ED Coding and Reimbursement Alert

Medicare has a special requirement for tissue adhesive

Several variables govern coding for wound repair and -- especially for wounds of different severity and location -- selecting the appropriate codes and modifiers can prove daunting. By tackling these procedures with a step-by-step, one-at-a-time approach, however, you can greatly simplify even the most confusing scenarios.

Step 1: How Was It Closed?

Initially, you must determine if the wound repair/closure codes apply.

According to CPT, codes 12001-13160 -designate closure utilizing sutures, staples or tissue adhesive (e.g., 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips- [emphasis added].

In other words: Under CPT guidelines, if the physician applies any tissue adhesive or places a single stitch or staple, the wound care codes are appropriate.CPT does not differentiate among stitches, staples and tissue adhesive, and the coding does not change regardless of the physician's method of closure.

Medicare designates special codes for tissue adhesive only: If the physician only uses liquid skin adhesive (Dermabond) to close a wound, however, you should report G0168 (Wound closure utilizing tissue adhesive[s] only) for Medicare payers.

If the physician uses sutures or staples with Dermabond to perform a laceration repair, you can report only the layered laceration repair code based on the length and site of the wound, and you should not report G0168.

Adhesive strips alone don't qualify for wound repair: If the physician closes the wound using adhesive strips only, you may not report the repair/closure codes. Instead, you would report wound closure using adhesive strips as the sole repair material as a part of any E/M service the physician provides.

Example: The physician attends to a child who has sustained a laceration after falling from a swing. She examines the child, cleans the wound and places five stitches. In this case, the repair/closure codes are appropriate.

If the doctor determines that the severity of the laceration does not warrant stitches, staples or tissue adhesive, and instead closes the wound using Steri-strips or butterfly bandages, however, you may report only the appropriate E/M service code, as supported  by documentation.

Step 2: Consider Wound Severity

After you-ve determined that the wound repair/closure codes apply, you must assess the severity of the wound itself.

CPT classifies repairs as simple, intermediate or complex, according to wound depth, with each category receiving its own complement of codes.

- Simple repairs involve superficial wounds that involve -primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures,- according to CPT. Additionally, CPT stresses -only simple, one layer, primary suturing is required.-  Physicians will refer to these as single-layer closures.  CPT code range 12001-12021 covers such repairs, which include local anesthesia and chemical or electro-cauterization of wounds left unclosed.

- Intermediate repairs are more extensive and involve -one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure,- according to CPT. If the physician mentions -layered closure,- you probably have an intermediate repair.

A single-layer closure may qualify as an intermediate repair if the wound is heavily contaminated and requires extensive cleaning or removal of -particulate matter.- A common example of this is repair of -road rash- wounds that result from falling on gravel, blacktop or concrete surfaces.

CPT code range 12031-12057 describes intermediate closures.

- Complex repairs involve more than layered closure, such as extensive undermining, stents or retention sutures. If the physician mentions repair to the depth of muscle or deeper, it's complex.

Complex repairs are often reconstructive procedures and include creation of a defect to be repaired (for instance, excision of the scar and subsequent closure). Such repairs do not, however, include excision of lesions (see below for more information).

Report complex repairs using code range 13100-13160.

To determine the level of repair, pay close attention to the operative report: Single-layer closures are generally simple unless the physician has noted extensive cleansing of the wound, in which case they may be intermediate. Dual-layer closures are intermediate, and extensive revision or repair of traumatic lacerations or avulsions is complex.

Don't take a guess: If the operative report does not provide sufficient detail to determine beyond doubt the repair level, check with the operating physician.

Step 3: Determine Location

Within each level of repair, CPT further classifies wounds according to anatomic location. Note that these categories are not identical for each repair level.

Example: For simple repairs, CPT groups the scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet) together as covered by 12001-12007.

