General Surgery Coding Alert

Also, don't miss separate debridement opportunity.

Feeling overwhelmed by all the changes in the CPT® 2012 integumentary section? We've got the scoop for you, with a little help from the AMA's CPT® Editorial Committee, to keep your skin repair claims clean and earn all the pay you deserve.

Note New Modifier Advice for Repairs

2012 offers new introductory notes that provide guidance on how to report skin closures (12001-13160). While the guidelines previously advised the use of modifier 51 (Multiple procedures) when reporting different wound repair classifications together, that guidance is old news as of Jan. 1.

"The guidelines were clarified for repair, changing the modifier 51 that had been there to the distinct procedural service modifier, 59," said Albert E. Bothe, Jr., MD, during his "CPT® Changes: General Surgery" seminar at the CPT® 2012 Annual Symposium in Chicago on Nov. 17.

In black and white: The 2012 CPT® manual reads, "When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier 59."

What's "complicated?" Because CPT® offers simple, intermediate, and complex repairs, you'd consider the "simple" repair the least complicated, and the "complex" repair the most complicated. Therefore, if the surgeon closes a leg wound with a simple repair such as 12001(Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less) and an intermediate repair, such as 12032 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm), you'll report the intermediate repair first, followed by the simple repair with the modifier: 12032, 12001-59.

Know When Debridement is 'Separate'

When surgeons perform skin grafting, it's common for coders to spend a lot of time and effort trying to determine whether they can bill debridement separately, as many physicians request. Bothe shed some much-needed light on this complicated issue during his presentation, explaining when CPT® considers debridement to be "separate."

"Debridement is considered a separate procedure only when gross contamination requires a prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure," he said.

Tip: Your documentation should fully describe the surgeon's work cleansing the contamination and removing the devitalized tissue before you separately bill your insurer for debridement.

Skin Substitute Coding Overhaul Simplifies Processes

Although you may have been stunned when you saw that CPT® 2012 made massive changes to the skin substitute coding section (15271-15278, Application of skin substitute graft ...), you should know that the AMA's goal was to make your life easier, not more difficult, said Christopher K. Senkowski, MD, at the Nov. 17 "CPT® Changes: General Surgery" seminar.

"For wounds that are smaller than 100 square centimeters, you'll follow one code structure -- if your wound is 100 square centimeters or greater, you'll follow a separate code structure," he said. "We felt that about 80 percent of the wounds would fit into the 'less than 100 sq. cm' designation," he said.

Small wounds: Under the new coding rules, a skin substitution graft performed for a wound surface area up to 100 square centimeters would only have two possible primary coding options: 15271 (for trunk, arms, and legs) or 15275 (for face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits). Each of these codes represents the first 25 square centimeters repaired. For each additional 25 sq. centimeters repaired (or part thereof), you'll use either the add-on code +15272 (for trunk, arms, and legs) or +15276 (for face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits).

Example: A diabetic patient presents with a 50-square centimeter ulcer on the base of her foot. The surgeon applies a skin substitute graft to the entire wound. In this situation, you'll report one unit of 15275 (to represent the first 25 sq. cm) and one unit of +15276 (for the second 25 sq. cm repaired).

Large wounds: When performing skin substitute applications to wounds that are 100 square centimeters or larger, you'll only have two primary coding options: 15277 (for the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits) or 15273 (for trunk, arms, and legs). To represent each additional 100 square centimeters or part therof, you'll report a unit of the add-on code +15278 (for the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits) or +15274 (for trunk, arms, and legs).

Example: A patient falls asleep smoking a cigarette and suffers burns to 20 percent of her body. The surgeon applies 300 square centimeters of skin substitute to her arms. In this case, you'll report one unit of 15273 (to represent the first 100 square cm), and two units of the add-on code +15274 to represent the remaining 200 square cm.

Don't miss: "The wound-size part of this change is quite different than other coding," emphasizes Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. "If the patient has a large wound but the surgeon covers only part of the wound with skin substitute, the code for the larger wound is still appropriate," she says.

Do this: "Surgeons will need to be more specific in their op notes about both the size of the wound and the size of the graft," Bucknam says.