Dermatology Coding Alert

Tip: Don't count on separate lesion removal payment.

When your dermatologist performs a wound repair closure, you could be miscoding if you automatically turn to 12001-13160. You need to dig deep into the surgeon's documentation to see if a tissue transfer code is more appropriate -- but knowing the difference between wound repairs and tissue transfers is only the beginning. Ensure your surgeon gets the reimbursement he deserves with three steps.

1. Get to Know the Difference Between Transfers and Repairs

For wound closure procedures, you'll first need to decide between wound repair codes 12001-13160 and adjacent tissue transfer codes 14000-14300 (Adjacent tissue transfer or rearrangement ...).

The basics: In simplest terms, if your surgeon only cleans and sutures the wound you'll choose a simple, intermediate, or complex repair code (12001-13160). If your surgeon documents that he freed tissue from around the wound and rearranged it to cover and repair the wound area, you're dealing with a tissue transfer and need to turn to 14000-14300.

"The wound repair/closure CPT codes 12001-13160 describe direct wound closure employing sutures, staples, or tissue adhesives (cyanoacrylate)," explains Gary W. Barone, MD, a physician  and associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock. "The tissue transfer CPT Codes 14000-14300 are used for the repair of traumatic wounds and for the excision of a lesion (benign or malignant) and the repair of the resulting 'primary defect' (and the resulting 'secondary defect') by adjacent tissue transfer or rearrangement (including Z-plasty, W-Plasty, V-Y plasty, rotational flap, randon island flap, or advancement flap."

Other types of flaps are reported two other places in CPT, notes Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas: "Flaps (Skin and/or Deep Tissues)" (15570-15738) and "Other Flaps and Grafts" (15740-15776). "Traumatic wounds that incidentally result in one of these configurations are not reported with these codes," she advises.

Tip: One easy way to determine if your dermatologist performed a tissue transfer is to look for a flap creation that results in a "secondary defect" in addition to the "primary defect" of the wound itself. The primary defect is the one being repaired, and the secondary defect is the defect created by lifting or removing the adjacent tissue.

"The size and how this secondary defect is repaired will depend on the type and location of flap and the size of the primary defect as to whether the secondary defect can itself be closed primarily or may be need a separate skin graft for closure,"Barone says.

Keep in mind that you can separately report any skin grafting necessary for closure of the secondary defect, as follows:

• 15100-15136 for autologous skin grafts
• 15150-15157 for autologous tissue-cultured epidermal grafts
• 15040 for autologous keratinocytes and dermal tissue harvesting for tissue cultured skin grafts
• 15170-15176 for acellular dermal replacement.

Bottom line: During a procedure described by 12001-13160, the dermatologist will not create a secondary defect. "Undermining a wound without an additional incision(s) is not considered as an adjacent tissue transfer," Barone warns.

2. Determine Overall Area and Location

Once you determine that your dermatologist performed a tissue transfer, you'll need to narrow down your code selection by determining the total area of the primary and secondary defects, according to CPT instructions.

After adding up the affected area, look at the repair's anatomical location to narrow your choices even further.

Example: Your dermatologist removes a lesion measuring 2 cm x 2 cm from a patient's back including margins. To repair this primary defect, the surgeon creates a flap measuring 4 cm x 2.5 cm.

To determine the total area, add together the area of the primary defect (2 x 2 = 4 sq cm) and the area of the secondary defect (4 x 2.5 = 10 sq cm) for a total area of 14 sq cm. In this case, you should choose 14001 (Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm) for a repair totaling 14 sq cm on the back, says Charlotte T. Tweed, RHIA, CPC, coding auditor and inpatient/surgery coder in the department of medical education/coding at Florida Hospital in Orlando.

Remember: When you're reporting tissue transfers, you should report each repair separately. This is different from wound repair coding using 12001-13160. For wound repairs, CPT instructs you to use one code to describe the repair, even if it involves more than one wound.

This is not true of adjacent tissue transfers, however. "Multiple wounds repaired in the same anatomic location and with the same classification (simple, intermediate, or complex) are grouped together by adding the all the lengths of repair into the same CPT descriptor. This is not true for adjunct tissue transfer," Barone says.

How it works: For each adjacent tissue transfer repair, report one code based on the defect's size.

3. Skip Separate Lesion Removal Coding

You should not separately report any lesion removals your surgeon performs during a tissue transfer procedure, Tweed cautions. "The excision of the benign lesion (CPT 11400-1446) or of the  malignant lesion (CPT 11600-11646) is not separately reported with the tissue transfer codes (CPT 14000-14302)," Barone confirms. Both CPT and CMS/Correct Coding Initiative guidelines reinforce this guidance.

Exception: If your surgeon performs an excision on a separate day from the tissue transfer, you may report the procedures separately. You might see this scenario if your surgeon is waiting for the pathology report to be sure the lesion margins are clear before closing the operative wound. If the tissue transfer occurs during the excision's 10-day global period, append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to the tissue transfer code.