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 Step: How Was It Closed? 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. Second Step: How Bad Is It? 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 [...]