General Surgery Coding Alert

" CPT 2000 introduced several add-on codes for the repair of lacerations. These codes may be confusing at first, but by using them properly surgeons can legally maximize their reimbursement for wound repairs.

Until Jan. 1, 2000, general surgeons had to use one code (11330, now deleted) to describe any complex repair of lacerations of more than 7.5 cm. Consequently, whether the surgeon repaired a wound of eight or 18 centimeters, he or she was paid the same amount. Now, however, CPT 2000 has included four new add-on codes for such situations, says Kathleen Mueller, RN, CPC, CCS-P, a coding and reimbursement specialist in the office of Allan K. Lieffer, MD, a general surgeon in Lenzburg, Ill.

Repair, or closure, of wounds or lacerations is performed using sutures, staples or tissue adhesives. Coding for such repairs can be confusing, because these procedures are categorized in three different ways: anatomic site, the depth of the wound, and the size of the repair.

CPT 2000 provides codes for three types of laceration repairs: simple, intermediate and complex (for a more complete discussion of these repairs, see side bar on page 4). Within each of these categories, there also are separate codes depending on the anatomic site of the wound that is being repaired.

Correctly Code Simple Repairs

When a wound is superficialwhich CPT defines as involving primary epidermis, dermis or subcutaneous skin tissues without significant involvement of deeper structuresits repair is considered simple. Such repairs require one single layer closure and include local anesthesia and electrocauterization of wounds not closed.

For simple repairs, the CPT codes differentiate between the face and the rest of the body and are further broken down by the size of the wound or laceration being repaired:

12001simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less

120022.6 cm to 7.5 cm
120047.6 cm to 12.5 cm
1200512.6 cm to 20.0 cm
1200620.1 cm to 30.0 cm
12007over 30.0 cm
12011simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less
120132.6 to 5.0 cm
120145.1 cm to 7.5 cm
120157.6 cm to 12.5 cm
1201612.6 cm to 20.0 cm
1201720.1 cm to 30.0 cm
12018over 30.0 cm

Note: CPT 2000 now differentiates between wounds closed with adhesive strips and those closed by other means. All the listed codes should be used to designate wound closure using sutures, staples, or tissue adhesives (e.g., 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Wound closure using adhesive strips (such as Dermabond) as the sole repair material should be coded using the appropriate evaluation and management (E/M) code.

Get the Right Code for Intermediate Repairs

Intermediate repairs are more extensive. They require layered closure of one or more of the deeper layers of subcutaneous tissue and non-muscle fascia in addition to the skin closure, CPT says. Also included in this category are heavily contaminated wounds that, even though they were single layer closures, required extensive cleaning or removal of particulate matter.

In the case of intermediate repairs, there are three anatomic areasneck, hands, feet and external genitalia; scalp axillae, trunk and/or extremities excluding hands and feet; and the face. Again, the codes are defined by the size of the wound repair:

12031layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less
120322.6 cm to 7.5 cm
120347.6 cm to 12.5 cm
1203512.6 cm to 20.0 cm
1203620.1 cm to 30.0 cm
12037over 30.0 cm
12041layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less
120422.6 cm to 7.5 cm
120447.6 cm to 12.5 cm
1204512.6 cm to 20.0 cm
1204620.1 cm to 30.0 cm
12047over 30.0 cm
12051layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less
120522.6 cm to 5.0 cm
120535.1 cm to 7.5 cm
120547.6 cm to 12.5 cm
1205512.6 cm to 20.0 cm
1205620.1 cm to 30.0 cm
12057over 30.0 cm

Cynthia Thompson, CPC, senior coding consultant with Gates, Moore & Company, an Atlanta-based medical management consulting firm, cites the following example. A 10-year-old boy has a nasty fall from his bicycle, and the surgeon has to perform simple repairs on a 2.6 cm facial laceration, a 0.5 cm wound on his ear, a 2.1 cm nasal laceration, and a 2.0 cm wound on the boys left leg. The surgeon also must perform intermediate repairs on a 2.8 cm left knee wound that included removal of particulate matter and a 2.5 cm laceration on his left elbow. Based on the CPT 2000 guidelines, the procedures would be billed as follows:

