is because the fee for items 46112, 46124 and 46136 was set at a level that incorporates the additional complexity of whole of face procedures.

The derived fee for claims including the modifier item will be an additional 40% of the fee for the co-claimed service.

There may be circumstances where a whole of face burns item (46112, 46124 or 46136) can be claimed in the same procedure as a combination of the modifier item (46100) and a co-claimed service covered by clause (b) of item 46100.

For example, a patient may have burns that require excision and immediate definitive closure for the whole of face as well as the anterior neck. The treating surgeon could claim items 46112 and 46124 for the excision and closure of the whole of face. In addition, the surgeon could claim item 46103 for the excision of the anterior neck with the modifier item (46100) and item 46115 for the definitive closure of the anterior neck with the modifier item (46100), because the excision and closure on the anterior neck involves at least 3% but less than 10% of the total body surface area.

Claiming the modifier item

The modifier item (46100) should be claimed immediately after the burns excision or closure item it is associated with.

If multiple burns excision/closure item are eligible to be claimed with the modifier items (i.e. the excision of burnt tissue and definitive burn wound closure involves greater than 1% of the hands, face or anterior neck for multiple items) then the modifier item should be claimed immediately after each of the burns excision/closure items it is associated with. However, where multiple burns excision/closure items are claimed, the modifier item may not necessarily apply to each of the items.

For example, for a claim involving burns excision and closure items 46102, 46114 and 46125, where the modifier item only applies to items 46102 and 46114, the following items should be claimed:

When claiming the modifier item with one of the burns excision or closure items:

• the modifier item and the associated burns excision or closure item is treated as one service for the purpose of the Multiple Operation Rule
• the derived fee resulting from claiming the modifier item is calculated before the Multiple Operation Rule is applied/calculated.

Related Items: 46100 46101 46102 46103 46104 46105 46106 46107 46108 46109 46110 46111 46112 46113 46114 46115 46116 46117 46118 46119 46120 46121 46122 46123 46124 46125 46126 46127 46128 46129 46130 46131 46132 46133 46134 46135 46136

Only one item can be claimed from the excision of burnt tissue items (items 46101 to 46111) for one provider in one operation, based on the total percentage excised by that provider.

Item 46112, for excision of burnt tissue involving the whole of face, may be claimed by one provider with one excision of burnt tissue item (items 46101 to 46111), based on the percentage of total body surface area excised by that provider (excluding the face).

Only one item can be claimed from the immediate closure items (items 46113 to 46123) for one provider in one operation, based on the total percentage treated by that provider.

Item 46124, for immediate closure of the whole of face, may be claimed by one provider with one immediate closure item (items 46113 to 46123), based on the percentage of total body surface area treated by that provider (excluding the face).

Only one item can be claimed from the delayed definitive closure items (items 46125 to 46135) for one provider in one operation, based on the total percentage treated by that provider.

Item 46136, for delayed definitive closure of the whole of face, may be claimed by one provider with one delayed definitive closure item (46125 to 46135), based on the percentage of total body surface area treated by that provider (excluding the face).

For any size of burn, each surgeon can work with another surgeon, and each surgeon chooses the excision or closure item based on the area that they, as an individual surgeon, have treated.

Where two surgeons are claiming excision or closure items, the sum of items of each of the surgeons should match the percentage of total body surface area excised or closed for that patient during the procedure.

Excision of burnt tissue items (items 46101 to 46112) can be co-claimed with immediate closure items (items 46113 to 46124), but not with delayed definitive closure items (items 46130 to 46136).

When immediate closure is being performed, if it is indicated, both an immediate closure item (items 46113 to 46124) and a non-excisional debridement item (items 46125 to 46129) can be claimed.

Delayed definitive closure items (items 46130 to 46136) cannot be co-claimed with excision of burnt tissue items (items 46101 to 46112), immediate closure items (items 46113 to 46124) or non-excisional debridement items (items 46125 to 46129).

Related Items: 46100 46101 46102 46103 46104 46105 46106 46107 46108 46109 46110 46111 46112 46113 46114 46115 46116 46117 46118 46119 46120 46121 46122 46123 46124 46125 46126 46127 46128 46129 46130 46131 46132 46133 46134 46135 46136

Autologous skin cell suspension (ASCS) can be used on its own or in conjunction with autologous skin grafting for definitive burn wound closure (either immediate or delayed) where the total burn area being treated in the procedure (by one or multiple surgeons) is:

• at least 10% of total body surface for a patient aged less than 15 years; or
• at least 20% of total body surface for a patient aged 15 years or over; or
• for the whole of face.

For definitive burn wound closure using ASCS or ASCS in conjunction with autologous skin grafting, there may be procedures where the burn area being treated by a single surgeon is less than 10% of total body surface for a patient aged less than 15 years or less than 20% of total body surface for a patient aged 15 years or over. However, the total burn area being treated by multiple surgeons must be at least 10% of total body surface for a patient aged less than 15 years or at least 20% of total body surface for a patient aged 15 years or over.

For example, a single surgeon may be performing immediate definitive burn wound closure under item 46115 on 6% of total body surface for a patient aged less than 15 years. At the same time, another surgeon is performing immediate definitive burn wound closure under item 46115 on 6% of total body surface for the same patient. Because the total area being treated in this procedure is at least 10% of total body surface, ASCS or ASCS in conjunction with autologous skin grafting can be used.

Related Items: 46113 46114 46115 46116 46117 46118 46119 46120 46121 46122 46123 46124 46130 46131 46132 46133 46134 46135 46136