For intermediate repairs, 12031-12037 describe layered closure of wounds of scalp, axillae, trunk and/or extremities excluding hands and feet, whereas 12041-12047 apply for repair of wounds to neck, hands, feet and/or external genitalia.

For complex repairs, the subclassifications are still more precise, with separate sections for trunk; scalp, arms and/or legs; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet, etc.

Step 4: Grab the Ruler -

In addition to severity (depth) and anatomic location, CPT groups repair/closure procedures according to the size (length) of the wound.

Example: Code 12001 describes -simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less,- whereas 12004 describes repair of the same severity and location, but of 7.6 cm to 12.5 cm length.

Step 5: - and Add It Up

After you have performed steps 1-4 for all individual repairs/closures, add together the lengths of the various wounds at each identical level of severity and classified anatomic location to arrive at a total length.

In other words: CPT treats all wounds at the same level of severity and anatomic subcategory as a single, -cumulative- wound.

For instance: Returning to the earlier example of the child injured in a playground accident, the physician tends to a 2.5-cm superficial cut on the left leg and a 4-cm superficial cut on the right arm, closing the wounds with stitches.

Both repairs are simple and located on the extremities. Because the severity level and anatomic location fall within the same subcategory of codes (12001-12007), you must add the lengths together to arrive at a total of 6.5 cm. Consulting CPT, the correct code for a simple repair of a 6.5-cm wound on the extremities is 12002 (... 2.6 cm to 7.5 cm).

Example 2: A bicyclist crashes, cutting his face (3 cm), both hands (3 cm and 5 cm), both arms (4 cm and 9 cm) and right leg (12 cm). All repairs are intermediate because the physician must remove debris from and thoroughly cleanse the wounds.

In this case, the wounds to the face, hands and arms and legs fall within different anatomic subcategories. For the face wound, report 12052 (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm); for the hands, add together the 3-cm and 5-cm wounds for a total of 8 cm to report 12044 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12 cm); and for the arms and legs, add together all wounds (4 cm + 9 cm + 12 cm = 25 cm) to report 12036 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 20.1 cm to 30.0 cm).

Example 3: A man falls while cleaning the rain gutters of his home, catching his arm on a sharp metal edge and receiving a deep, jagged laceration, along with some less severe cuts on his trunk and legs.

The arm requires a complex repair 30 cm long. A 15-cm cut on the leg requires a two-layer closure, while another, 3-cm scrape on the same leg requires a few stitches. Likewise, a 5-cm laceration on the chest requires a simple repair.

In this case, report 13121 (Repair, complex, scalp, arms and/or legs; 2.6 cm to 7.5 cm) and +13122 (- each additional 5 cm or less [list separately in addition to code for primary procedure]) x 5 for the arm wound repair, 12035-51 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 12.6 cm to 20 cm; multiple procedures) for the intermediate leg repair, and 12004-51-59 (Distinct procedural service) for the combined length of the superficial leg and trunk wounds.

Look to 59 for Wounds of Different Severity at the Same General Location

The addition of modifier 59 to the last code specifies that the superficial wound(s) indicated by 12004 are separate and distinct from the intermediate leg wound indicated by 12035. Without modifier 59, many payers will bundle the simple repair to the intermediate repair of the same anatomic location.

Coding for complex repairs differs somewhat in that CPT assigns add-on codes for each additional 5 cm beyond 7.5 cm. You may bill multiple units of these add-on codes when necessary, as demonstrated in the above example.

Bill Lesion Excision Separately

Never include excision of lesions, whether benign (11400-11471) or malignant (11600-11646), in wound repair. Note, however, that lesion excision may include wound repair, depending on size and/or complexity.

Example: NCCI bundles intermediate (12031-12057) and complex (13100-13153) repairs to excision of benign lesions of 0.5 cm or less (11400, 11420 and 11440) -- presumably because even complex repair of such a small wound does not increase surgeon effort appreciably. Medicare does not, however, bundle intermediate and complex repairs of malignant lesions of 0.5 cm or less.