General Surgery Coding Alert

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.

First, 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, if the surgeon 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 surgeon's method of closure.

Note: The above guidelines apply to non-Medicare payers only. Medicare designates a special code G0168 (Wound closure utilizing tissue adhesive[s] only) for sole use of tissue adhesives (see accompanying sidebar in acticle 2).

If, however, the surgeon closes the wound using adhesive strips only, you may not report the repair/closure codes, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator, Clarkson College, Omaha, Neb. Rather, as CPT specifies, "Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code."

For example, the surgeon 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 wound repair/closure codes are appropriate, Bucknam says. If she 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, you may report only the appropriate E/M service code, as supported by documentation.

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, or those that do not reach significantly below the skin "involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures," according to CPT and require only a single-layer closure.

"A simple laceration repair includes trimming or removing fatty tissue and cleaning the wound," says Mandy Storman, RHIT, CPC, a coding consultant for Health Information Services at Eastern Maine Medical Center in Bangor, Maine. 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," CPT says. 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 scar revision, extensive undermining, stents or retention sutures. These are often reconstructive procedures and include creation of the defect to be repaired, e.g., excision of the scar and subsequent closure. Such repairs do not, however, include excision of lesions. 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 surgeon 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. If the op report does not provide sufficient detail or if you are otherwise in doubt, check with the operating surgeon.

Within each level of repair, CPT further classifies wounds according to anatomic location. Note that these categories are not identical for each level of repair. For example, for simple repairs, CPT groups the scalp, neck, axillae, external genitalia, trunk and extremities (including hands and feet) together as covered by codes 12001-12007.

For intermediate repairs, 12031-12037 describe layered closure of wounds of scalp, axillae and extremities excluding hands and feet, while 12041-12047 apply for repair of wounds to neck, hands, feet and external genitalia. For complex repairs, the subclassifications are still more precise.

In addition to severity (depth) and anatomic location, CPT groups repair/closure procedures according to the size (length) of the wound. For 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, while 12004* describes repair of the same severity and location, but of 7.6 cm to 12.5 cm length.

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, Bucknam says.

For instance, returning to the earlier example of the child injured in a playground accident, the surgeon 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 level of severity 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 wound on the extremities of 6.5 cm is 12002* (... 2.6 cm to 7.5 cm).

In a second example, a bicyclist crashed, 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, as the surgeon 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).

When reporting multiple wound closures in this manner, append modifier -51 (Multiple procedures) to the second and subsequent procedures for payers who still observe this modifier. Consult the Physician Fee Schedule to select the highest-paying procedure as the primary code (in this case 12036, with 9.79 relative value units), because the payer will reduce the fee for the second and subsequently listed codes. In the above example, optimum coding is 12036, 12044-51, 12052-51.

In a final example, 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) for the intermediate leg repair, and 12004-51-59 (Distinct procedural service) for the combined length of the superficial leg and trunk wounds.

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, says Cynthia Thompson, CPC, senior coding consultant with Gates, Moore & Company, an Atlanta-based medical management consulting firm.

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. In addition, these codes are modifier -51 exempt and are not subject to multiple-procedure reductions: The value of the code already reflects its status as an "additional" procedure.

Next month: Reporting lesion excision, debridement, dehiscence, adjacent tissue transfer and other related services with wound repair/closure.