Dermatology Coding Alert

Deletions in the most recent round of edits may pleasantly surprise you

When your dermatologist performs layer closures, you can report 12042 with either 12052 or 12053 and receive full pay for each procedure. 

Background: The National Correct Coding Initiative previously declared these codes as mutually exclusive and bundled 12042 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm) with codes 12052 (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) and 12053 (... 5.1 cm to 7.5 cm). Good news: The most recent NCCI edits (version 11.1), effective April 1, designate these bundles as nonmutually exclusive, which means you can bill them together.

 

---

Explanation: When codes are mutually exclusive, you should not bill them together due to conflicting CPT definitions or "the medical impossibility/improbability that the procedures could be performed at the same session," NCCI states.

When you report codes identified as mutually exclusive for a single surgical session, usually the carrier will recognize and reimburse only the lesser-valued procedure.

Mutually exclusive edits have a status indicator of 1, meaning you can override the edit using modifier -59 (Distinct procedural service), which allows you to break bundles under the proper circumstances.

Remember, -59 is not a license to unbundle - you must be able to justify the unbundling to the payer, says William J. Conner, MD, founder of Conner Health Clinic, a multispecialty practice in Charlotte, N.C.

---

Check for Anatomic Site

You can now bill 12042 with either 12052 or 12053 when the dermatologist completes a layer closure on different anatomic sites of the patient. Don't miss: The documentation must include specific details to justify reporting both procedures.

Example 1: Your dermatologist performs a layer closure on a wound on the patient's neck that measured 7.0 cm (12042) and a separate wound on the patient's eyelid that measured 2.8 cm (12052).

Old way: Since codes 12042, 12052 and 12053 were bundled, carriers would deny full payment for the two procedures. Even if you attached modifier -59, you would only receive partial payment.

New way: Now, since NCCI deletes these mutually exclusive bundles, you can report 12042 with either 12052 or 12053 and receive full reimbursement for  each procedure.  

Example 2:  A patient presents to your dermatology practice. He has several lacerations that require layered repairs: one to his neck (5.0 cm), eyelids (2.7 cm), and face (several totaling 5.5 cm). 

The dermatologist repairs the lacerations. In this case, you should apply 12042, 12052 and 12053 without any modifiers. 

The newest deletion of layer closure bundles allows you to bill each of these procedures that often occur on the same patient at the same session but at different anatomic sites, says Linda Martien, CPC, CPC-H, National Healthcare Review in Woodland Hills, Calif. 

Example 3: A patient comes to the emergency department with self-inflicted wounds to his neck and face. Due to the nature of the wounds, the ED physician contacts the dermatologist on call. 
 
The wounds to the neck total 4.8 cm, and the wounds to the face total 3.4 cm. After cleaning and exploring the wounds, the dermatologist performs a layered repair to all wounds. You should bill these services using codes 12042 and 12052.