General Surgery Coding Alert

Notice adhesive strip exclusion.

Don’t be fooled by the adage that wound repair coding simply depends on the depth of the defect. Ignoring other documented details could lead you to fraudulent upcoding or lost revenue for your surgeon’s work.

Check out our experts’ advice about the specifics you should consider for each wound repair case you code.

Master Code Options

Before you start coding a wound closure case, you need to get a bird’s eye view of the code choices you’ll face. CPT^® does not group all closure codes together, so here’s a cheat sheet of the code families to consider:

Simple closure:

• 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less)
• 12002 (… 2.6 cm to 7.5 cm)
• 12004(… 7.6 cm to 12.5 cm)
• 12005 (… 12.6 cm to 20.0 cm)
• 12006 (… 20.1 cm to 30.0 cm)
• 12007 (… over 30.0 cm)

Other simple repair sites of various lengths include codes 12011-12018 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes…).

Intermediate closure: Similarly, you’ll find intermediate repair codes organized by site and repair length, as follows:

• 12031-12036 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet) …)
• 12041-12047 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia …)
• 12051-12057 (Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes …)

Complex closure: These codes follow a similar pattern of distinguishing codes based on anatomic site and repair length.

• 13100- +13102 (Repair, complex, trunk …)
• 13120- +13122 (Repair, complex, scalp, arms, and/or legs …)
• 13131-+13133 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet …)
• 13151-+13153 (Repair, complex, eyelids, nose, ears and/or lips …)

Focus on Closure Details

Carefully read your surgeon’s operative report to see how he closed the defect. Look for phrases like “layered closure,” “single-layer,” “staples,” “sutures,” or “adhesive.” Also notice tissue descriptions such as “epidermis,” “dermis,” “muscle fascia,” or “subcutaneous.”

Tissue adhesives: Surgeons may use tissue adhesives alone (such as Dermabond), or in addition to staples or sutures. “A combination of methods won’t impact your code choice, but if your surgeon performs a single-layer repair on a Medicare patient and uses only tissue adhesives, you should report G0168 (Wound closure utilizing tissue adhesive(s) only) instead of a CPT^® code,” advises Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, national director of marketing and revenue management at FasPsych in Omaha, Nebr.

Strips are different: When the physician closes the wound using adhesive strips as the only repair material, you should report this service with the appropriate evaluation and management (E/M) code, not a repair code, according to CPT^®.

Watch for tissue layers: For cases that involve primarily epidermis/dermis with no deeper subcutaneous tissue using a single-layer closure, you’ll most likely turn to a simple closure code. But additional services (which you’ll read about in the next section) may lead you to choose an intermediate repair code for a single-layer closure.

Cases that involve layered closure of significant levels of deeper subcutaneous tissues and structures will require an intermediate or complex repair code. Again, the additional services are the tipping point between the two families of codes.

Add in Site Preparation

Sometimes you’ll use op note details beyond closure and tissue-layer information to drive your code choice. Specifically, the surgeon may describe site preparation work that warrants a higher-level code.

Debridement: The closure guidelines allow movement from simple to intermediate, or intermediate to complex code families if the surgeon documents extensive debridement of the wound site before performing the closure. For instance, CPT® identifies one type of intermediate repair as “single-layer closure of heavily contaminated wounds requiring extensive cleaning or removal of particulate matter.” Similarly, the guidelines distinguish some types of complex repair from a multi-layer intermediate repair due to “the debridement of complicated lacerations or avulsions.”

Defect preparation: If the op note describes the surgeon preparing the defect for closure using steps such as scar excision, extensive undermining, stents, or retention sutures, you’ll need to use a complex instead of intermediate repair code for a layered closure.

For instance, the physician may create a limited defect when he removes deep tissue, but cannot replace it, which would leave a crater-like deformity that he may need to pack open or possibly graft, explains Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan.

Lesion excision: Remember that CPT^® codes for benign lesion excision (11400-11446) and malignant lesion excision (11600-11646) include simple repair, which you should not separately report. If the surgeon performs an intermediate or complex closure following a lesion excision, you should separately report the appropriate code for both procedures.

Don’t Miss Additional Details

A few more details from the op report could have a huge impact on your code choice.

For instance, if the surgeon repairs multiple wounds, the type and anatomic site of the repairs could lead to vastly different coding.

• For multiple repairs of the same type (such as intermediate) and the same anatomic site group (such as axillae and trunk), you should add the excision lengths together to determine the single code for the surgeon’s work.
• For multiple repairs involving different types (such as simple and intermediate) or different anatomic site groups (such as eyelid and hands), code each repair using a distinct code.

Pointer: Pay attention to body groupings described by the codes, because these may change according to the repair class. For instance, CPT^® includes hands, feet, and/or extremities in the same anatomic site for simple repairs, but excludes hands and feet from intermediate repair codes for extremities.

Put it All Together

Study the following case to see how all the preceding details impact your code choice and your surgeon’s pay.

Case: The surgeon repairs the following lacerations for a patient involved in a bike wreck: right shin 8.2 cm, right hand 3.3 cm, chin 4 cm. All lacerations involve only dermis and epidermis and single-layer closure. The wounds on the shin and hand contain significant gravel and debris requiring extensive removal and cleaning.

Coding: Report the chin closure as a simple repair using 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm).

You should code the shin and hand repair using intermediate repair codes based on significant debridement, despite the fact that the closure was single layer. Because the shin and hand are in different anatomic site groupings in CPT^®, you’ll need to use different codes for the two lacerations: 12042 for the hand (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm) and 12034 for the shin (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm).

Sacrifice pay: If you had failed to note that debridement bumped the shin and hand repair from simple to intermediate repair, you would have used 12004 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm) to report the shin (8.2 cm) plus hand (3.3 cm), which equals 11.5 cm total repair length. That code pays $130.10. Compare the simple repair pay for the shin and hand to the intermediate repair pay: $326.87 for 12034 and $303.09 for 12042 for a total of $629.96.

Bottom line: Missing the intermediate repair in this case would cost your practice $499.86. (All values in the example based on national non-facility Medicare Physician Fee Schedule amount and 2019 conversion factor 36.0391).