General Surgery Coding Alert

Question: Recently, a payer rejected a claim for wound repair (12005) using a combination of stitches and adhesive strips. We carefully documented the wound length(s). What's the problem?

North Carolina Subscriber

Answer: Your payer may be confusing CPT's rules regarding tissue adhesive.
 
Wound closure 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], according to CPT. 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.
 
If, however, the surgeon closes the wound using adhesive strips only, you may not report the repair/closure codes. Rather, as CPT specifies, "Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code."
 
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.
 
For example, the surgeon attends to a child who has several lacerations from a playground accident. She examines the child, cleans the wound and places a combination of stitches and adhesive strips to close the 15-cm wound. In this case, the wound repair/closure code 12005 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 12.6 cm to 20 cm) is appropriate. 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.
 
Your payer may be assuming that you used only adhesive strips, or perhaps misinterpreted the CPT rules to mean that any use of adhesive strips calls for an E/M service only. In either case, you should appeal the payer's decision, being careful to note that the surgeon used both adhesive strips and stitches to repair the wound.

 - Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.