12032intermediate, extremities, 5.3 cm total including left knee and elbow
12014simple, face, ear nose, 5.2 cm total
12001simple, leg, 2.0 cm

Complex Repair Coding

Finally, there are complex repairs, which are performed on complicated wounds such as scar revisions, debridements, extensive underminings, stents or retention sutures, all of which require more than layered closure. According to CPT, the complex repair may include creation of the defect and necessary preparation for repairs or the debridement and repair of complicated lacerations and avulsions.

Complex repairs are defined using four anatomical sites: trunk; scalp, arms or legs; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and feet; and eyelids, nose, ears and lips. As with the simple and intermediate repairs, the anatomic site is further broken down by the size of the wound or laceration being repaired.

Until this year, the repair of wounds more than 7.5 cm had to be billed using 13300 (now deleted). In CPT 2000, however, four new add-on codes 13102, 13122, 13133 and 13153have been included.

The following CPT codes (including the four new add-on codes) should be used for such complex repairs:

13100repair, complex, trunk; 1.1 cm to 2.5 cm
131012.6 cm to 7.5 cm
13102each additional 5 cm or less (list separately in addition to code for primary procedure)
13120repair, complex, scalp, arms, and/or legs; 1.1 to 2.5 cm
131212.6 cm to 7.5 cm
13122each additional 5 cm or less (list separately in addition to code for primary procedure)
13131repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm
131322.6 cm to 7.5 cm
13133each additional 5 cm or less (list separately in addition to code for primary procedure)

Note: For 1.0 cm or less in the preceding three anatomic categories, see simple or intermediate repair.

13150repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less
131511.1 cm to 2.5 cm
131522.6 cm to 7.5 cm
13153each additional 5 cm or less (list separately in addition to code for primary procedure)

The four new add-on codes are used as follows: The code that precedes them in the book (a 2.6 cm to 7.5 cm code) would be billed first, followed by the add-on code. When reporting wound closures, the size of the repairs in the same category (simple, complex or intermediate) are added together and coded according to anatomic site, Mueller says, with every additional five centimeters of all the repairs in the same anatomic category billed with another unit of the appropriate add-on code.

Surgeons should remember that the lengths added together must be in the same classification and the same anatomic site grouping, Thompson says. Do not add together intermediate and complex closures, and do not add together repairs of the face and the extremities.

Note: Wound repair differs from excision of lesions, because the total size of multiple lesions in the same category of anatomic site is not combined.

For example, during an operative session, the general surgeons op report notes a 3 cm complex repair of the right calf, a 2.5 cm complex repair of the right thigh, a 5 cm complex repair of the left thigh, a 2.5 cm intermediate repair of the cheek, and a 4.5 cm simple repair of the left forearm, the proper coding sequence would be as follows:

13121ICD-9 894.1, multiple and unspecified open wound of lower limb; complicated
13122894.1
12051873.41, other open wound of head; cheek
12002-59881.00, open wound of forearm, without mention of complication

Modifier -59 (distinct procedural services) should be added to 12002 to indicate separate repairs in the same anatomic area, Mueller says, because both lacerations involve the extremities and the simple repair is bundled into the complex closure. She notes, however, that the repair of the facial laceration is not bundled because it involves a different anatomic site.

Documentation Must Reflect Level of Repair

As is always the case when billing for procedures, the documentation contained in the operative report must reflect the level of repairs that were performed, Mueller says, adding that the surgeon should document the depth of the repair in simple terms and include the size of the laceration for each closure.

Occasionally, however, surgeons fail to document the depth, length or even the number of repairs they perform. For example, if the surgeon merely writes repair of multiple lacerations in the operative report, then only the lowest level repair in any given category may be billed.

In addition, if the surgeon indicates that he or she performed a plastic repair, coders cannot simply assume this was a complex repair. Instead, they need to get more information about the procedure from the surgeon."