General Surgery Coding Alert

Any number of procedures, including debridement, blood vessel and nerve repair(s), lesion excision and others, may accompany wound repair (12001-13160). Knowing when these procedures are bundled and when they are separately reportable and how to report them properly will greatly improve claims' accuracy and reimbursement turnaround.

Debridement (cleansing and removal of devitalized tissue) commonly accompanies wound repair at any level (simple, intermediate or complex). According to CPT instructions, wound repair includes debridement unless "gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure."

Note: For more information on reporting primary wound repairs, see General Surgery Coding Alert, November 2002.

For example, a motorcyclist involved in an accident suffers extensive lacerations of varying depth due to "road rash." Several of the wounds require repair/closure, but they also contain gross contamination (asphalt, dirt, etc.). And significant areas of tissue surrounding wounds on the leg and forearm require trimming. In this case, the wounds are primarily superficial and qualify as simple or, at best, intermediate repairs. But because the amount of cleansing and tissue removal greatly exceeds that which typically accompanies such repairs, the surgeon may report debridement separately.

In a second example, a bicyclist has similar but less severe injuries. In this case, contamination of the wound is greater than that associated with simple repair, but not unusually extensive. Consequently, the surgeon may choose the intermediate repair codes (due to the contamination) but cannot report debridement separately.

For extensive debridement of soft tissue or bone not associated with open fracture(s) and/or dislocation(s) (as in the first example above), choose the appropriate code from the 11040-11044 range, e.g., 11043, Debridement; skin, subcutaneous tissue, and muscle. For extensive debridement associated with open fracture(s) and/or dislocation(s) (e.g., in the first example above, the motorcyclist also has an open fracture of the tibia), select the appropriate code from the 11010-11012 range.

When reporting wound repair and debridement codes together, you must observe two important guidelines, says Cindy McMahan, CPC, an independent coding consultant based in Albany, Wis. First, provide documentation to justify the separate debridement code(s). The attending surgeon should specifically note that the wound required extensive debridement and record the area and time involved, as well as the extent (i.e., depth superficial, full thickness, skin and muscle, etc.) of the procedure. Without this information, the coder cannot choose an appropriate code, and/or the payer will reject the debridement code(s) as bundled to wound repair. Second, append modifier -59 (Distinct procedural service) to the debridement code(s). The modifier tells the payer that the debridement is a separate and distinct procedure, beyond that usually associated with wound repair.

As with debridement, CPT may bundle repair of blood vessels, nerves and tendons with the wound closure, or you may be able to report it separately, depending on the repairs' extent and severity, McMahan says. Specifically, CPT instructs, "The repair of these associated wounds is included in the primary procedure [i.e., wound repair] unless it qualifies as a complex wound." Likewise, simple exploration of nerves, blood vessels or tendons exposed in an open wound is incidental to wound repair unless "appreciable dissection is required," CPT continues.

For example, a man cuts his leg with an ax while chopping wood. The surgeon cleans the wound, examines it to be sure there is no damage to underlying muscle or tendons and ligates several small vessels to stop excessive bleeding. In this case, the wound repair includes the exploration and simple ligation, so you may not report them separately.

Again, however, you may separately report repairs significantly beyond those typically associated with wound closure using the codes appropriate to the item(s) repaired (e.g., musculoskeletal codes for tendons, cardiovascular codes for blood vessels, and nervous system codes for nerves), which will vary from situation to situation.

In a variation of the above example, the ax penetrates deep into the lower leg, severing the medial sural nerve. In this case, the work involved in repairing the nerve is far more involved than that which typically accompanies even complex wound repair. Therefore, the surgeon may report the repair separately, e.g., 64856, Suture of major peripheral nerve, arm or leg, except sciatic; including transposition. The national Correct Coding Initiative (CCI) does not specifically bundle such repairs to wound repair codes, so you don't have to use modifier -59. Nonetheless, you should append modifier -51 (Multiple procedures) to the lesser-valued code(s) in this example, the wound repair to indicate that the surgeon performed multiple procedures during the same operative session.

CPT further notes, "If the wound requires enlargement, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous, and/or muscular blood vessel(s) of the subcutaneous tissue, muscle fascia, and/or muscle," you may separately report codes 20100-20103 for exploration of penetrating wounds, as appropriate. For example, a compressed-air tank fails, sending shards of metal into a construction worker's back. In addition to the usual wound repair and debridement, the surgeon must examine and in some cases enlarge the wounds to remove the metal shards, as well as ligate several severed blood vessels. In this instance, report 20102 (Exploration of penetrating wound [separate procedure]; abdomen/flank/back) for each wound explored in addition to the appropriate wound repair code(s). Once again, apply modifier -51 to the lesser-paying procedure(s) to indicate multiple procedures.

Never include excision of lesions, whether benign (11400-11471) or malignant (11600-11646), in wound repair, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM Program Coordinator at Clarkson College in Omaha, Neb. Note, however, that lesion excision may include wound repair, depending on size and/or complexity.

For example, according to CCI, 11400 (Excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) bundles simple repairs (12001-12018), intermediate repairs (12031-12057) and complex repairs (13100-13152) for excision and repair at the same site. Likewise, CCI subjects 11420 (Excision, benign lesion, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) to the same edits.

But the edits are not consistent for all lesion excision codes or all payers; for instance, CCI only bundles simple repairs to 11401-11406. Contrary to CCI, CPT instructs providers, "The closure of defects created by incision, excision or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately." Therefore, when reporting lesion excision in addition to wound repair, ask your payer for its guidelines. If the payer observes CCI, carefully examine your coding to be sure that you may report wound repair in addition to excision. If the payer observes CPT guidelines, you may generally report all but simple repairs in addition to lesion excision.

You may report a separate code for each lesion excised. Do not add together the size of individual lesions to arrive at a collective total, as you would with wound repairs of the same complexity and location. Do not append modifier -59 when reporting multiple excisions, but do append modifier -51 to wound repairs reported at the same time as excisions. The excision codes reimburse at a higher rate, so you should list them as the primary procedure, Bucknam says.

For example, a surgeon removes two benign lesions of about 2.5 cm each, one on the chest and the other on the left arm, each of which requires an intermediate repair and closure. Report the excisions first using 11403 x 2 (Excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs; lesion diameter 2.1 cm to 3.0 cm). Next, report the repairs using 12032-51 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm). Remember, to select the appropriate repair code, add together the lengths of all repairs to arrive at a single total. In this case, 2.5 cm + 2.5 cm = 5 cm.

Note that excision of lesion is not the same as excision of scar or other defect to be repaired during complex repair. CPT includes these procedures in the complex repair codes, and you may not report them separately.

Next month: Adjacent tissue transfers.